managing copd as a long term condition: emerging learning from the national improvement projects

NHSNHS Improvement

Lung

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

Managing COPD as aLong Term Condition:Emerging Learning from theNational Improvement Projects

NHS Improvement - Lung

Patients and their carers are the reason the health service existsand therefore they should be at the heart of our services. Serviceredesign and improvement generate opportunities to involveservice users who will provide a different perspective on theservice, so that we can better understand whether our service orimprovements make any difference to the patient.

Only when we understand patients’ needs – by asking them, notsecond guessing – can we work in a way that meets those needsand ensures they get maximum benefit from our service.

Foreword 4

Executive summary 5

Improvement stories: Improving patients’ ability to self manage 8

Key messages 8

‘Think ABC To self manage your COPD’ – One practice’s approach to improve patients’management of exacerbations: Veor Surgery, Camborne, Cornwall 9

Embedding the use of effective self management approaches in primary care: NHS Blackpool 11

How can support groups increase patients’ ability to self manage? NHS Stoke on Trentand North Staffordshire Breathe Easy Group 14

The role of secondary care in increasing consistent use of self management plans to reduceoutpatient attendance and emergency admission: Southampton University Hospitals NHS Trust 16

Improvement stories: Management of COPD 18

Key messages 18

Systematic review of patients’ inhaler technique and medication use:Victoria Practice, Aldershot, Hampshire 19

How can respiratory specialists support primary care to improve management andreduce admissions? Imperial College Healthcare NHS Trust & Central LondonCommunity Healthcare NHS Trust 21

Earlier identification of COPD patients & preventing inappropriate admissions:Surrey Community Healthcare 23

Supporting people with moderate or severe COPD to self manage throughclinical and behavioural interventions: NHS West Sussex 25

Data 27

Why is data so important? 27

What have we learned about data from the project sites? 28

Improvement stories: Turning data into information for improvement 33

Key messages 33

Understanding variation in primary care management of COPD - Using practice data tomake the case for change: Leicestershire County & Rutland PCT in conjunction with OPC –Optimum Patient Care 34

Using information to target support to practices and patients, in order to reducevariation in diagnosis and management of COPD – NHS Sheffield 37

Top tips for COPD management projects 40

Top tips for service improvement 42

Contact details 44

Acknowledgements 45

Contents

Managing COPD as a Long Term Condition - EmergingLearning from the National Improvement Projects

3

Foreword4

Since July 2010, NHS Improvement –Lung has worked with a number ofclinical teams across England as part ofthe Department of Health RespiratoryProgramme. Its aim has been to supportthe development of patient centred,evidenced based and clinically led servicesby identifying and sharing innovativeways to reduce variation in care andimprove the quality and experience ofpatients with chronic obstructivepulmonary disease (COPD).

The national improvement projects havetested approaches at key stages of theclinical pathways which have included:

• Improving home oxygen services• Early accurate diagnosis• Transforming acute care• Managing COPD as a long termcondition

• Improving end of life care

Following the first six months of theimprovement programme, thispublication signals the mid-way point inthe project cycle and has been written toshare the learning from the testing phaseof the work. Through a series of casestudies and examples, it aims to highlightareas of innovative and emerging goodpractice that can be used locally to deliverimprovements for COPD patients andtheir carers.

In order to address the paucity of currentevidence, particularly around the modelsand principles of implementation, theprogramme will continue to adapt andrefine the learning. However, theselessons will be of value now to any teamworking to improve the care it deliversand commissions for people with COPD.The publication contains a number ofexamples that demonstrate value formoney, increased productivity andapproaches that can sustainimprovements over the long term.

Foreword

Professor Sue Hill

Dr Robert Winter

This publication contains information forhealthcare professionals and thoseworking in commissioning or interfacingwith COPD services. This includes thosewho are:

• Involved in the care of patients whorequire COPD services

• Responsible for commissioning COPDservices

• Managing COPD services• Local or regional leads

The project sites were encouraged toemploy a range of service improvementtools and techniques. These includedprocess mapping, demand and capacityand data analysis, the application of Leanprinciples, process redesign and thehuman dimensions of change. NHSImprovement - Lung also supported thetesting of new ideas and pathwaysthrough site visits and project team peersupport.

There are lots of practical examples withinthis report to support clinical teams indelivering quality and productivitybenefits to patients and a wider range ofstakeholders. Over the next six months,NHS Improvement – Lung will continue totest the key principles for change andimplementation. As this learningemerges, it will be shared with COPDservices and the wider NHS.

