Chronic Obstructive Pulmonary Disease Pathway Review September 2015 Final Draft

Transcription

1 Chronic Obstructive Pulmonary Disease Pathway Review September 2015 Final Draft Public Health Department Date of publication: Date for review:

2 Authors Leona Patel, Public Health Lead, London Borough of Richmond upon Thames Acknowledgements Hannah Brown, Respiratory Care Team Lead and Physiotherapist- Richmond & Teddington Localities, HRCH Dr Ben Wright, Consultant Psychiatrist in Medical Psychotherapy, Lead Clinician Richmond Wellbeing Service, Associate Medical Director for Clinical Information Julie Chong, Interim Stop Smoking Service Coordinator (Kingston & Richmond), Kick It, Thrive Tribe Ltd. Simon Nadolski, Head of Stop Smoking Services, Kick It, Thrive Tribe Ltd. Dee Vadukul, Senior Practice Pharmacist, NHS Richmond CCG Dr. Alexander Norman, GP, NHS Richmond CCG Oliver McKinley, Commissioning Manager, NHS Richmond CCG Sean McMenamin, Commissioning Project Manager, LBRuT Anna Bryden, Consultant in Public Health, LBRuT Anna Raleigh, Consultant in Public Health, LBRuT Clair Harris, Public Health Principal, LBRuT Amanda Killoran, Public Health Principal, LBRuT Usman Khan, Public Health Principal, LBRuT Peter Yuen, Health Intelligence Specialist, LBRuT Angela Aboagye, Public Health Lead, LBRuT ii

3 Contents Authors... ii Acknowledgements... ii Contents... iii Executive Summary Aim Case for Change Evidence Based Practice Local Picture Local Services End of life Care Recommendations Next Steps... 9 Introduction Aim Who is this for? Background Case for Change Outcomes Strategy for COPD Evidence Based Practice Evidence Based Guidance on COPD includes: NICE Pathway Local Picture Prevalence Outcomes Local Services Case Finding and Early Identification Staying Healthy Reducing Admissions End of Life Care Trajectory of COPD iii

4 End of Life Care Pathway End of Life Care in Richmond Possible Cost Savings Pathway Indicators Conclusion Recommendations Primary and Community Care Community Based Specialist Care and Acute Care End of Life Care References Appendices Appendix COPD Clinical Working Group Recommendations Appendix 2. NICE Clinical Guideline 101: Key Priorities for Implementation. 60 Appendix 3. COPD prevalence by GP Practice 13/ Appendix 4. Smoking Prevalence by GP Practice, 2013/ Appendix 5. HRCH Respiratory Care Team (Richmond) Appendix 6. HRCH Single Point of Access (Richmond) Appendix 7. British Thoracic Society Guideline on Pulmonary Rehabilitation in Adults Appendix 8. Medicines Optimisation: COPD Briefing Sheet Appendix 9. Richmond Response and Rehabilitation Team Appendix 10. HRCH Respiratory Home Oxygen Service Guidance Appendix 11. Supportive and Palliative Care Indicators Tool (SPICT) iv

5 1 Executive Summary 1.1. Aim This document reviews current COPD needs and services for Richmond patients and puts forward recommendations to improve the quality of care in the community Case for Change There are around 835,000 people currently diagnosed with COPD in the UK and an estimated 2,200,000 people with COPD who remain undiagnosed. Smoking is the greatest risk factor in the development of COPD. COPD is one of the most common causes of emergency admissions to hospital and one of the most costly inpatient conditions to be treated by the NHS. Ten percent of acute admissions for COPD are in people without a prior diagnosis of the condition. If these patients are identified earlier, they can be managed properly, and possibly avoid acute admission. Development of a COPD pathway remains a priority for NHS Richmond Clinical Commissioning Group (CCG), which is included in the 2015/16 Commissioning Intentions for planned care and Better Care Fund. The intention is to invest in integrated community services that provide care closer to home and reduce the number of emergency hospital admissions. COPD is one key area identified to target to achieve a reduction in avoidable admissions Evidence Based Practice NICE provides comprehensive guidance on the diagnosis, treatment, and care of adults with COPD, including clinical guidelines, pathways, and quality standards. The Outcomes Strategy for COPD and Asthma (DH 2012) covers prevention, case finding, early detection and organisation of care and should be considered together with NICE to make improvements across the range of COPD services Local Picture Prevalence In 2013/14, QOF COPD prevalence in Richmond was 0.95% (London: 1.1% and England: 1.8%). There has been a decline in COPD prevalence since 2011/12, with 5

6 a -2% change from 2012/ /14. However, the absolute number of people on the COPD register was on the rise until 2011/12, but has remained stable since then. There is a wide variation in the prevalence between GP Practices, ranging from 0.3% to 1.6%. In England, it is known that deprived populations have the highest prevalence and the highest under-diagnosis of COPD 1. However, there is a weak correlation between COPD prevalence and index of multiple deprivation in Richmond, based on the deprivation score of GP Practices. This could be due to under-diagnosis of COPD in the deprived areas. Modelled estimates (2011) for Richmond suggest that the expected prevalence of COPD for the population should be 3.35% (5,093 patients), which is more than triple the current prevalence of registered COPD patients (around 3,000 extra patients). This may be due to a proportion of patients who are currently undiagnosed; however this model may also over-estimate the number of people with COPD in Richmond. An estimated 11.4% of adults (age 18 and over) in Richmond smoke (London: 18.4% and England: 17.3%). The prevalence is based on a survey; thus it is an estimate and not true prevalence, and the estimate has fluctuated over the last few years Outcomes The Commissioning for Value (2014) work programme highlighted key indicators and improvement opportunities (compared to the average of 10 CCGs most similar). Areas where NHS Richmond CCG are performing better include: % of COPD patients with a record of FEV1 % of COPD patients with a review (15 months) <75 Mortality from bronchitis, emphysema and COPD Areas where NHS Richmond CCG are performing worse, though not statistically significant from the average of the 10 most similar CCGs, include: Reported to estimated prevalence of COPD Non-elective spend Admissions for COPD in Richmond are higher than would be expected for the demographic of NHS Richmond CCG. Emergency admissions and re-admissions for COPD are largely preventable through better case management. Around 30% of admissions were short stay (0 or 1 day), and a high proportion of these short stays may have been treated in their homes with appropriate support and treatment. 6

7 In Richmond, the 3-year average ( ) for deaths due to COPD was 40.7 directly standardised rate (DSR) per 100,000 2 (England: 51.5 DSR and London: 50.9 DSR. The most recent life expectancy gap analysis for Richmond shows that respiratory diseases account for 33% of the gap in life expectancy for females and 20% for males, between the most deprived quintile and the least deprived quintile 3. Over the period of , it is estimated that there were 30 excess deaths among females due to COPD in the most deprived quintile area of Richmond Local Services Case Finding and Early Detection There are a number of people with undiagnosed COPD and further work around case finding and early detection is needed to identify these people and provide them with appropriate care in the community. There is potential for case finding initiatives through GP practices, community pharmacy, and stop smoking services, focusing on deprived areas with higher smoking prevalence and high risk groups Staying Healthy HRCH Respiratory Care Team (RCT)- provides a respiratory specialist service in the community for adult patients with long-term respiratory conditions Stop smoking- one of the most important and cost effective components of management and support is available through community pharmacies, GPs, the dedicated stop smoking service Kick It and outreach clinics Physical activity- promote regular physical activity in all people with COPD and refer to appropriate physical activity services Pulmonary Rehabilitation- The RCT provides pulmonary rehabilitation, comprising individualised exercise programmes and education Immunisations- offer annual flu vaccine and one off pneumococcal vaccination Medicines optimisation- for local prescribing advice, based upon national guidelines and local Trust formularies, refer to NHS Richmond CCG Medicines Optimisation Team COPD Briefing Sheet Patient review- review people with mild/moderate COPD at least once a year and those with very severe COPD at least twice a year, in line with NICE guidance Psychological therapy- clinicians should assess and address co-morbid mental health problems in patient reviews, and refer to Richmond Wellbeing Service 7

8 Patient Support Group- weekly group, Breathe for Life, for people with respiratory conditions, providing an opportunity to discuss and share experiences Self-management- support people to self-manage their condition through selftreatment at home, Expert Patient Programme, and health improvement services Reducing Admissions Richmond Response and Rehabilitation Team- health and social care support packages to regain independence and wellbeing, for prevention of hospital admission, hospital discharge, or community rehabilitation Managing exacerbations- prescription for emergency exacerbation medication provided following diagnosis and identification of being at risk of exacerbations Oxygen Therapy- provision is for more advanced cases and is managed by RCT Enhanced Service for Avoiding Unplanned Admissions- practices identify patients at high risk of admission and manage them using risk stratification tools, a case management register, personalised care plans and same day telephone access. GRASP-COPD- audit tool that can support GP practices with case finding, early detection, and management of their COPD patients 1.6. End of life Care Because of the chronic nature of COPD, the terminal phase is often not detected by clinicians until death is imminent. As a result, people who are dying and their carers frequently do not receive appropriate care. The Richmond End of Life Care target is to increase the proportion of people who die in their usual place of residence from 39% in to 44% in Patients with end-stage COPD, their family, and carers should be informed of the full range of information on end of life care services Recommendations These recommendations were developed in consultation with key stakeholders: Primary and Community Care 1. Identify patients with COPD early through pro-active case finding 2. Ensure all newly diagnosed COPD patients have access to community respiratory care, through referral to HRCH Respiratory Care Team 3. Health care professionals support self-management, refer to appropriate services, and develop self-management plans 8

9 3a. Promote regular physical activity in all people with COPD and refer to appropriate services 3b. Refer to Psychological Therapies 3c. Refer to Expert Patient Programme 3d. Promote AirTEXT service for information on air quality 4. Ensure changes/updates to provider contracts (completed action) 4a. Incorporate recent evidence based guidance within provider contracts 4b. Monitor equalities data in provider contracts Community Based Specialist Care and Acute Care 5. Reduce avoidable emergency hospital admissions 6. Develop a local respiratory care group to improve coordinated care End of Life Care 7. Assess people with COPD for end of life care needs and refer for appropriate treatment and support 7a. Identify people at risk of deteriorating health and dying, using the Supportive and Palliative Care Indicators Tool (SPICT ) 7b. Adapt end of life care pathway for COPD specific patients (NHS Improvement), reflecting local provision for COPD patients 7c. A focus on personalisation and choice at the end of life, including improved information regarding different service options and the types of support available 1.8. Next Steps The COPD Care Pathway Review will be presented and discussed at the Richmond & Barnes Clinical Network and Teddington, Twickenham, and Hampton Clinical Network in November NHS Richmond CCG will lead on taking forward recommendations, with support from Public Health. Additionally, relevant stakeholders will be included to inform planning and delivery of the recommendations. 9