We would like to take this opportunity tothank the project sites for their hardwork, dedication and commitment andlook forward to the full extent of theimprovement work as it comes to fruition.

Professor Sue HillDr Robert WinterJoint National Clinical Directorsfor the Respiratory Programme

5Executive summary

Chronic obstructive pulmonary disease(COPD) is a progressive disease and cannotbe cured. However it can be treated, andwith the right care the impact of the diseasecan be modified1,2,3. In particular, effectivemanagement of medications, regularreview, care planning and self managementcan help people cope with their disease andreduce the need for hospital admission.

The intention of NHS Improvement - Lung’sworkstream on Managing COPD as a LongTerm Condition is to demonstrate how selfmanagement, regular review and medicinesmanagement can best be delivered andhow they can affect outcomes and use ofhealthcare resources. This in turn canimprove patients’ experience, theprogression of their disease and their needfor hospital admission when their conditionflares up.

The recently published outcomes strategyfor people with chronic obstructivepulmonary disease (COPD) and asthma4

highlights the need to focus on high qualitycare and support, in particular the effectivemanagement of patients with COPD usingchronic disease management approaches.In this initial phase of the programme, theprojects have been exploring the reality ofmaking this happen – systematically takingstock of current practice and understandinghow to ensure that patients receive optimalcare, in a climate where there are limitedresources.

This interim publication summarises thework of the projects at the mid point oftheir duration, and highlights the earlylearning and emerging themes that willinform the next stage of work. This learningmay also be helpful for both primary andsecondary care in supporting theircommissioning plans, with its emphasis onpatient centred care and delivering thequality, innovation, productivity, prevention(QIPP) and safety agenda.

Executive summary

Summary of emerging learningThe early learning from the project sites todate demonstrates some of the practicalissues around implementing those elementsof supported self care and good chronicdisease management that we already knowto be effective. This highlights not onlywhat works and how people are doing it,but also what barriers still exist and wherewe still need to find solutions to enablepeople to adopt best practice.

Improving people’s ability to selfmanage: Implementing effective supportfor people to manage their condition moreeffectively requires time, excellentcommunication and motivationalinterviewing skills, as well as focused effort.Early indications are that a comprehensiveconsultation of at least 30 minutes – andprobably 45 to 60 minutes – is required toestablish rapport with the patient andidentify the issues that need to beaddressed in order to have greatest impact.This is a challenge for teams to implementwithin existing resources and ways of doingso need further exploration and testing. Italso appears that working closely with ateam and a group of patients appears tohave greater impact than a large scale rollout of a common approach, which can takelonger to become embedded in practice.Various self management plans have beendeveloped and are in use, and cleardocumentation of a self management planhelps ensure a consistent approach, but thereal key is professionals’ approach to theplanning that they do with the patient,rather than the plan documentation itself.

Management of COPD: Making time fora comprehensive consultation including selfmanagement support ensures that patients’regular reviews are of maximum value.Various templates are becoming available tosupport clinical checklists, but it is important

that issues of significance to the patient arealso explored, and this is highlighting theneed to consider how best to provideregular review for those patients with co-morbidities. It is essential that supportbetween reviews is also optimised, and earlyindications are that a systematic approachto provision of rescue medication andfollow up for exacerbations can reducedemand for GP urgent appointments orhome visits, as well as admissions for somepatients. Optimising medications use, alongwith systematic and opportunistic checks ofinhaler technique, and regular staff trainingin how to demonstrate it, can furtherimprove patient adherence and reducewaste, with cost savings of 10%demonstrated in one site.

Use data to make a difference: COPDexacerbations are not consistently coded ingeneral practice but addressing this allowsrapid identification of patients whosecondition is beginning to deteriorate and ofhow well exacerbations are being managed.A key indicator is the proportion ofexacerbations resulting in admission – goodmanagement means exacerbations arerecognised, but early intervention shouldmean fewer admissions and lower length ofstay. Significantly more information isavailable from primary care systems than iscaptured by practices’ Quality andOutcomes Framework (QOF) score and thiscan be used to highlight how well COPD isbeing managed across primary care, themarked level of variation that exists and theimpact that this has on secondary care useand prescribing. While providing the dataalone does not instigate change in practice,it does allow a much more comprehensivepicture of the current position to bedeveloped and intervention to be targetedto drive up quality and reduce waste.