10 2 Introduction 2.1. Aim This document reviews current COPD needs and services for Richmond patients and puts forward recommendations to improve the quality of care in the community. This document describes COPD prevalence and outcomes, and maps current COPD services provided for Richmond patients. The latest guidance, evidence, and best practice are referenced and incorporated. Recommendations are provided for commissioning and implementation in line with best practice Who is this for? A pathways project team was set up to lead and coordinate pathway reviews for planned care, with input from relevant stakeholders as needed. Presentation of the COPD pathway will be to the Clinical Networks. 3 Background 3.1. Case for Change There are around 835,000 people currently diagnosed with COPD in the UK and an estimated 2,200,000 people with COPD who remain undiagnosed 5. Smoking is the greatest risk factor in the development of COPD. COPD is one of the most common causes of emergency admissions to hospital and one of the most costly inpatient conditions to be treated by the NHS. Ten percent of acute admissions for COPD are in people without a prior diagnosis of the condition 6. Most of these have severe disease and some are in respiratory failure. If these patients are identified earlier, they can be managed properly, and possibly avoid acute admission. Richmond consistently performs well on emergency admissions and has the third lowest rate of preventable admissions for chronic conditions in London 7. Despite this good performance, there is still room for improvement. In 2010, a COPD Clinical Working Group was set up to reduce hospital admissions and bring care closer to home as part of the Long Term Conditions care pathway for NHS Richmond. The group developed a COPD pathway with a number of recommendations for 10

11 implementation (Appendix 1). One of the key areas of success from 2010 was that the Respiratory Care Team was commissioned as a comprehensive service to provide respiratory services. This enabled the team to make appropriate and timely referrals to specific services e.g. Pulmonary Rehabilitation, Oxygen Therapy, Rapid Response etc. Furthermore, a brief analysis of COPD data (2009/ /12) showed a reduction of 28% in emergency admissions since the 2009 JSNA work highlighted this as an issue and the 2010 COPD pathway was developed 8. There was a reduction in both the number of patients admitted and frequent fliers. Development of a COPD pathway remains a priority for NHS Richmond Clinical Commissioning Group (CCG), which is included in the 2015/16 Commissioning Intentions for planned care. Additionally, the CCG and Council are working together, with other stakeholders to support integrated care using the pooled Better Care Fund. The intention is to invest in integrated community services that provide care closer to home and reduce the number of emergency hospital admissions. The aim is to further reduce emergency admissions by 3.5%, which is a total of 479 admissions avoided in COPD is one key area identified to target to achieve a reduction in avoidable admissions Outcomes Strategy for COPD The Department of Health published an outcomes strategy for COPD and Asthma in 2012, which is intended to improve the quality of care for people with suspected COPD, as well as those with a confirmed diagnosis. It has a broad scope covering prevention, case finding, early detection and organisation of care and includes the following high level objectives to improve outcomes for people with COPD 10 : Objective 1: To improve the respiratory health and well-being of all communities and minimise inequalities between communities. Objective 2: To reduce the number of people who develop COPD by ensuring they are aware of the importance of good lung health and well-being, with risk factors understood, avoided or minimised, and proactively address health inequalities. Objective 3: To reduce the number of people with COPD who die prematurely through a proactive approach to early identification, diagnosis and intervention, and proactive care and management at all stages of the 11

12 disease, with a particular focus on the disadvantaged groups and areas with high prevalence. Objective 4: To enhance quality of life for people with COPD, across all social groups, with a positive, enabling, experience of care and support right through to the end of life. Objective 5: To ensure that people with COPD, across all social groups, receive safe and effective care, which minimises progression, enhances recovery and promotes independence. Achieving these COPD objectives set out in the outcomes strategy will help the NHS Commissioning Board and clinical commissioning groups improve against the higher-level measures in the NHS Outcomes Framework and the Commissioning Outcomes Framework. Additionally, as part of this focus, it recommends piloting certain interventions and strategies to determine the best ways of delivering different models of care. 12

13 4 Evidence Based Practice 4.1. Evidence Based Guidance on COPD includes: NICE clinical guideline 101: Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) (June 2010) NICE costing report (February 2011) NICE COPD pathways (May 2011) NICE quality standard for COPD (QS10 July 2011) NICE commissioning guide for commissioning services for people with COPD (October 2011) Department of Health Outcomes Strategy for COPD and Asthma in England (2012) Department of Health Outcomes Strategy for COPD and Asthma: NHS Companion Document (2012) Department of Health Commissioning Toolkit on COPD (2012) Global initiative for Chronic Obstructive Pulmonary Disease (GOLD) -Global Strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (2015) The advice in NICE clinical guideline 101 covers the diagnosis, treatment and care of adults with COPD. The key priorities for implementation are included in Appendix 2. The NICE quality standard focuses on assessment, diagnosis and the treatment of COPD. It is based on current NICE guidance and is consistent with the Outcomes Strategy for the areas it covers. The HRCH Respiratory Care Team references and ensures application of the quality standards for COPD. GPs and hospitals also have a responsibility to address the quality standards. The quality standard should be considered together with the outcomes strategy and other highlighted guidance to make improvements across the range of COPD services, and are referenced throughout the document where applicable. 13

14 List of NICE Quality Statements 11 : Statement 1. People with COPD have one or more indicative symptoms recorded, and have the diagnosis confirmed by post-bronchodilator spirometry carried out on calibrated equipment by healthcare professionals competent in its performance and interpretation. Statement 2. People with COPD have a current individualised comprehensive management plan, which includes high-quality information and educational material about the condition and its management, relevant to the stage of disease. Statement 3. People with COPD are offered inhaled and oral therapies, in accordance with NICE guidance, as part of an individualised comprehensive management plan. Statement 4. People with COPD have a comprehensive clinical and psychosocial assessment, at least once a year or more frequently if indicated, which includes degree of breathlessness, frequency of exacerbations, validated measures of health status and prognosis, presence of hypoxaemia and comorbidities. Statement 5. People with COPD who smoke are regularly encouraged to stop and are offered the full range of evidence-based smoking cessation support. Statement 6. People with COPD meeting appropriate criteria are offered an effective, timely and accessible multidisciplinary pulmonary rehabilitation programme. Statement 7. People who have had an exacerbation of COPD are provided with individualised written advice on early recognition of future exacerbations, management strategies (including appropriate provision of antibiotics and corticosteroids for self-treatment at home) and a named contact. Statement 8. People with COPD potentially requiring long-term oxygen therapy are assessed in accordance with NICE guidance by a specialist oxygen service. Statement 9. People with COPD receiving long-term oxygen therapy are reviewed in accordance with NICE guidance, at least annually, by a specialist oxygen service as part of the integrated clinical management of their COPD. 14

15 Statement 10. People admitted to hospital with an exacerbation of COPD are cared for by a respiratory team, and have access to a specialist early supported-discharge scheme with appropriate community support. Statement 11. People admitted to hospital with an exacerbation of COPD and with persistent acidotic ventilatory failure are promptly assessed for, and receive, noninvasive ventilation delivered by appropriately trained staff in a dedicated setting. Statement 12. People admitted to hospital with an exacerbation of COPD are reviewed within 2 weeks of discharge. Statement 13. People with advanced COPD, and their carers, are identified and offered palliative care that addresses physical, social and emotional needs NICE Pathway The NICE pathways for diagnosing and managing COPD are accessible online: This pathway covers COPD in adults (aged over 16 years) in primary and secondary care. The following sections highlight the NICE guidance on the key steps for diagnosing and managing COPD Diagnosing COPD There is no single diagnostic test for COPD. Diagnosis relies on a combination of history, physical examination, and spirometry to confirm airflow obstruction. A diagnosis of COPD should be considered in patients over the age of 35 who have a risk factor (generally smoking) and who present with one or more of the following symptoms: exertional breathlessness chronic cough regular sputum production frequent winter 'bronchitis' wheeze. 15

16 One of the primary symptoms of COPD is breathlessness. The Medical Research Council (MRC) dyspnoea scale (see Table 1) should be used to grade the breathlessness according to the level of exertion required to elicit it. Table 1. MRC dyspnoea scale Grade Degree of breathlessness related to activities 1 Not troubled by breathlessness except on strenuous exercise 2 Short of breath when hurrying or walking up a slight hill 3 Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace 4 Stops for breath after walking about 100 metres or after a few minutes on level ground 5 Too breathless to leave the house, or breathless when dressing or undressing Adapted from Fletcher CM, Elmes PC, Fairbairn MB et al. (1959) The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. British Medical Journal 2: Source: NICE clinical guideline 101 (2010) Spirometry Measure post-bronchodilator spirometry to confirm the diagnosis of COPD. Spirometry should be performed to reconsider the diagnosis, if patients show an exceptionally good response to treatment Identification of early disease Spirometry should be performed in patients who are over 35, current or ex-smokers, and have a chronic cough. Spirometry should be considered in patients with chronic bronchitis. A significant proportion of these will go on to develop airflow limitation Assessment of severity and prognostic factors COPD is heterogeneous, so no single measure can give an adequate assessment of the true severity of the disease in an individual. Severity assessment is important because it has implications for therapy and relates to prognosis. Be aware that disability in COPD can be poorly reflected in the FEV 1. A more comprehensive assessment of severity includes the degree of airflow obstruction and disability, the frequency of exacerbations and the following known prognostic factors: 16

17 FEV 1 T LCO breathlessness (MRC scale) health status exercise capacity (for example, 6-minute walk test) BMI partial pressure of oxygen in arterial blood (PaO 2) cor pulmonale. Calculate the BODE index (BMI, airflow obstruction, dyspnoea and exercise capacity) to assess prognosis where its component information is currently available Assessment and classification of severity of airflow obstruction The severity of airflow obstruction should be assessed according to the reduction in FEV 1 as shown in Table 2, in line with NICE clinical guideline 101 (2010). Table 2. Gradation of severity of airflow obstruction Post-bronchodilator FEV 1 /FVC FEV 1 % predicted Severity of airflow obstruction Post-bronchodilator < % Stage 1 Mild* < % Stage 2 Moderate < % Stage 3 Severe < 0.7 < 30% Stage 4 Very severe** *Symptoms should be present to diagnose COPD in people with mild airflow obstruction. **Or FEV 1 < 50% with respiratory failure. Source: Adapted from NICE clinical guideline 101 (2010) Managing COPD The NICE clinical guideline for COPD recommends providing proactive chronic disease management appropriate for the severity level assessed mild, moderate or severe. Management should include clear action plans, optimisation of therapy and support for self-management and home provision of standby medication, and referral for pulmonary rehabilitation, or home oxygen when indicated. Additionally, prompt support for people when they develop new or worsening symptoms, with access to specialist-led care in the community when appropriate, should be available. These various current local services are detailed in sections 6.2 Staying Healthy and 6.3 Reducing Admissions. 17

18 5 Local Picture 5.1. Prevalence QOF COPD Prevalence Table 3 and Figure 1 show changes in COPD prevalence from In 2013/14, COPD prevalence in Richmond was 0.95%, compared to 1.1% in London, and 1.8% for England. There has been a decline in prevalence since 2011/12, with a -2% change following both years, 2012/13 and 2013/14. However, the absolute number of people on the COPD register was on the rise until 2011/12, but has remained stable since then. Table 3. Richmond CCG Percentage of the population on the QOF COPD register for Number on Percentage % change from register on register previous year 2009/10 1, % /11 1, % 6% 2011/12 1, % 2% 2012/13 1, % -2% 2013/14 1, % -2% Source: QOF 2009/ /14 Figure 1. GP Observed Prevalence of COPD, Source: Richmond Public Health Intelligence COPD data pack,