Executive summary6

Summary of projectsVeor Surgery, Cornwall: Trialling asystematic approach to improving patients’recognition and management ofexacerbations using self managementaction plans and rescue medication.

NHS Blackpool: Developed acomprehensive self management plan withpatients and tested ways to embed use inprimary care.

NHS Stoke on Trent & NorthStaffordshire Breathe Easy Group:Exploring what impact patient supportgroups can have on people’s use of healthcare resources and their ability to selfmanage.

Southampton University HospitalsNHS Trust: The role of secondary care inimproving patient self management toreduce outpatient attendance, emergencyadmissions and readmissions.

Victoria Practice, Aldershot: Testing theimpact of a practice clinical pharmacist insystematically reviewing patient inhalertechnique and medication use to improveoutcomes and make best use of resources.

Imperial College Healthcare & CentralLondon Community Healthcare NHSTrusts: Exploring how respiratory specialistscan best support primary care to improvemanagement and reduce admissions.

Surrey Community Healthcare: Howteams can support earlier identification ofCOPD patients and prevent avoidableadmissions.

NHS West Sussex: Supporting people toself manage with clinical and behaviouralinterventions

Leicestershire County & Rutland PrimaryCare Trust with Optimum Primary Care:Understanding variation in primary caremanagement of COPD and using practicedata to make the case for change.

NHS Sheffield: Using information totarget support to practices and patients, inorder to reduce variation in the diagnosisand management of COPD.

Quality Innovation Productivity andPrevention (QIPP) and expectedoutcomesDemand for healthcare is increasing andthere are areas where we could increase thequality, efficiency and value for money ofservices as well as improving outcomes forpeople with COPD. Efforts need to beconcentrated on three components to makethis possible. First, improving quality whilstimproving productivity, using innovationand prevention to drive and connect them.Second, having local clinicians andmanagers working together acrossboundaries to spot the opportunities andmanage the change. Finally, to act now forthe long term.

The ambition is to achieve efficiency savingsof up to £20 billion for reinvestment overthe next four years. This represents a verysignificant challenge to be deliveredthrough the detailed work the NHS hasalready undertaken on QIPP and theadditional opportunities presented in Equityand Excellence: Liberating the NHS.

In relation to the QIPP challenge, the NHShas been developing proposals to improvethe quality and productivity of its servicessince the challenge was first articulated inMay 2009. The challenge is to ensure thatthe NHS continues to make quality happenduring a period in which growth inexpenditure on the NHS will be restricteddespite increased demand.

Many of the measures outlined in thisdocument are designed to support the NHSto meet the QIPP challenge, either byidentifying where resources might bereleased or by improving understanding ofthe key interventions that have greatesteffect.

Success for many of the Managing COPDprojects will be indicated by their impact onfrequency or severity of exacerbation, andthe proportion of exacerbations that resultin admission, as well as by patientsatisfaction measures.

Early examples of QIPP impact include:• A systematic approach to selfmanagement and early intervention forexacerbation is beginning to demonstratea reduction in the proportion ofexacerbations admitted, releasingcapacity in secondary care

• In secondary care or specialist teams,targeted intervention with those patientswho have repeated admissions is alsobeginning to demonstrate reduction inadmissions.

• Similarly systematic medicinesmanagement, inhaler techniqueeducation and medicines review isdelivering savings of 10% or around£1,000 per month on respiratory chapterprescribing for a practice

Further examples and more details arecontained in the improvement stories.

It is anticipated that these examples andinitial phases of work will demonstratewhich elements of supported self care andchronic disease management for COPD arekey components, and which approaches toimplementation are most effective.

7Executive summary

Potential for future workIt is known that patients who understandwhat to do in the event of an exacerbationare more confident to seek help earlier andcan avoid admissions, while regularmedication reviews and inhaler techniquechecks can help reduce waste in prescribing.It is also acknowledged that while it iscritical to have access to tools like plans,reviews and templates to help patientsmanage their condition, effectivemanagement needs to be underpinned by aset of skills, an approach and aninfrastructure that will allow delivery. Thesecomponents can be considered as:

• The resources that patients need• What professionals need to do• The infrastructure that needs to be inplace to facilitate to delivery

For patients to be effectively supported toself care and for professionals to deliverchronic disease management successfullyeach of these components needs to be inplace. The challenge now is to identify howbest to implement this consistently, reliablyand cost effectively. Further work is alsorequired to identify the essential elementsand most effective means to put these intopractice, including:

• Planning for early intervention in theevent of exacerbation

• Medicines management and good inhalertechnique

• Adequate time for regular review thatencompasses what is important to boththe clinician and the patient/carer andsupports self management

• Skills to deliver support, education andtreatment

As a result the workstream will now focuson demonstrating how to improvemanagement and self care for people withCOPD to reduce admissions, optimisemedicines use and enhance patientexperience by testing:

• The optimal time and components of aneffective review from both patient andclinician perspective

• Practical ways of implementing this anddelivering it within existing resources

• How to optimise medicines use and theimpact of doing so on cost, experienceand use of other health care resources

• The key components that need to be inplace for patients to be able to effectivelyself-manage and the benefits of doing so

This will allow the production of a modelthat demonstrates what needs to be inplace for care to be delivered effectively andhow to implement it, to ensure that everyminute of contact is used to maximumeffect, every time.

Catherine BlackabyNational Improvement Lead,NHS Improvement – Lung

Phil DuncanDirector, NHS Improvement - Lung

Catherine BlackabyNational Improvement Lead,NHS Improvement – Lung

Phil DuncanDirector,NHS Improvement -Lung

Person who is informed,willing and able to self care

What the person needse.g. written self management plan; regular review;

rescue medication; medicines; point of contact;knowledge; confidence; carer support

What we need to doe.g. inhaler technique checks; annual holistic review, patientled consultation, prescribing, listening, referral, identify risk,

support smoking cessation, planning for exacerbations

What needs to be in placee.g. motivational interviewing skills, 30 – 60 minute appointments,

data and information, access to specialist support, coding of patientsand exacerbations, accurate diagnosis; ongoing training

Components for effective delivery of supported selfcare and ongoing management

Key messages• Just giving patients a plan and telling

them what they should do probablywon’t change behaviour

• Effort, time and skills are needed tobuild rapport and focus on the person’sown goals and motivation so that theywant to do the right thing

• Different approaches work for differentpeople

• We think that the more time you investup front with people, the less frequentlyyou will probably see them – we aretesting how to achieve this and how tooptimise resources

Improvement stories: Improvingpatients’ ability to self manage

It’s not the plan,but the planningthat is important.

“”

Improvement stories: Improving patients’ ability to self manage8

Improvement stories: Improving the patients’ ability to self manage 9

What were the issues?The Veor Surgery team wanted to testwhether chronic obstructive pulmonarydisease (COPD) patients who had a selfmanagement plan, with courses ofantibiotics and steroids at home, couldinitiate medication early and so reducethe need for hospital admission.

The team already knew that earlyintervention reduces complications, butwanted to test whether a patient havinga self management plan was sufficientand robust enough to enable them toreliably and safely start their medication.

Questions that arose from this initialproposal included:• Was it safe for patients to take thisresponsibility?

• Would they understand?• Would it create more work for thepractice?

• Would patients feel empowered?

Where did we start from?The team initially drew up a process map,involving all team members and patientrepresentation, to determine whatcurrently happens along the patientjourney. This highlighted the need toidentify which patients were beingadmitted and who provides what type ofcare at each stage, particularly followingadmission. The practice computerrecords provided the register of COPDpatients required and in order to includehouse bound patients the communitymatron was invited to be involved withinthe team. It was found that the practicerecords provided plenty of baseline datato initially start the project and it wasagreed that this was an accurate sourceof information.

What we didInitially, the team met and agreed its aimsand objectives; this was essential as itensured all individuals stayed focused onthe task and would not get diverted intowider issues. Having identified the selfmanagement plan the task was then toidentify those patients who would besuitable for this type of patient pathwayand invite those individuals for anappointment. This took longer toarrange and organise and the impact ofpatients who did not attend (DNA) wassignificant as a longer appointment hadbeen allocated.

Once patients had committed to theprogramme they were assessed and baseline data was taken using the COPDAssessment Test (CAT) score. To alleviateany patient anxieties about the risk ofrescue medication being inappropriatelyused, the practice established a safety netsystem which entailed seeing patientstwo days after the self initiated therapy.This was to ensure the patients weremanaging and that there were no existingor further problems.

The team were anxious to identifysuitable patients to test this approach. Itwas imperative to work with thoseindividuals who would understand andaccept the responsibility for selfmanagement, in order to minimise anyrisks.