19 There is wide variation in the prevalence between GP Practices, ranging from 0.3% to 1.6% (see Appendix 3). Figure 2 shows that five GP practices are significantly above the Richmond average for patients on their COPD register, with three practices significantly above the London average. Figure /14 Percentage of GP List Size on COPD Register by Practice, QOF Source: Richmond Public Health Intelligence COPD data pack, 2014 In England, it is known that deprived populations have the highest prevalence and the highest under-diagnosis of COPD 12. However, the scatterplot in Figure 3 shows that there is a weak correlation between COPD and index of multiple deprivation in Richmond, based on the deprivation score of GP Practices. This could be due to serious under-diagnosis of COPD in the deprived areas. 19

20 Percentage on register Figure 3. Prevalence of COPD and Index of Multiple Deprivation Index of multiple deprivation Source: Health and Social Care Information Centre, QOF, and Department for Communities and Local Government, Index of Multiple Deprivation, Modelled Estimate of COPD Prevalence Modelled estimates (2011) for NHS Richmond CCG suggest that the expected prevalence of COPD for the population should be 3.35% (5,093 patients), which is more than triple the current prevalence of registered COPD patients (around 3,000 extra patients) 13. This may be due to a proportion of patients who are currently undiagnosed. The model takes into account age, sex, ethnicity, smoking status, rurality and deprivation score. However, it is important to note that this model may over-estimate the number of people with COPD in Richmond Smoking Prevalence It is estimated that Richmond borough has a relatively low smoking prevalence at 11.4% of adults (age 18 and over) compared to 18.4% in London and 17.3% in England 14. The prevalence data is based on a survey; thus it is an estimate and not true prevalence, and the estimate for Richmond has fluctuated over the last few years. Published QOF data also allow useful estimation of smoking prevalence within practice populations. Around 21% of the general practice population (aged 15 and above) in Richmond have a record of smoking, compared to 23% for London and 20

21 29% for England 15. However, this could be an underestimate of the overall smoking prevalence, as it does not capture people who are not registered with a GP or whose smoking status is not recorded by their GP. Smoking prevalence by GP practice based on QOF 2013/14 is shown in Appendix 4. Nine GP practices are significantly above the Richmond average for patients on their smoking register, with six practices significantly above the London average Outcomes Commissioning for Value The Commissioning for Value (2014) work programme supports CCGs to identify the most impactful opportunities for change. COPD was one area identified where the CCG could potentially make the greatest improvements in terms of spend and quality/outcomes. Figure 4 includes a selection of key indicators, shown as the percentage difference from the average of the 10 CCGs most similar. Figure 4. Commissioning for Value COPD Pathway Source: Commissioning for Value, Pathways on a Page, November 2014 *10 most similar NHS CCGs: North East Hampshire and Farnham, North & West Reading, Windsor, Ascot and Maidenhead, Surrey Heath, Wokingham, Sutton, North West Surrey, Kingston, North Hampshire, Bromley 21

22 Areas where NHS Richmond CCG are performing better include: % of COPD patients with a record of FEV1 % of COPD patients with a review (15 months) <75 Mortality from bronchitis, emphysema and COPD Areas where NHS Richmond CCG are performing worse, though not statistically significant from the average of the 10 most similar CCGs, include: Reported to estimated prevalence of COPD Non-elective spend Admissions Admissions for COPD in Richmond are higher than would be expected for the demographic of NHS Richmond CCG. Emergency admissions and re-admissions for COPD are largely preventable through better case management. In 2014/15, the number of Richmond patients that presented to secondary care and were emergency admissions, slightly increased to 149 patients (from 135 in 2011/12) with 190 emergency admissions (compared to 175 in 2011/12). These admissions in 2014/15 amounted to 1,466 bed days, which amounted to a total of 415,900. The current tariff charged for a COPD patient for an emergency admission for one day or less is 492, going up to over 3,600 for more complicated COPD admissions. Thirty one percent of the admissions were short stay (0 or 1 day). The high proportion of these short stays could conceivably have been treated in their homes with appropriate support and treatment. The treatment of admissions of 0 or 1 day in the community has potential for cost savings. Multiple admissions are a possible indicator of patients that would benefit from case management from specialist respiratory care services like the community respiratory team or the Admissions Avoidance DES. Table 4 shows that the number of patients with admissions fluctuates year on year. There was a dip in admissions in 2013/14, possibly due to the introduction of the Community Ward in 2012/13. The number of multiple admissions for patients has not varied much. Table 5 shows that the percent of patients having a single admission has not changed between 2011/12 and 2014/15 (81% in 2011/12 and 82% in 2014/15). 22

23 Table 4. Multiple admissions for COPD in 2011/ /15 Number of admissions Number of Patients (per year) 2011/ / / / Total Patients Source: NHS South East CSU Table 5. Percent of patients that have multiple admissions for COPD in 2011/12 and 2014/15 Number of Admissions Percent of admissions 2011/ / % 82% 2 14% 12% 3 1.5% 3% 4 2% 2% % 1% Source: South East London Commissioning Support Unit (SUS) Mortality Data from the World Health Organisation shows that premature mortality from COPD was almost twice as high in the UK as in the rest of Europe (EU-15) in Fifteen percent of those admitted to hospital with COPD die within three months, and around 25% die within a year of admission 17. The co-morbidities of COPD patients needs to be considered, as there is a higher prevalence of diabetes, hypertension, and cardiovascular disease in advanced stages of COPD. Eighty percent of people with COPD have at least one other long-term condition 18. COPD is linked with an increased risk of mortality from cardiovascular disease, and having depression and/or an anxiety disorder. In Richmond, the 3-year average ( ) for deaths due to COPD was 40.7 directly standardised rate (DSR) per 100, Richmond has a lower rate of mortality from COPD compared to England (51.5 DSR) and London (50.9 DSR). 23

24 The most recent life expectancy gap analysis for Richmond shows that respiratory diseases account for 33% of the gap in life expectancy for females and 20% for males, between the most deprived quintile and the least deprived quintile 20. From , it is estimated that there were 30 excess deaths among females due to COPD in the most deprived quintile area of Richmond National COPD Audit Programme The National COPD Audit Programme (2014) commissioned by the Health Quality Improvement Partnership (HQIP), for the first time looked at COPD care across the patient pathway, both in and out of hospital, bringing together key elements from the primary and secondary care sectors. The recommendations are directed with equal weight towards commissioners and providers, as they are relevant to both good clinical practice and the commissioning of COPD services. The key recommendations linking primary, secondary, and community care are 21 : All hospitals/units should make spirometry results accessible from every computer desktop; there should be a data sharing agreement between primary and secondary care that allows general practice spirometry data to be made universally available. Post discharge pulmonary rehabilitation services should be available within 4 weeks of referral. Each unit should nominate a respiratory clinical lead for discharge care and integrating services, this individual having designated time to improve the uptake of discharge bundles, improve the quality of discharge information and work collaboratively with colleagues in primary care to improve integrated pathways for COPD. Acute and community providers, primary care, patient groups and commissioners should work collaboratively via local respiratory programme groups to improve coordinated care and formalise COPD pathways; respiratory specialists should take a lead in this process, forming such groups if they do not exist at present. 24

25 6 Local Services 6.1. Case Finding and Early Identification As stated, there is a lower than expected prevalence of COPD in NHS Richmond CCG and greater mortality among females in the most deprived quintile area in Richmond. In order to increase the detection of COPD in previously undiagnosed patients, a multi-disciplinary approach is needed. The COPD Outcomes strategy also highlights a proactive approach to early identification of COPD Previous initiatives A. Community Pharmacies screened customers who had specific risk factors for being at high risk of COPD using a symptom-based questionnaire and referred particular patients to their GP for investigation (June-October 2010). B. Community Pharmacies conducted Health Promotion Campaigns Targeted customers over 50 years of age and promoted exercise and healthy living (May 2010) Delivered a Stop Smoking Campaign (February-March 2013). C. All GPs in Richmond were sent a letter advising of best practice spirometry in line with NICE guidance and suggesting opportunistic case finding of high risk patients, including inviting certain patients for spirometry (June 2010). D. NHS Richmond held a GP education event with representation from primary care, community services, and secondary care, covering key points from NICE guidance regarding case finding and the requirements for spirometry (October 2010) Potential initiatives A. Lung Cancer and COPD screening service in Community Pharmacies- The DH COPD Outcomes Strategy highlights the need to recognise the link between COPD and lung cancer and explore the use of proactive strategies to diagnose earlier 22. Community pharmacies in Croydon, Wandsworth, and Sutton and Merton offered a pilot service to help identify patients with lung cancer, COPD, and/or other respiratory conditions. The service resulted in 25

26 significant new diagnosis of respiratory conditions, mainly COPD. Twenty seven pharmacies in Richmond expressed interest in offering this service, but due to lack of funding, it did not run in Richmond. However, this could be reviewed for consideration by the CCG and Cancer Strategy Steering Group. B. Targeted case finding through GP register audit- to identify people whose treatment history and symptoms suggest COPD may have been missed, and inviting for spirometry. NICE recommends that a diagnosis of COPD should be considered in people over the age of 35 who have a risk factor (generally smoking) and who present with exertional breathlessness, chronic cough, regular sputum production, frequent winter bronchitis or wheeze. The Lancet Respiratory Medicine recently highlighted that missed opportunities for diagnosis exist in primary care practices and suggest that a case-finding approach should be modified to include: all patients older than 40 years with a diagnosis of asthma and who currently smoke; all smokers older than 40 years who have a lower respiratory prescribing event; and follow-up of existing recommendations for smokers aged older than 40 years with any respiratory symptoms, especially if they are male 23. A scheme for case finding through GP register audit could be considered, such as focusing on deprived areas with higher smoking prevalence in Richmond. At North West Surrey CCG, GPs were keen on early identification and have funded a project to identify a proportion of the unidentified patients with COPD. They planned to run extracts in 21 practices and fund respiratory (external) nurses to do COPD reviews, put patients on treatment, and make referrals to smoking cessation services etc. In the first practice, almost 50% of the patients reviewed were newly diagnosed with COPD 24. C. Spirometry in GP practices- It is unclear how many practices in Richmond perform spirometry; however, this is key in confirming a diagnosis of COPD. Practices/staff not currently performing spirometry, but are interested in doing so, should be supported by the CCG with appropriate equipment and/or training. Practices who don t feel capable could potentially refer to the HRCH Respiratory Care Team to confirm diagnosis. However, the team is not currently commissioned to diagnose, so this would need consideration. 26

27 D. GP education event- A GP education event covering key points around case finding and spirometry for diagnosis could be delivered to support quality assurance and training needs. Additionally, information about current local services should be provided to support management in the community. E. Stop smoking services- A Department of Health report A strategic approach to prevention and early identification of COPD (February 2011) makes the case for prioritising defined high risk groups (e.g. older smokers and ex-smokers, routine and manual men and women). As smoking is the greatest risk factor in developing COPD, stop smoking services are well placed to support targeted identification of people with early or more advanced stages of COPD. Kick It can provide training to stop smoking practitioners on COPD, including signs, symptoms, and high risk groups. Practitioners can then advise people on recognising and responding to the symptoms of COPD, and support referral to their GP for further investigations GRASP-COPD GRASP-COPD is part of the GRASP suite of tools developed in partnership with NHS Improving Quality. It assists GP practices to interrogate their clinical data, enabling them to improve patient outcomes, reduce costs and avoid inappropriate treatment for patients with COPD. 25 This audit tool can help practices with: case finding; identifying patients who may have a missing diagnosis code for COPD and identifying those at risk of developing the disease auditing their management of patients against NICE Clinical Guideline 101 checking a patient's severity against current treatment, ensuring patients receive optimum care, and highlighting potential savings (by reviewing treatments that are not clinically indicated) It is recommended that GP practices consider using GRASP- COPD to support case finding, early detection, and management of their COPD patients. The tool is free to download from the PRIMIS website (free PRIMIS Hub registration is required): It will run on all practice systems in England. For 27

28 practices already using GRASP, the new tool can be downloaded from within the PRIMIS CHART update facility Staying Healthy HRCH- Respiratory Care Team The Respiratory Care Team (RCT) service was established in 2006 to provide a respiratory specialist service in the community for adult patients with long-term respiratory conditions. See Appendix 5 for team details and referral criteria. In 2013/14, the RCT had 288 new referrals for newly diagnosed patients. This includes all referrals for other respiratory conditions other than COPD; possibly around 85% of these are for COPD. The RCT has a larger ongoing caseload as once a patient is referred to the team they are not discharged. A small cohort of patients will have three or four referrals and they may repeat pulmonary rehabilitation if they have deteriorated (pulmonary rehabilitation is run by the RCT and home oxygen is also overseen by the team). Previously, when the GP LES was in place in 2010, a total of 685 patients were referred to the team that year. This has significantly reduced back down to around 250 per year now that the LES is no longer in place. This suggests that possibly not all newly diagnosed COPD patients are being referred and highlights the importance of the GP referral of COPD patients to the RCT. Referrals should be made through the HRCH Single Point of Access (SPA) (Appendix 6) Smoking Cessation As stated in NICE guidelines: All COPD patents still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity. Encouraging patients to stop smoking is one of the most important and cost effective components of their management and is the only measure that will reduce the rate of decline in lung function. The Public Health team at LBRuT have commissioned smoking cessation services. Smoking cessation support is available through community pharmacies, GPs, the 28

29 dedicated stop smoking service Kick It and outreach clinics (including at Kingston Hospital). The Kick It contact number is , and the latest information can be found at: Smoking cessation referrals for GP practices can be monitored through QOF. The 4- week smoking quitter indicator provides information on service performance. Smoking002: The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder, or other psychoses whose notes record smoking status in the preceding 12 months. Achieved 94.2% for 2013/14 Smoking005: The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder, or other psychoses who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 12 months. Achieved 97.4% for 2013/14 NHSCP 07: Number of self-reported 4 week smoking quitters. Achieved 261 quitters (target 625) in 2014/15 The primary reason for the below-target performance is a substantial drop in GP and pharmacy stop smoking activity. This has also been seen within other local authorities. This is a complex, long-term issue and unlikely to be resolved with the current service model. Likely reasons include the increasingly popularity of e-cigarettes, declining prevalence (i.e. smaller numbers of people going through service) and a reduced profile of smoking cessation in primary care (i.e. no longer a major national target for NHS). Discussions about revision to the future service model have taken place and options to vary the contract are currently under consideration. 29

30 Physical Activity The DH Outcomes Strategy highlights a study showing that regular moderate physical activity is associated with a 30-50% reduction in risk of both hospital admission and respiratory mortality and with improvements in quality of life measures in COPD patients. 26 The same study demonstrated a median survival difference of seven years between those who take very low levels of physical activity compared with those taking moderate or high levels. Patients receiving pulmonary rehabilitation are currently referred onto the Exercise Referral Scheme. People with mild COPD are generally not sufficiently disabled by their condition to warrant participation in pulmonary rehabilitation. However, people with mild COPD should receive the same physical activity messages from healthcare professionals as the general population at least 30 minutes of moderate intensity physical activity, five times a week is good for your physical and mental health. This message may need to be tailored to overcome negative expectations about physical activity, including getting out of breath. Positive messages need to underscore the importance of maintaining ability to carry out activities of daily living. The important message is about volume (150 minutes per week, in chunks of 10 minutes or more). It would be beneficial to promote regular physical activity in all people with COPD and refer to appropriate physical activity services (e.g. Exercise Referral, Health Walks, and other opportunities in parks and fitness centres/groups) Pulmonary Rehabilitation NICE guidance recommends that all patients with an MRC dyspnoea score of 3 or above should be referred for pulmonary rehabilitation. However, Richmond recommends that all patients newly diagnosed with COPD should be referred to the RCT for assessment (whether they need pulmonary rehabilitation or not). The respiratory care nurses and physiotherapists then provide pulmonary rehabilitation to appropriate patients once they have been assessed. The majority of COPD patients will go on to have pulmonary rehabilitation once diagnosed. Exclusions usually include people with severe cognitive impairment or those who refuse. The RCT provides pulmonary rehabilitation to Richmond patients, comprising individualised exercise programmes and education. A pulmonary rehabilitation home 30

31 service for housebound patients is offered, as well as two out-patient classes held at Teddington Memorial Hospital & Richmond Rehabilitation Unit. In 2013/14, 128 patients commenced pulmonary rehabilitation, with 86 of which completed the 6 week programme. The RCT has a programme completion rate of 67%; this is above the NHS London average of 40%. All referrals should be made via the HRCH SPA (Appendix 6). Figure 5 contains key points to consider for pulmonary rehabilitation: Outline the commitment required for pulmonary rehabilitation and the consequent benefits to people with COPD Offer to all appropriate people with COPD, including those who have had a recent hospitalisation for an exacerbation and those who consider themselves functionally disabled by COPD (usually MRC grade 3 and above) Pulmonary rehabilitation is not suitable for people who cannot walk, have unstable angina or who have had a recent myocardial infarction 27 Tailor the programme to individual needs, and include physical training, disease education, and nutritional, psychological and behavioural intervention 28 Hold pulmonary rehabilitation sessions at a practical time in a conveniently located, accessible building to increase concordance Figure 5. Flowchart on providing pulmonary rehabilitation Source: Department of Health, An Outcomes Strategy for COPD and Asthma: NHS Companion Document, May

32 Further guidance from the British Thoracic Society on Pulmonary Rehabilitation in Adults is included in Appendix Immunisations All patients diagnosed with COPD should be offered the flu vaccine annually and the one off pneumococcal vaccination. All health care professionals managing COPD patients should encourage the uptake of appropriate immunisations. In 2013/14, 95.2% of people on the COPD register had the seasonal flu vaccine. Practice achievement varied from 66.7%-100% take-up Medicines Optimisation For local prescribing advice, based upon national guidelines and local Trust formularies, NHS Richmond CCG Medicines Optimisation Team developed a comprehensive COPD Briefing Sheet. The full document can be found in Appendix 8 and also on the NHS Richmond CCG Intranet: 0System/COPD%20Briefing%20Sheet%20October% pdf Patient Review All COPD patients should receive regular reviews in line with NICE guidance (see Table 6 below). People with mild or moderate COPD should be reviewed at least once a year and those with very severe COPD at least twice a year. People with stable severe COPD do not normally need regular hospital review, but there should be locally agreed mechanisms to allow rapid hospital assessment when necessary. Specialists should review people requiring interventions, such as long-term noninvasive ventilation, regularly. Additionally, the need for specialist and therapy services, such as psychological therapy should be included in reviews (see section Psychological Therapy). Any healthcare professional with experience of COPD can perform patient reviews and if patients are under the care of the RCT, they can perform the review alongside the FeV1 reading. 32

33 Table 6. Follow up of people with COPD in Primary Care Source: NICE Clinical Guideline 101: Management of chronic obstructive pulmonary disease in adults in primary and secondary care, 2010 COPD patient reviews formed part of 2013/14 QOF and were covered by: COPD003 - The percentage of patients with COPD who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using the Medical Research Council dyspnoea scale in the preceding 12 months (93.9% for 2013/14) COPD004 - The percentage of patients with COPD with a record of FEV1 in the preceding 12 months (88.1% for 2013/14) GPs and the Respiratory Care Team provide patient reviews, even for those with mild COPD. The Respiratory Care Team provides direct access for patients; patients can ring when they feel they need support Psychological Therapy Mental health problems are around three times more prevalent among people with COPD than in the general population, with anxiety disorders being particularly common 29. There is also evidence of increased service use in COPD patients with co-morbid mental health problems, such as more acute exacerbations and higher rates of hospitalisation. 30 However, there is evidence that supporting the psychological and mental health needs of people with long-term conditions more effectively can lead to reduced use of other services. For example, research has 33

34 found that referral to psychological therapy was associated with reduced emergency department attendance. 31 As part of patient reviews, GPs, respiratory care teams, and other health/social care professionals should assess and address co-morbid mental health problems by: 1. Screening all patients with COPD annually for common mental health problems by completing the Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder Assessment (GAD 7). Those scoring above 10 on either should be referred to the Richmond Wellbeing Service (with patient consent). 2. Providing all patients and their carers with an information leaflet, explaining anxiety, depression, stress, trauma and panic, the impact on physical health, and the option of self-referral to Richmond Wellbeing Service if they have concerns or difficulties for both the patient, their carers and family/friends. This should be provided at a minimum yearly. The Richmond Wellbeing Service can be accessed through self-referral, referral by GP or referral by any other health or social care professional. Richmond Wellbeing Service Richmond Royal Hospital Kew Foot Road Richmond upon Thames TW9 2TE Single Point of Referral Tel number: and Fax Patient Support Group The RCT supports a weekly patient group, Breathe for Life, for people with all kinds of respiratory conditions. People with conditions, such as chronic bronchitis, emphysema and COPD, may feel isolated and anxious, particularly after treatment or rehabilitation. The group encourages them to discuss and share their experiences and provides an opportunity to socialise. The group meets at Elleray Hall in Teddington, every Friday from 10:30-12:00 in the Activity Room and costs 50p per person. The participants of this group are provided with contact information for the RCT, and occasionally a member of the RCT joins the support group. 34

35 Self-Management and Shared Decision-Making It is important to ensure that people with COPD are offered support to self-manage their condition, and are provided access to integrated community care teams with access to specialist respiratory advice. Healthcare professionals and people with COPD should be partners in care, to self-manage their condition, and to exercise choice in the treatment they receive and where it is delivered. The benefits for all stakeholders could include: Provision of high quality health at home to enable people to feel supported at home Improved knowledge and awareness of disease management for those with long term limiting illness (LTLI). Decrease in unplanned admissions and disruption for people and their families. Improvement in longer term health and wellbeing for those with a LTLI Self-treatment at Home The RCT counsel all patients referred to them. They are given a COPD booklet in which clinicians can record all their latest clinical readings, instructions for emergency medication on suspicion of an exacerbation and contact numbers of who to call if in need of support. As recommended in the NICE clinical guideline for COPD, people at risk of exacerbations should be given a course of antibiotic and corticosteroid tablets to keep at home for use as part of a self-management strategy. 32 (See section Managing Exacerbations) Expert Patient Programme (EPP) The evidence base shows that the EPP can provide support to patients living with a long-term condition, with participants feeling more confident in managing their condition, making more effective use of healthcare resources, with fewer attendances at accident and emergency departments and hospital admissions, and feeling better prepared for consultations with professionals. 33 Access to the EPP was previously through referral to LiveWell Richmond (up to August 2015); however there was no record of attendance of COPD patients. There is a need for a clear and direct referral pathway for patient cohorts to the EPP. The 35