The decision was then taken to developand adapt the existing self managementplan which had been generated by thelocal hospital respiratory nurse.

‘Think ABC to self manage your COPD’ - onepractice’s approach to improve patients’management of exacerbationsVeor Surgery, Camborne, Cornwall

Process mapping to understand what currently happens on the patient’s journey

Improvement stories: Improving the patients’ ability to self manage10

A recording system was initiated in orderto identify major and minor significantevents; it was also an opportunity tohighlight that the self management planswere working and working safely. Oncedata started to accumulate they werethen in a position to reflect back on theprevious year’s exacerbations and foreach current year for a patient as it arose.

As time went on, they worked throughseveral amendments to the plan, aschanges were identified based onpatients’ experience and feedback.

Where are we now?The practice are now seeing patientsshortly after they have self medicated andare ensuring that they have used the selfmanagement plan appropriately. It hasbeen noted that some patients do notcontact the practice after startingmedication and when questioned explainthat this is because they are feeling betternow and did not want to bother thedoctor/nurse. As a single practice, thenumbers are small so it is difficult toquantify or prove the impact onadmissions, but the team is confidentthey have avoided admissions for somepatients. For example, one patient whohad several admissions over the previousfour months successfully managed anexacerbation at home just beforeChristmas which was very rewarding forthe team.

Work so far has identified other questionsthat arise from initiating self managementaction plans:

• Can patients understand the plan? Ifnot, why not?

• Why don’t they follow the plan?• Does early intervention increase orreduce practice work load?

• Are self management plans costeffective?

• Does early intervention reduce hospitaladmission?

• Are patients happy with managing theirown conditions?

• Have we done good or harm with selfmanagement plans?

What have we learnt?• Projects need to be flexible and beadaptive as they are tried out in real life

• It is essential to have a close workingteam who understands the aim of theproject in order to be its driving forceand to seek further improvement

• Keeping focused on the aim of theproject can be challenging, particularlyas projects generate lots of data andthen lots more questions

• Which of these questions needanswering and which are for newprojects?

• Coding in a consistent manner isfundamental and recording of data onthe computer system is paramount

• Finding time to explain plans ischallenging, but important, to ensurethat all patients understand theimplications of a self management plan

• Safety nets are essential• Record all eventualities includingsuccesses and failures in order to learnfrom them

• Keep numbers small and manageable• Try and involve carers in theconsultation so they know andunderstand what to do and why. It canbe frightening for the carer when theirpartner is unwell so ensure they knowwho to contact when, and what tolook out for

• Having a contact person and/or numberthat is not the GP can encouragepeople to get in touch. They may notwant to trouble the GP with theirquery, but might feel happier talking toa nurse, especially one they know dealswith them when they are well

Above all try and answer thequestion you have proposedat the start of the project.

ContactDr Peter Perkins, GPAngie Bennetts, Advanced NursePractitioner, Veor Surgery, CornwallEmail:[email protected]


What were the issues?Blackpool has a relatively high recordedprevalence of chronic obstructivepulmonary disease (COPD) at 2.6%, anestimated prevalence of 5.9%, a smokingrate of 31% and the 15th highestmortality rate for COPD out of 152Primary Care Trusts (PCTs). COPD makesa significant contribution to the area’slowered life expectancy and as such wasrecognised as an area for improvement.While Blackpool has the highest totalspend per 100,000 weighted populationof English PCTs, the proportion of spendin primary care is relatively low. All thesefactors suggested that there wassignificant scope to improve careplanning approaches in primary care witha view to increasing patients’ ability toself manage and so reduce unplannedadmissions.

Where did we start from?• In 2007/08, there were 599 COPDnon-elective admissions costing£1.26 million

• There was no formalised selfmanagement plan or approach inroutine use across the PCT area.

• As part of a more integrated approachto COPD care, the team wanted toimprove both patient and clinicianeducation in order to establish selfmanagement and embed it withinprimary care so patients are able tomanage their disease

What we didThe team developed a self managementplan through the respiratory steeringgroup, which includes patient input aswell as clinical representatives fromprimary and secondary care and from arange of different disciplines.The self management plan was tested infour practices with the ‘Breathe EasyGroup’ and adaptations were madebased on feedback before rolling outmore widely.

This highlighted issues aroundterminology as well as identifying thetime and commitment required toimplement it. For example, patientsrequested they change ‘MRC scale’ to‘breathlessness scale’, and ‘sputum’rather than using the term ’phlegm’.