36 EPP is not currently running, but Richmond CCG is currently reviewing options for delivery of the EPP Telehealth Telehealth can play a key role in supporting independence through remote monitoring of vital signs and providing support through electronic devices. Evidence shows that in COPD, telehealthcare interventions can significantly reduce the risk of emergency department attendance and hospitalisation 34. Telecare services for people with heart disease and obstructive sleep apnea are being progressed in Richmond. COPD patients could also be a suitable client group for telehealth services to support them in monitoring their condition. It is important to note that telehealth would be offered as one component of a patient s management plan, and would not replace contact with healthcare professionals or home visits when needed. Leicester City CCG has implemented telehealth for patients with COPD, which flags up early warning signs to a nurse who can initiate prompt intervention. Patients were also supported with health coaching and education. Over 52 weeks, 183 hospital admissions were averted, saving 698,000 for Leicester City CCG 35. Richmond CCG considered developing a telehealth service for patients with COPD, however, there is currently not sufficient commissioning capacity or funding to progress at this stage (July 2015). The CCG may consider this further when additional resource and capacity becomes available Reducing Admissions Richmond Response and Rehabilitation Team (RRRT) The RRRT service is provided by HRCH, in partnership with Richmond upon Thames Council. The service offers individual health and social care packages of support to help people regain their independence and wellbeing, offering support for prevention of hospital admission, hospital discharge, or community rehabilitation. The service is available 7 days a week (further details in Appendix 9). Table 7 details NICE guidance on when to treat COPD patients at home or hospital. 36

37 Table 7. Factors to consider when deciding where to manage exacerbations Source: NICE Clinical Guideline 101: Management of chronic obstructive pulmonary disease in adults in primary and secondary care, 2010 All healthcare professionals are encouraged to refer any patients that are at risk of needing to be admitted hospital to the SPA. This will enable the SPA to provide the most appropriate care for the patient whether this is RRRT or other community services. The SPA also refers any patients needing continuing care onto the community respiratory service or other community service as appropriate. The RCT will provide weekday 9-5 rapid response services and the community matron service will attend the patient out of hours. Community Matrons are a nonspecialist service, but they link with the RCT and can access support with handling COPD patients, oxygen, and assessing whether a patient can be treated at home or should be admitted. They are also able to conduct joint home visits if needed. Often, they refer patients directly to the RCT. As part of the RRRT service, there is a need for short term urgent social care for COPD patients with little home support. Patients that live on their own are particularly vulnerable to being unable to cope at home in acute periods of COPD exacerbation and disease progression. Access to social care for patients previously unknown to social care or with an urgent need may increase the patient s ability to cope at home and prevent an admission. All referrals should be made via the HRCH SPA (see Appendix 9 for details). 37

38 Main service base: Elsie Foley Suite Teddington Memorial Hospital Hampton Road Teddington Middlesex TW11 0JL Monday to Friday: 8am-6pm Saturday, Sunday and Public Holidays: 8am-4pm Tel: Secure Managing exacerbations It is recommended that all COPD patients receive a prescription for emergency exacerbation medication as soon as they are diagnosed with COPD and being at risk of exacerbations. There is good evidence that prompt therapy in exacerbations results in less lung damage, faster recovery and fewer admissions (and subsequent readmissions) to hospital The impact of exacerbations should be minimised by 37 : Giving self-management advice on responding promptly to the symptoms of an exacerbation. Adjust SABA therapy to control symptoms. Oral corticosteroids should be started as early as possible. Antibiotics should only be used when there is an increase in the volume and purulence of sputum, or if there are other signs of infection Actions 38 Patients should be educated in self-management (written self-management plans are available from the Respiratory Care Team) to enable them to recognise worsening symptoms and to respond promptly by: o Starting oral corticosteroid therapy (unless contraindicated) if increased breathlessness interferes with activities of daily living o Starting antibiotic therapy if their sputum is purulent 38

39 o Adjusting bronchodilator therapy to control symptoms Give people at risk of exacerbations a course of antibiotic (amoxicillin: 500mg TDS for 5 days or doxycycline: 200mg stat and then 100mg OD for 4 days) and corticosteroid tablets (prednisolone 30mg OD for 7-14 days) to keep at home. Monitor the use of these drugs and advise people to contact a healthcare professional if their symptoms do not improve. Patients admitted to hospital with an exacerbation of COPD should be reviewed within 2 weeks of discharge (in primary or secondary care depending on local arrangements) Oxygen Therapy Oxygen provision for COPD patients is for more advanced cases and should be managed by the RCT. Patients who require oxygen therapy, but are not currently registered with the RCT, should be referred to the team immediately. Long-term oxygen therapy can improve survival rates by around 40%. 39 Possible indications for Long Term Oxygen Therapy are: very severe airflow obstruction (FEV1 less than 30% predicted) cyanosis polycythaemia peripheral oedema a raised jugular venous pressure oxygen saturations less than or equal to 92% breathing air. The RCT are able to prescribe home oxygen for certain patient groups: COPD Pulmonary Fibrosis Respiratory Palliative patients Cluster headaches Exclusion criteria: Patients with non NHS Richmond GP, Children 0-17 years, and Patients without long term respiratory condition or ventilator failure. 39

40 See Appendix 10 for HRCH Respiratory Home Oxygen Service Guidance The RCT are able to do the following: Assess the individual by measuring arterial blood gases on two occasions at least 3 weeks apart in people with confirmed, stable COPD who are receiving optimum medical management. Offer long-term oxygen therapy (LTOT) to people with PaO2 less than 7.3 kpa when stable or greater than 7.3 and less than 8 kpa when stable and secondary polycythaemia or peripheral oedema or nocturnal hypoxaemia or pulmonary hypertension. All healthcare settings should have a pulse oximeter to ensure all people needing long term oxygen treatment are identified. All referrals should be made via the HRCH SPA (Appendix 6) Supportive Discharge Collaborative working between the RCT and acute trusts for supportive discharge, aims to reduce the duration of stay of each spell for acute exacerbations of COPD. Liaising with secondary care clinicians and providing support in the patient s home or appropriate care setting, helps to ensure patients can be treated closer to home. If patients are admitted to hospital, the RCT have asked for patients to contact them. Following discharge, the patient will be reviewed, similar to an annual review, and are often put in Intermediate Care Community Intravenous (IV) Therapy Service A Community IV therapy service aims to reduce the need for admission into hospital and facilitate hospital discharge for patients requiring IV antibiotics, previously only able to be treated in hospital. After discussions with Richmond CCG Medicine Optimisation, Kingston Hospital (KH) and West Middlesex University Hospital (WMUH) microbiologists, and clinicians, it has been agreed that a community IV therapy service will not be going ahead at this stage. However, both KH and WMUH have an IV Outpatient clinic, which HRCH can pick up referrals from, thus removing issues of initiation of prescribing. 40

41 Enhanced Service for Avoiding Unplanned Admissions The NHS England Avoiding Unplanned Admissions DES began in September 2014 to identify and manage 2% of each GP population who is at risk of hospital admissions 40. A GP Led Model of Care Locally Commissioned Service (LCS) was developed across Richmond, which supports the Admissions Avoidance DES and builds on the 2% requirement of the DES by identifying a total of 3% (4,800 patients). The DES/LCS has significant potential to identify and manage COPD patients who are at high risk for admission and is designed to help reduce avoidable unplanned admissions by improving services for vulnerable patients and those with complex physical or mental health needs. Practices identify patients who are at high risk of hospital admission or readmission and manage them appropriately with the aid of risk stratification tools, a case management register, and personalised care plans. To support the delivery of the DES/LCS, the CCG will be developing a Patient Tracking List for the 3% at risk population to track them for non-elective activity 41. The CCG can monitor the non-elective admissions by practice to identify areas of concern and highlight good clinical practice (e.g. practices with low non-elective admissions due to a combination of internal processes etc.). Practice(s) with high levels of non-elective activity will be offered learning opportunities through clinical networks where other practices will be encouraged to share their experience of successfully reducing the A&E attendances and emergency admissions. Also a yearly/point in time comparison can allow the CCG to plan for known trends of surge in demand. 41

42 7 End of Life Care 7.1. Trajectory of COPD In COPD, end stage illness is complex and it can be difficult to predict when a patient is moving into the last phase of life due to the relatively long period of time people often suffer from moderate to severe COPD, with dips and declines before they reach the end stage of the disease (see Figure 6). This trajectory is very different to the trajectory for other diseases, such as cancer. Figure 6. Trajectory of COPD Source: NHS Improvement-Lung: National Improvements Projects, Improving end of life care in chronic obstructive pulmonary disease (COPD): testing the case for change, End of Life Care Pathway The end of life care pathway that features in the Department of Health End of Life Strategy (2008) contains all the components of a gold standard approach to care and is the model against which NHS organisations should aim to plan their services. Figure 7 shows how this pathway could be adapted for COPD specific patients. 42

43 Figure 7. End of Life Care Pathway for COPD specific patients Source: NHS Improvement-Lung: National Improvements Projects, Improving end of life care in chronic obstructive pulmonary disease (COPD): testing the case for change, 2011 Because of the chronic nature of COPD, the terminal phase is often not detected by clinicians until death is imminent. As a result, people who are dying, and their carers, frequently do not receive appropriate care 42. A localised adaptation of the NHS Improvement End of Life Care pathway for COPD specific patients (Figure 7) should be considered for development, reflecting local provision. This would ensure people identified with end of life care needs are referred for appropriate treatment and support End of Life Care in Richmond Place of death A previous local survey showed that the majority of people prefer to die at home. By reducing the number of emergency admissions and length of stay through out-ofhospital care, the quality of patient and carer lives can be improved, and the likelihood of patients dying in their preferred place of care can be increased. 43

44 The Richmond End of Life Care target is to increase the proportion of people who die in their usual place of residence from 39% in to 44% in , for all causes of death 43. After implementation of the End of Life Care Strategy in 2008, the percentage of deaths in hospital due to COPD decreased and the percentage of deaths at home or in a care home increased in These percentages fluctuate annually, but overall, hospitals are the main setting where COPD deaths occur. Table 8 shows that in Richmond, there has been an increase in the percent of deaths at hospital due to COPD; from 67% to 73% from 2007 to The percent of deaths at hospices is consistently low. Compared to other long-term conditions, respiratory diseases have the largest proportion of hospital deaths and the smallest proportion of home deaths 44. Place of death by underlying cause of death for Richmond residents, Total No. of deaths due to COPD % of deaths at hospital % of deaths at home or care home % of deaths at hospice % of deaths elsewhere Source: Richmond Public Health Intelligence analysis using primary care mortality data, 2014 A research report shows that while the popularity of residential and hospital care remain consistent (and low) over time, it is clear that fewer people want to be at home the closer they are to death, and more people want to be in a hospice 45. Findings from the report show that more people want to die in a hospice the closer they get to death rising from 4% to 17% to 28% in the final year, months and days before death respectively. At the same time, fewer people want to die at home from 91% to 75% to 63% over the same period. However, this shift is most dramatic for those with experience of hospice care. These findings could suggest that peoples priorities change over the course of their end of life journey, or alternatively, that their understanding of where these might be best catered for changes. It is 44

45 important to consider end of life care as a journey, and people will want and need different services, delivered in different locations, depending on how their needs change over time. Hospices are able to provide personalised, person-centred holistic care, in a home like environment. The report findings suggest that people are not very familiar with dying in care homes or in hospices, and many people have particular assumptions regarding the care delivered in these locations. With better information regarding the pros and cons of hospices, hospitals, care homes, and home deaths, patients and their families can make an informed choice regarding the service setting which best delivers the type of care they want Supportive and Palliative Care Indicators Tool (SPICT ) SPICT is a guide describing clinical signs that can help primary care teams identify patients who are at risk of deteriorating and dying from one or more advanced conditions 1. It is unclear if the SPICT is currently being used by primary care teams, or if any other prognostic indicatory tool is being used. However, the tool can help identify patients that would benefit from earlier, holistic needs assessment, a review of care goals, and anticipatory care planning. See Appendix 11 for the SPICT tool. The tool can be downloaded from The CCG can support promotion and use of the screening tool, exploring mechanisms for GP practices to run the tool in their electronic patient record systems to provide lists of patients to be discussed at practice multi-disciplinary palliative care meetings Specialist Respiratory Care and Palliative Care Clinical Teams NICE highlights the importance of palliative care within the COPD clinical guideline and quality standard: NICE clinical guideline 101 recommends: 1 Advanced conditions include: Respiratory disease, cancer, dementia/frailty, neurological disease, heart/vascular disease, kidney disease or liver disease. 45

46 Patients with end-stage COPD and their family and carers should have access to the full range of services offered by multidisciplinary palliative care teams, including admissions to hospices. (recommendation ) NICE quality standard for COPD states: People with advanced COPD, and their carers, are identified and offered palliative care that addresses physical, social and emotional needs. (Statement 13) Patients with COPD identified as end of life patients should already be known to the community RCT, who will be able to support the management of these patients. For patients where further support is required, the specialist palliative care clinical team is a community service accessed through the single point of access for community services. The Palliative Care Team can be used for patients with the following: existing or potential difficulties with: symptoms, psychosocial needs, dying where the usual strategies have not worked high levels of distress Indicative markers for people who are likely to benefit from palliative care include but are not limited to: severe airflow obstruction (FEV1 <30% predicted) respiratory failure low BMI (less than 19) house bound (MRC dyspnea score 5) history of two or more admissions for exacerbations during the previous year need for non-invasive ventilation for an acute exacerbation eligibility for long-term home oxygen therapy The specialist palliative care team comprises: The Community Team: o o o CNS main contact, but access to whole MDT 24/7 telephone support 9-5 visiting 7 days a week 46

47 o o o o Planning new 8-8 overnight service Lymph oedema management Counselling Day Hospice / Outpatient service Social, rehabilitative and therapeutic models The In-patient unit: o o o Terminal Care / Symptom control / Respite / Palliative Rehabilitation Average length of stay days Complimentary Therapies The specialist palliative care clinical team provides access to Princess Alice Hospice Breathlessness Groups, which provides a four week outpatient course, offering holistic advice and support, including group discussions, exploration of fears, and strategies for coping with breathlessness. 47

48 8 Possible Cost Savings By ensuring evidence based practice, early identification, and management in the community, quality of care and outcomes can be improved, as well as cost savings. Long term cost savings through earlier diagnosis and appropriate treatment leading to better outcomes for patients and reduced hospital admissions and re-admissions Short term possible cost pressure due to increased cases of COPD requiring more resources and referrals e.g. to smoking cessation, referrals to community respiratory team, and pulmonary rehabilitation Long term earlier intervention with staying healthy services should improve patient outcomes and lead to cost savings Commissioners and providers will want to consider the cost-effectiveness of treatments. The London Respiratory Team produced a pyramid of interventions that shows the cost per quality adjusted life year (QALY) of the interventions people with COPD can receive (Figure 8). The treatments below triple therapy in the pyramid will provide more cost-effective interventions for many people, such as stop smoking support, one of the most important components of management. Prescribing of triple therapy will only be cost-effective if it is done according to the NICE evidence-based guidelines, which detail when and in which people it will be most effective 46. Figure 8. London Respiratory Team- COPD value pyramid Source: Department of Health, Outcomes Strategy for COPD and Asthma: NHS Companion Document, May

49 9 Pathway Indicators Table 9 below summarises all the indicators for the COPD patient pathway and can be used as a dashboard of COPD service performance. Table 9. COPD Indicators Indicator Baseline reading Progress Richmond CCG COPD Prevalence (QOF indicator COPD001) Benchmarking CCG to SHA and National Prevalence Benchmarking GP Practices against CCG average COPD 002: Diagnosis confirmed by post bronchodilator spirometry COPD003 Patient review in the last 12 months COPD004 Patients that have had an FEV1 recorded COPD005- Patients that have dyspnoea grade 3 at any time in the last 12 months, with a subsequent record of oxygen saturation value Smoking002: Patients with CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder, or other psychoses whose notes record smoking status Smoking005: Patients with CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder, or other psychoses who are recorded as current smokers who have a record of an offer of support and treatment NHSCP 07: Number of self-reported 4 week smoking quitters 0.9% (2008/09) 0.95% (2013/14) 0.9%, SHA (1.0%), National (1.5%) (2008/09) Range 0.3%-1.5% (2008/09) 0.95%, London (1.1%), England (1.8%) (2013/14) Range 0.3%-1.6% (2013/14) 92.5% (2008/09) 91.7% (2013/14) 93.9% (2009/10) 93.9% (2013/14) 84.1% (2008/9) 88.1% (2013/14) New QOF Indicator 2013/ % (2013/14) 94.5% (2011/12) 94.2% (2013/14) 94.7% (2011/12) 97.4% (2013/14) 646 quitters (2012/13) 261 quitters (target 625) (2014/15) Number of admissions for COPD total 175 spells (2011/12) 190 spells (2014/15) 3-year average for deaths due to COPD 37.8 ( ) 40.7 ( ) 49

50 (directly standardised rate- per 100,000) Percent of short stay admissions 40% less than 48 hours (2009/10) Percentage of COPD patients who die in hospital 30% 0 or 1 day (2014/15) 74% (2008) 73% (2013) 10 Conclusion COPD is an area where NHS Richmond CCG is performing well, but there are clear areas for improving quality, while simultaneously reducing cost. A greater emphasis on case finding work is needed to increase detection in the undiagnosed population in order to provide appropriate and timely care to improve symptom control, quality of life, and outcomes. There is a need to tackle health inequalities and address equalities issues with early diagnosis, appropriate management, and quality of services, focusing on high risk groups and areas of deprivation. The COPD pathway maps commissioned services, which helps improve health and social care professionals awareness of the services available to support patients in staying healthy and managing them in the community. Stopping smoking is one of the most important and cost effective components of management and is the only measure that will reduce the rate of decline in lung function. It is important to ensure that people with COPD are offered support to self-manage their condition, and are referred to integrated community care teams with access to specialist respiratory advice and services. COPD is one area identified to target to achieve a reduction in avoidable admissions; a proportion of short stay admissions could be managed in the community, with appropriate support. The RRRT service and the DES/LCS for avoidable admissions have significant potential for identifying and managing COPD patients who are at high risk for admission. By reducing the number of emergency admissions and length of stay through out-of-hospital care, the quality of patient and carer lives can be improved, and the likelihood of patients dying in their preferred place of care can be increased. Healthcare professionals and people with COPD should be partners in care in managing their condition, with a focus on promoting informed choice at the end of life based on the outcomes people want to achieve. 50

51 11 Recommendations Primary and Community Care Recommendation 1: Identify patients with COPD early through pro-active case finding Richmond has a lower than expected prevalence of COPD, and higher than expected COPD deaths among females in the most deprived quintile area. A further focus on case finding is needed, implementing initiatives to increase diagnosis and early identification, focusing on high risk groups and deprived areas, such as: CCG commission lung cancer/copd screening service in community pharmacies, can be reviewed for consideration by the Richmond Cancer Strategy Steering Group GP practices audit registers to identify missed opportunities for diagnosis and invite for COPD investigations (e.g. deprived areas with higher smoking prevalence) GP Practices download/run the GRASP-COPD tool on practice systems to support case finding, early detection, and management of COPD patients CCG to support practices with appropriate equipment and/or training at GP education event on spirometry for confirming diagnosis Kick It to provide training on COPD signs, symptoms, and high risk groups to stop smoking practitioners, as part of contractual training element. Practitioners can then advise people on recognising and responding to the symptoms of COPD, and support referral to their GP for further investigations. Recommendation 2: Ensure all newly diagnosed COPD patients have access to community respiratory care, through referral to HRCH Respiratory Care Team GP referrals to the Respiratory Care Team reduced after the end of the 2010 LES, suggesting that all newly diagnosed COPD patients are not being referred. Integrated community care teams, with access to specialist respiratory advice, is key to helping people with COPD manage their condition in the community and prevent hospital admissions. Awareness about the HRCH RCT can be included in GP education events. 51

52 Recommendation 3: Health care professionals support self-management, refer to appropriate services, and develop self-management plans Recommendation 3a: Promote regular physical activity in all people with COPD and refer to appropriate services Regular moderate physical activity is associated with a reduced risk of hospital admission and respiratory mortality, and with improvements in quality of life measures in COPD patients. GPs, respiratory care team, and other health care professionals should provide tailored physical activity messages for all people with COPD and refer to appropriate physical activity services. Recommendation 3b: Refer to Psychological Therapies As part of patient reviews, GPs, respiratory care team, and other health professionals should screen all patients with COPD annually for common mental health problems by completing the Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder Assessment (GAD 7). Those scoring above 10 on either should be referred to the Richmond Wellbeing Service (with consent). Recommendation 3c: Refer to Expert Patient Programme (EPP) GPs, respiratory care team, and other health care professionals should refer all COPD patients to the EPP to help provide people with the knowledge and skills to manage their condition better on a day-to-day basis. The EPP is not currently running, but Richmond CCG is currently evaluating possible options for delivery. Recommendation 3d: Promote AirTEXT service for information on air quality GP Practices, pharmacists, and respiratory care teams should promote the free airtext service to patients suffering from respiratory conditions. The service provides information on the air quality index and helps people prepare, and if necessary take action to reduce harmful effects. Recommendation 4: Ensure changes/updates to provider contracts (completed actions) Recommendation 4a: Incorporate recent evidence based guidance within provider contracts (completed) NICE quality standard for COPD (QS10) was published in 2011, and covers assessment, diagnosis and clinical management of COPD and should be 52