Patients also particularly liked the colourcharts for sputum which they felt wouldhelp them to identify problems quicklyand the visual aid colour chart wasreported as easy and simple to use. Localcontact numbers and services were alsoadded as a specific request from bothpatients and clinicians.

Patients named the plan ‘My BreathingBook’ and it is coloured blue to make iteasily identifiable.

A series of educational events forstakeholders was provided, to ensurethere was good level of awareness andunderstanding with regards to the selfmanagement approach and plan beforerolling it out.

Embedding the use of effective selfmanagement approaches in primary careNHS Blackpool


Where we are nowThe plan is initially being used to targetthose most at risk of admission and thecombined predictive model is being usedto look for the most vulnerable group ofpatients. It has been adopted so far byall 22 practices and while it is too early tosay what impact it has had on admissionrates overall, one GP dedicated threeeducational sessions to a patient who hadfrequent problems in the previous 12months. This has now prevented at leastone admission and embedded anapparent change in understanding andbehaviour for that patient.

One practice is now testing groupsessions for patients as a means tominimise the impact of any failures toattend and to enhance the potential forpeople to share experiences and providesupport.

Presently 40 plans are in place from theoriginal pilot with another 100 initiatedand data is still coming in from some ofthe practices. It is also being used bypulmonary rehabilitation, communitymatrons, and the acute Trust.

To ensure that the self management plansare being delivered appropriately anduniformly, in order to underpin clinicaleffectiveness and promote change.changes to the way clinicians havetraditionally delivered learning are beingtested, including approaches used indiabetes structured education.

Some key aspects of this are:• To find out what is important to thepatient, not what you think isimportant for them in order to establishmeaningful goals and life style changes

• For every piece of information you give,make sure you get some informationback

• Try not to solve problems for peoplebut encourage them to solve problemsfor themselves

To do this effectively clinicians need skillsin setting measurable goals, negotiation,and the ability to build rapport with thepatients.

To determine what impact the plan ishaving, the team is currently monitoringadmission rates on a high level. However,to be meaningful the impact needs to beidentified at a more personal level sowork is currently being undertaken with a

few practices. Standardisation in theconsistent use of Read codes has beenagreed with all practices in order tofacilitate data capture and analysis. Thiswill also allow tracking of unplannedadmissions for patients who have beengiven a self management plan and toexplore and identify reasons in gaps inservice or highlight any common trends.


By focusing on these few practices theteam will also be able to quantify thetime required to plan effectively withpatients and evaluate the impact on totalcontact time as well as secondary careadmissions.

What we learntInvolving all associated stakeholders,including patients in developing the planensures it has greater relevance to themand therefore there is greatercommitment to its value and use. Thetesting process allowed clinicians toexperience the potential of the plan, andto share knowledge and expertise withcolleagues at the launch of the project,which was more powerful than justproviding research data or evidence. TheGP chair of the PBC endorsed the selfmanagement plan and was activelyengaged in its launch and in promoting itto all practices in Blackpool. One clinicianreported that investment in time wasessential in order to reap the rewards.

Clinical education is a vital component ifthis approach is to be properly embeddedin practice. Just providing the selfmanagement plans to patients will notensure its success. Clinicians need theskills and confidence to take a different,longer term approach in order to developrapport and instigate behaviour changewith patients.

Similarly, the time required to delivereffective care planning for selfmanagement is significant. For practicesand other teams to take on this approachit requires compelling evidence that itdoes pay dividends, as well additionalguidance on how to do it with existingresources.

ContactRos InceProject Lead/Lead Nurse -Diabetes and RespiratoryEmail: [email protected]


What were the issues?The Primary Care Trust (PCT) is rated 11thhighest for COPD risk nationally withpeople 38% more likely to be admittedto hospital with COPD than elsewhere inthe UK. Stoke on Trent is an area of highsignificant deprivation where the publicare less likely to engage with statutoryauthorities, to initiate change in lifestyle,or engage in effective self care. Workingwith the British Lung Foundation and thelocal Breathe Easy North Staffordshire(BENS) patient support group offered adifferent route to increase self care andpromote healthy activity. It was also away to evaluate how support groups canbest add value for patients.