53 incorporated into provider contracts to ensure high quality care. Achieving highquality care set out in the quality standard will improve the effectiveness, safety, and experience of care for COPD patients, as well as reduce complications associated with COPD. CCG to include during HRCH service specification reviews. Recommendation 4b: Monitor equalities data in provider contracts (completed) There are currently gaps in equality data for commissioned services. Contracts do not currently include a requirement to obtain and monitor equality data. It is recommended to include a requirement in contracts for service providers to monitor and routinely report on equality data for protected groups. CCG to include during HRCH service specification reviews. Community Based Specialist Care and Acute Care Recommendation 5: Provide support for successful outcomes of the NHS England DES and GP LCS for avoidable admissions, through monitoring nonelective admissions by practice The NHS England DES and GP LCS for avoidable admissions have significant potential to identify and case manage patients with COPD that are at high risk for admission or re-admission. Additionally, increasing referrals to RRRT has the potential in helping to reduce emergency admissions among COPD patients. The GP LCS service specification (2015/16), mentions that the CCG can monitor non-elective admissions by practice, identifying areas of concerns and highlighting good clinical practice. Practice(s) with high levels of non-elective activity will be offered learning opportunities through clinical networks where other practices will be encouraged to share their experience of successfully reducing the A&E attendances and emergency admissions. Recommendation 6: Develop a local respiratory care group to improve coordinated care The National COPD Audit Programme Report (2014), states that a greater emphasis is needed for improving processes for managing COPD around discharge and beyond. Acute and community providers, primary care, patient groups and commissioners should work collaboratively via a local respiratory programme group to improve coordinated care and formalise COPD care pathways. It is recommended 53

54 that the JCC take an active role in leading this process, in helping to develop interface services and advise, and form such a group if they do not exist at present. End of Life Care Recommendation 7: Assess people with COPD for end of life care needs and refer for appropriate treatment and support Recommendation 7a: Identify people at risk of deteriorating health and dying, using the Supportive and Palliative Care Indicators Tool (SPICT ) Health and social care professional should use the SPICT to identify patients who are at risk of deteriorating and dying from one or more advanced conditions. The CCG can support promotion and use of the tool, exploring mechanisms for practices to run the screening tool in electronic patient record systems to provide lists of patients to be discussed at practice meetings. Recommendation 7b: Adapt end of life care pathway for COPD specific patients (NHS Improvement), reflecting local provision for COPD patients A localised adaptation of the NHS Improvement End of Life Care pathway for COPD specific patients (Figure 7, page 43) should be considered for development by the JCC, reflecting local provision. This would ensure people identified with COPD end of life care needs are referred for appropriate treatment and support. Recommendation 7c: A focus on personalisation and choice at the end of life, including improved information regarding different service options and the types of support available Fewer people want to be at home the closer they are to death and more people want to be in a hospice. As people s priorities and needs change over time, hospices should be an option for health and social care professionals to discuss with people over the course of their end of life journey. With better and earlier information regarding the pros and cons of hospices, hospitals, care homes, and home deaths, patients and their families can make an informed choice regarding the service setting which best delivers the type of care they want. To support this, Local authorities duty to provide information regarding care services (as laid out in the Care Bill 2013) should include the full array of end of life care options in the same way as they would about any other aspect of adult social care- 54

55 that is, with a focus on promoting informed choice based on the outcomes people want to achieve. 12 References 1 Department of Health, An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England, July Public Health England, Local Tobacco Control Profiles for England, November LBRuT Public Health, JSNA Newsflash: Segmenting Life Expectancy Gaps, January London Borough of Richmond upon Thames and NHS Richmond CCG, Better Care Fund planning template Part 1, July Department of Health, An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England, July NHS Medical Directorate, COPD Commissioning Toolkit, August London Borough of Richmond upon Thames and NHS Richmond CCG, Better Care Fund planning template Part 1, September London Borough of Richmond upon Thames Public Health Intelligence Team, QOF Quality and Productivity (QP) indicator points for 2012/13 Emergency admissions, October London Borough of Richmond upon Thames and NHS Richmond CCG, Better Care Fund planning template Part 1, September Department of Health, An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England, July NICE COPD Quality Standards (QS10), July Department of Health, An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England, July ERPHO, East of England Public Health Observatory, Modelled estimate of prevalence of COPD in England, December 2011 version Public Health England, Public Health Outcomes Framework, Health and Social Care Information Centre, QOF, 2013/14. 55

56 16 Department of Health, An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England, July Department of Health, An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England, July Department of Health, Outcomes Strategy for COPD and Asthma: NHS Companion Document, May Public Health England, Local Tobacco Control Profiles for England, November LBRuT Public Health, JSNA Newsflash: Segmenting Life Expectancy Gaps, January National COPD Audit Programme, COPD: Who cares? National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme: Resources and organisation of care in acute NHS units in England and Wales 2014, November Department of Health, An Outcomes Strategy for COPD and Asthma: NHS Companion Document, May Jones, Rupert C M et al. Opportunities to diagnose chronic obstructive pulmonary disease in routine care in the UK: a retrospective study of a clinical cohort. The Lancet Respiratory Medicine, Volume 2, Issue 4, NHS North West Surrey CCG, Public Annual General Meeting (presentation), 1 July The University of Nottingham, PRIMIS, and NHS Improving Quality, 26 Garcia-Aymerich J, Lange P, Benet M et al. Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax 2006; 61: National Institute for Health and Clinical Excellence (NICE), Quality standards for COPD, National Institute for Health and Clinical Excellence (NICE), Quality standards for COPD,

57 29 National Institute for Health and Clinical Excellence (NICE), Depression in adults with a chronic physical health problem: Treatment and management (CG 91), October The King s Fund, Long-term conditions and mental health, February de Lusignan S., Chan T., Parry G., Dent-Brown K., Kendrick T. Referral to a new psychological therapy service is associated with reduced utilisation of healthcare and sickness absence by people with common mental health problems: a before and after comparison. J. Epidemiol. Community Health. 2012;66: National Institute for Health and Clinical Excellence (NICE), Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care, Department of Health, An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England, July McLean S, Nurmatov U, Liu JLY, Pagliari C, Car J, Sheikh A. Telehealthcare for chronic obstructive pulmonary disease: Cochrane Review and meta-analysis. The British journal of general practice: the journal of the Royal College of General Practitioners. 2012;62:e Spirit Healthcare, March Department of Health, An Outcomes Strategy for COPD and Asthma: NHS Companion Document, May NHS Richmond CCG, Medicines Management Team, COPD Briefing, September NHS Richmond CCG, Medicines Management Team, COPD Briefing, September Department of Health, Outcomes Strategy for COPD and Asthma: NHS Companion Document, May July NHS England, Avoiding Unplanned Admissions Enhanced Service: Proactive case finding and care review for vulnerable people, March NHR Richmond CCG, GP led model of care service specification, August March Department of Health, An Outcomes Strategy for COPD and Asthma: NHS Companion Document, May

58 43 London Borough of Richmond upon Thames and NHS Richmond CCG, Better Care Fund planning template Part 1, July London Borough of Richmond upon Thames, JSNA newsflash: End of Life Care CCG profile, July Sue Ryder, A time and a place: what people want at the end of life, July Department of Health, Outcomes Strategy for COPD and Asthma: NHS Companion Document, May

59 13 Appendices Appendix COPD Clinical Working Group Recommendations The COPD Clinical Working Group made the following recommendations for commissioning and implementation across NHS Richmond: All health care professionals should actively look to identify currently undiagnosed COPD patients and refer to GP for COPD investigations. All patients diagnosed with COPD should be referred for smoking cessation advice Ensure all patients diagnosed with COPD are offered the seasonal flu vaccine and the one off pneumococcal vaccination Clinicians should only prescribe from NHS Richmond formularies when prescribing for COPD patients to ensure all medication is the most cost effective available. All newly diagnosed COPD patients be referred to HRCH Respiratory Care Team All patients diagnosed with COPD should be referred for Pulmonary Rehabilitation Review people with mild or moderate COPD at least once a year. Clinicians are encouraged to screen for depression using validated tools (e.g. Patient Health Questionnaire (PHQ-9) in people who are hypoxic, are severely breathless or have recently been seen or treated at a hospital for an exacerbation. Any patients found to have depression should be referred for psychiatric support. Improved access to psychiatric care from primary care referral. All COPD patients should receive relevant patient information and counselling from the Respiratory Care Team when diagnosed with COPD. All healthcare professionals are encouraged to refer any patients that are at risk of needing to be admitted to the single point of access for the Rapid Response Service All community matrons providing out of hours care to COPD patients via the Rapid Response service should have experience of working with COPD patients by training with secondary care and HRCH Respiratory Care Team All COPD patients receive a prescription for emergency exacerbation medication as soon as they are diagnosed with COPD and as being at risk of exacerbations. All COPD healthcare settings should have a pulse oximeter to ensure all people needing LTOT are identified. Audit of oxygen treatment to ensure use is appropriate and charged at correct tariffs. NHS Richmond is implementing a locality wide electronic register to deliver high quality end of life care including patients with COPD. The register is called Coordinate My Care and all COPD patients identified as EOLC patients should be registered. Access to consultant advice in the community for clinicians should be available. GP would be able to receive advice from COPD specialist in secondary care to support them to make decisions about their patients and increase cross sector working and communication. Access to social care for COPD patients that may benefit from home support to help prevent admission to hospital where patients may not have been assessed or are known to be not entitled to social care support. 59

60 Appendix 2. NICE Clinical Guideline 101: Key Priorities for Implementation Diagnose COPD A diagnosis of COPD should be considered in patients over the age of 35 who have a risk factor (generally smoking) and who present with exertional breathlessness, chronic cough, regular sputum production, frequent winter 'bronchitis' or wheeze. [2004] The presence of airflow obstruction should be confirmed by performing postbronchodilator* spirometry. All health professionals involved in the care of people with COPD should have access to spirometry and be competent in the interpretation of the results. [2004] [*added 2010] Stop smoking Encouraging patients with COPD to stop smoking is one of the most important components of their management. All COPD patients still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity. [2004] Promote effective inhaled therapy In people with stable COPD who remain breathless or have exacerbations despite use of short-acting bronchodilators as required, offer the following as maintenance therapy: o if FEV 1 50% predicted: either long-acting beta 2 agonist (LABA) or long-acting muscarinic antagonist (LAMA) o if FEV 1 < 50% predicted: either LABA with an inhaled corticosteroid (ICS) in a combination inhaler, or LAMA. [new 2010] Offer LAMA in addition to LABA+ICS to people with COPD who remain breathless or have exacerbations despite taking LABA+ICS, irrespective of their FEV 1. [new 2010] Provide pulmonary rehabilitation for all who need it Pulmonary rehabilitation should be made available to all appropriate people with COPD including those who have had a recent hospitalisation for an acute exacerbation. [new 2010] Use non-invasive ventilation Non-invasive ventilation (NIV) should be used as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations not responding to medical therapy. It should be delivered by staff trained in its application, experienced in its use and aware of its limitations. When patients are started on NIV, there should be a clear plan covering what to do in the event of deterioration and ceilings of therapy should be agreed. [2004] Manage exacerbations The frequency of exacerbations should be reduced by appropriate use of inhaled corticosteroids and bronchodilators, and vaccinations. [2004] The impact of exacerbations should be minimised by: o giving self-management advice on responding promptly to the symptoms of an exacerbation o starting appropriate treatment with oral steroids and/or antibiotics o use of non-invasive ventilation when indicated o use of hospital-at-home or assisted-discharge schemes. [2004] Ensure multidisciplinary working COPD care should be delivered by a multidisciplinary team. [2004] 60