Where did we start from?• 2% recorded prevalence with estimatedprevalence of 5% (rising to 6.3% by2020)

• Smoking prevalence of 30% comparedto national average of 21%

• Approximately 20 people from Stokeon Trent attended BENS meetings eachmonth at outset

• There was significant variation inreferral to/attendance at the localBreathe Easy group by practice

• Little knowledge and understanding ofwho attends groups, why people don’tattend, what is of greatest value topatients who do attend and no formalrecording of the benefits people getfrom being part of a group

BENS did not monitor how thoseattending find out about the group or thenumbers of new members joining.

What we did• Established which practices do and donot refer to the group and working toraise awareness of the potential impactpeer support can have for theirpatients, and how this can be tested

• Developed protocols to allow easy datacapture around membership

• A health care professional from thespecialist community respiratory serviceprovides regular input to BENS groupmeetings to answer questions and offeradditional advice

• Testing the impact of including referralto the group as part of active careplanning and self management for agroup of patients who have hadexacerbations

• Establishing impact measures on thepatient’s health status and confidence

• Capacity was built in within the BreatheEasy group in order to support thecommittee which included a new venueand better opportunities to promotethe group via the communityrespiratory service and at pulmonaryrehab

• The development of a Breathe Easywelcome pack to be given out to newmembers, and formalised the processfor recording new members and wherethey found out about the group

• Monthly recording was implemented inorder to capture the number ofmembers attending Breathe Easy NorthStaffs meetings and the number of newmembers

• The Breathe Easy Group was involved inthe official launch of the communityrespiratory service where they had aworkshop to raise awareness of thegroup amongst healthcare professionals

Where we are now• The attendance of a health careprofessional at group meetings hashighlighted how many concerns peoplehave, and their reluctance to approachor voice these in ordinary consultations.Currently a list of frequently askedquestions are being determined fromthe meetings to identify any commonthemes and how they might be tackled

• Group members now have a slot on thepulmonary rehabilitation programme tohighlight BENS group and theadditional support they can provide

How can support groups increase patients’ability to self manage?NHS Stoke on Trent and North Staffordshire Breathe Easy Group

Members of the community respiratory team joining Breathe Easy North Staffordshire ata chronic obstructive pulmonary disease (COPD) awareness raising event in October 2010

BENS membership by postcode - August 2010

Referral source for members

Group membership by Stoke on Trent practice


• Personal health budgets are currentlybeing tested to see what impact theyhave on supporting a person withCOPD to self manage

What we learnt• This is not a quick fix as the group onlymeet once a month and it can taketime to witness changes. Measuringthe impact has taken longer thananticipated because of time factors andissues around data access. Evidence onthe group’s effectiveness depends bothon patient feedback (for examplearound confidence and health status)and measures of use of health careresources, such as appointments inprimary care, and self management ofexacerbation. In order for this tosucceed strong links and two waycommunication must be present withprimary care and patient consent

• Patients are more likely to raiseconcerns in an informal environmentthan in a formal consultation, whichmay highlight issues relating to clinicalcare elsewhere in the system

• While groups are not for everyone,more patients could benefit fromparticipation if professionals are awareof their existence and consistentlypromote theses groups within patientsupport information

• It is proposed that further work overthe next six months will define howsupport groups can enhance patientengagement with self managementand will specifically target one or twokey practices to focus work withpatients whose condition is moredifficult to manage.

ContactBecky Gowers, Project ManagerEmail: [email protected] Maguire, Project LeadEmail: [email protected]

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What were the issues?Self management plans were not widelyestablished across SouthamptonUniversity Hospitals Trust and the PrimaryCare Trust (PCT). Previously approacheswere variable, with disparate initiativesand lack of overall coordination. Patientswere confused about how to access careappropriately, particularly duringexacerbations. The goal was to work withcommissioners and other local providersto agree a uniform approach and acommon plan.

Where did we start from?• High prevalence of chronic obstructivepulmonary disease (COPD) modelled at6% with the PCT identified as a‘hotspot’ for the highest rate of COPDadmissions in the south of England

• Less than 10% of COPD patients underthe hospital COPD team had active selfmanagement plans

What we didWe analysed attendance and admissiondata for COPD patients using codes D39and D40 (admission with acuteexacerbation of COPD) and route of entryto hospital.

This identified a group of 34 patientswho accounted for 176 admissions in a12 month period. Each of these patientshad a one hour appointment with aconsultant and respiratory nurse, often intheir own home to help the teamunderstand why they were attending. Itwas also an opportunity to help thepatient to understand their conditionbetter and what to do in the event of anexacerbation. They were offered abespoke range of complex interventionsand support in self management. Thesepatients have subsequently only had eightadmissions in 12 months, a reduction of90%.