61 Appendix 3. COPD prevalence by GP Practice 13/14 Practice Code Practice Name List Size Register Count Prevalence (per cent) H84639 DR M FITZMAURICE 3, H84041 THE VINEYARD SURGERY 3, H84630 SINHA V 2, H84633 QUEENS MEDICAL CENTRE 3, H84014 DR C LEE 2, H84002 PARK ROAD SURGERY 12, H84039 CROSS DEEP SURGERY 9, H84032 HAMPTON WICK SURGERY 9, H84055 DR I A JOHNSON & PARTNERS 10, H84023 DR R FLOOD & PARTNERS 8, H84007 THE ACORN PRACTICE 8, Y01206 DR BOTTING & PARTNERS 9, H84048 TWICKENHAM PARK SURGERY 6, H84017 SEYMOUR HOUSE SURGERY 13, H84005 DR FM BATES & PARTNERS 7, H84060 SMITH C J & PARTNERS 7, H84059 DR A CHILDS & PARTNERS 3, H84012 THOMAS & PARTNERS 11, H84625 DR A P KUDRA & PARTNER 4, H84057 DR A SARAJLIC 2, H84043 CROWLEY & PARTNERS 6, H84044 STENT & PARTNERS 8, H84623 HAMPTON HILL MEDICAL CENTRE 8, H84632 DR A PALACCI & PARTNERS 3, H84018 DR P BHATIA 4, H84040 DR G LEWIS AND PARTNERS 12, H84615 DEANHILL SURGERY 2, H84031 JUBILEE AVENUE SURGERY 5, H84006 JEZIERSKI & PARTNERS 8, H84608 DR A SAYER 2, Y56 Richmond CCG 206,503 1, LONDON COMMISSIONING REGION 9,069, , ENGLAND TOTAL 56,324,887 1,004, Source: NHS Information Centre, QOF 2013/14 61

62 Appendix 4. Smoking Prevalence by GP Practice, 2013/14 62

63 Appendix 5. HRCH Respiratory Care Team (Richmond) The Respiratory Care Team (RCT) provides specialist assessment and case management for patients with long-term respiratory problems. Patients can be referred to the service via their GP or other healthcare professional. Referred patients receive a respiratory specialist assessment, which may result in changes to treatment to optimise their condition. Pulmonary Rehabilitation is run by the Respiratory Care Team at Teddington Memorial Hospital and Richmond Rehabilitation Unit. This is an exercise programme especially for patients with breathing problems to increase functional levels and manage breathlessness. The programme runs for six weeks and consists of exercise, education and relaxation sessions. The Respiratory Care Team also oversees home oxygen delivery within Richmond for respiratory patients and is able to assess and monitor patients on home oxygen via pulse oximetry or blood gases. The team comprises of: Respiratory Physiotherapists Respiratory Nurse Therapy Assistant Team contact details: Tel: The team visits patients in their homes. They also offer telephone advice. Opening times: Monday to Friday: 8.30am 5.30pm All referrals to the team should be made using the HRCH referral form through the Trust's Single Point of Access service. Referral criteria This service is for patients: who are aged 18 and over who are registered with a GP within the NHS Richmond CCG area who have a diagnosed respiratory long-term condition including COPD, Pulmonary Fibrosis and Bronchiectasis Exclusion criteria Breathless patients without confirmed appropriate respiratory diagnosis Asthma Non-respiratory home oxygen assessment and review 63

64 Appendix 6. HRCH Single Point of Access (Richmond) The SPA is the single point of access for all adult referrals with Richmond GPs to the following community-based services: Intermediate Care Team Community Physiotherapy District Nurses including specialist services Community matrons Community Neuro-rehabilitation Team Falls Service Respiratory Care Team Richmond Response and Rehabilitation Team The team triage all referrals and ensure that they are directed to the appropriate service. This service is for GPs and other referrers only. Referral Form: Contact: Address: Single Point of Access Team 3 rd Floor Heart of Hounslow 92 Bath Road Hounslow TW3 3EL hounslowandrichmond.spa@nhs.net Telephone: Fax: Out of hours calls divert to Careline. Opening times: Monday to Friday, 7am - 7pm. Switches to Careline outside of these hours. 64

65 Appendix 7. British Thoracic Society Guideline on Pulmonary Rehabilitation in Adults The British Thoracic Society recommends the following when assessing and referring patients for pulmonary rehabilitation 2 : Healthcare professionals referring patients to this service should be presented as fundamental treatment for COPD, rather than an option. Assess the patient s understanding of pulmonary rehabilitation, address any concerns and educate them about the benefits of participating in pulmonary rehabilitation. Patients with COPD should be referred for pulmonary rehabilitation, regardless of their current smoking status; however, their smoking status should be assessed and patients should be referred to smoking cessation services. Patients with COPD should be referred for pulmonary rehabilitation, regardless of the fact that they may have chronic respiratory failure or coexistent stable cardiovascular disease. This recommendation however, is not in accordance with NICE recommendations for the criterion for participating in pulmonary rehabilitation. For patients with COPD and abdominal aortic aneurysm (AAA) larger than 5.5 cm, but are not found fit for surgery, can still partake in pulmonary rehabilitation incorporating mild to moderate exercise, but not resistance training. 2 British Thoracic Society (BTS) (2013) BTS Guideline on Pulmonary Rehabilitation in Adults. BTS 65

66 Appendix 8. Medicines Optimisation: COPD Briefing Sheet 66

67 Appendix 8. Medicines Optimisation: COPD Briefing Sheet (continued) 67

68 Appendix 8. Medicines Optimisation: COPD Briefing Sheet (continued) 68

69 Appendix 8. Medicines Optimisation: COPD Briefing Sheet (continued) 69

70 Appendix 8. Medicines Optimisation: COPD Briefing Sheet (continued) 70

71 Appendix 9. Richmond Response and Rehabilitation Team The Richmond Response and Rehabilitation Team (or 'RRRT') is an integrated health and social care service for adults, primarily older people, in partnership with HRCH and the London Borough of Richmond upon Thames Council. The service offers individual health and social care packages of support to help people regain their independence and wellbeing. Rehabilitation is based on working towards achieving goals and can be anything from a few days to a few weeks, up to a maximum of 6 weeks. The team can provide a range of short-term interventions including intensive therapy and practical support following a period of illness, disability or following hospital discharge. For people who have been admitted to hospital, the team will support a safe and timely discharge home or to a community setting. The team provides a rapid response to manage crisis and support people to stay at home, preventing unnecessary admission to an acute hospital or a residential/ nursing home. The team also supports early discharge services aimed at facilitating shorter periods of hospital stay including elective procedures/admissions. The team is multi-disciplinary and includes: Nurses Occupational Therapists Physiotherapists Social Workers Dietician Rehabilitation/Therapy Assistants All referrals to the team should be made using the HRCH referral template through the Trust's Single Point of Access service (SPA). For prevention of hospital admission Rapid Response: 2 hour response time Please make referral for 2 hour response by phone call to followed up by written referral sent via Single Point of Access (SPA). For same day response - referrals must be received 2 hours before close of office hours (4pm weekdays, 2pm weekends and public holidays). For hospital discharge and urgent community rehabilitation Urgent: within 48 hours triage Referrals will be triaged within 48 hours and a response assigned. For community rehabilitation Routine: within 48 hours triage Referrals will be triaged within 48 hours and a response assigned 71

72 Appendix 10. HRCH Respiratory Home Oxygen Service Guidance 2013 The service follows national guidance and has also adopted local practice to ensure clinically appropriate and cost effective prescribing. The outcomes of the Home Oxygen Service can in part be attributed to the service being commissioned as part of a comprehensive respiratory service, as opposed to a stand-alone respiratory service. HRCH Respiratory Care Team 1. The current RCT Lead has clinical experience from primary, secondary and tertiary care. Also actively involved with Home Oxygen Supplier, NHS London & DH in oxygen supplier issues to develop and disseminate excellent respiratory clinical practice. 2. RCT has broad range of ITU and primary care experience. 3. RCT works closely with secondary and tertiary respiratory clinicians. 4. RCT is commissioned as a whole respiratory service (as opposed to a home oxygen service) therefore has greater understanding and clinical relationships with NHS Richmond patients enhancing prescribing decisions in conjunction with other respiratory management practices, particularly Pulmonary Rehabilitation. HRCH Respiratory Home Oxygen Prescribing 1. All HRCH RCT Staff are registered specialist HOOF B prescribers. New team members are closely mentored during first 3 months to develop Home Oxygen Prescribing skills. 2. RCT staff have an understanding of both the clinical and cost implications of their home oxygen prescribing to ensure value within prescribing HRCH Respiratory Home Oxygen Prescribing Processes. These processes will be used with the majority of patients as appropriate to ensure appropriate prescribing with an awareness of the cost implications by RCT members. 1. Respiratory patients are assessed via national guidance using pulse oximetry and/or capillary blood gas analysis. Oxygen will not be prescribed to non-hypoxic patients who are breathless. 2. Home Oxygen prescribed to respiratory patients by other services e.g. GPs, secondary and tertiary care will be reviewed for appropriateness of prescribing and oxygen modalities. 72

73 3. Respiratory patient s medical management will be optimised prior to oxygen assessment, including inhaled medication regime, pulmonary rehabilitation and diagnostic confirmation in the minority of patients where this is unclear. 4. Respiratory patients are reviewed at 4, 12, 26 and 52 weeks, more frequently if the patient requests review or experiencing difficulty with titrating levels. This patient cohort is familiar to the RCT which increases opportunities for open dialogue from NHS and patient perspective. 5. Ambulatory oxygen patients are assessed with 6MWT assessment. Ambulatory provision is determined by the RCT on hours the patients are not at home. RCT calculate this by the hours per week the patient leaves the house and then divide this by 7 (days of week) to determine best fit with compliance. 6. Following liaison with HOS cluster groups and HOS contract manager 5-7 ambulatory cylinders will be prescribed per week to reduce costs associated with service visits, which are higher than those associated with rental of assets. 7. Housebound exertional desaturators will be supplied with a concentrator rather than cylinders. 8. Home oxygen diaries are issued to patients to review compliance and issues against prescribed oxygen. 9. Patients not using home oxygen and request removal will be educated in risks of hypoxia. The oxygen will then be removed but informed that it can be reinstated within 1 working day if they wish to revoke their removal decision. 10. Respiratory palliative patients do not receive full assessment and review, but will have oxygen saturations assessed as a guide for RCT and patient education re: hours prescribed. Palliative care patients will usually be prescribed a concentrator to reduce issues with re-ordering cylinders, particularly at end of life. HOME OXYGEN NATIONAL GUIDANCE Primary Care Commissioning Home Oxygen Service Assessment & Review Good Practice Guide, April British Thoracic Society - Clinical Component for the Home Oxygen Service in England & Wales, Updated version due 2013/14. e/clinical%20adultoxygenjan06.pdf 73

74 Appendix 11. Supportive and Palliative Care Indicators Tool (SPICT) Source: The University of Edinburgh and NHS Lothian. Supportive and Palliative Care Indicators Tool (SPICT). 74