A discharge support plan was alsodeveloped which included a variety ofmeasures that should be in place for allCOPD patients admitted. This work willalso allow evaluation of how easy it is toimplement and the impact it can have onreadmissions.

Where we are nowA simple self management plan has beendeveloped for local use which it is hopedcan be more widely adopted.How best to bring psychological therapyinput into the pathway is now beingexplored as part of the patientassessment or follow up.Having identified a group of patients whofrequently use urgent care, work has nowbegun with the local ambulance service inorder to improve use of oxygen alertcards, emergency oxygen therapy andgeneral communication around patientsat risk of readmission.

The possibility of developing a local,comprehensive integrated service whichincludes the hospital, community, primarycare, social and emergency services isnow being examined. The benefits ofimplementing this type of service wouldprovide a patient centred approachfocusing on supported self managementwith access to an array of supportservices via a single point 24/7.

The role of secondary care in increasing consistentuse of self management plans to reduce out patientattendance and emergency admissionSouthampton University Hospitals NHS Trust

What we learntEstablishing the baseline data was timeconsuming, but was essential tounderstand:• Who is being admitted most frequently• Why they are being admitted,particularly from their point of view

• What is happening in the course of anadmission to explain variation in lengthof stay and readmission

• Time spent with patients to explaintheir condition and understand theirconcerns pays dividends

• There are gaps and overlaps in thepatient journey that need to beunderstood in order to make best useof available resources

• Ensuring a consistent discharge planmay reduce readmissions

It is also vital to work with colleagues,commissioners and other partnersinvolved in service provision, to maximisethe resources already in place to ensure aconsistent and coordinated approachboth to self management and toexacerbation management.

ContactDr Tom WilkinsonRespiratory PhysicianEmail: [email protected]


Key messages• Consistent recording of data across the

practice team is essential to allowstratification, monitoring of deteriorationand impact of changes in care

• Inhaler technique is a key area forimprovement in management – manypatients do not maintain correcttechnique and many staff may not bedemonstrating correctly. There may beevidence of the cost effectiveness ofusing trainer devices to improvetechnique

• Take time to understand what ishappening in your current system andwho is doing what. You may be able todo things more quickly, safely andreliably without additional resources

• Significant variation across primary caremay not be immediately apparent.Identifying low prevalence, highadmission rates and prescribingperformance can help target effortsfor improvement

Improvement stories:Managing COPD

• It is important to work together toimprove management of COPD anddevelop consistent and reliableapproaches

• Understanding the current system andwhy things do or don’t work well isimportant before you start

• Change is slow and depends on peopleworking together

• Data is essential. There is plenty of itavailable but it is important to identifywhat is most useful and how best topresent it. Targeting patients or practiceswith high resource use can help showbenefits more quickly

Improvement stories: Managing COPD18

What were the issues?The Victoria Practice is a five partnerpractice of 8,352 patients based inAldershot. The practice was alreadyactively managing its chronic obstructivepulmonary disease (COPD) patients, butwanted to ensure it was making best useof available resources to deliver consistenthigh quality care. Evidence from aprevious project on the Isle of Wightsuggested inhaler technique andmedication adherence could help improvepatient experience and reduce frequencyor severity of exacerbation, and use ofhealth care resources. The practicewanted to explore how best to do this,using existing skills within the practice,including their clinical pharmacist.

Where did we start from?• Prescribing costs for respiratorymedicine of £11,000 per month

• Practice COPD prevalence: 1.58% (15.8cases/1000 patients.)

• Admission rate for COPD 10.6% (14admissions in last 12 months)

• Four patients had two or moreadmissions in previous 12 months

• Four patients accounted for nineadmissions (out of a total from thepractice of 14)

• Inhaler technique baseline: 66 patientswith GOOD technique (663H) ; Tenwith POOR (663I)

What we did• The practice systematically checkedinhaler technique and medicationreview during the COPD annual check

• Patients now complete a COPDAssessment Test (CAT) score at the startof their planned review and at recallafter four weeks, where medication hasbeen changed, to see what impact thechange has had for them

• Common coding has been agreed forall practice team members in order toidentify and record exacerbations ofCOPD more accurately. It was decidednot to go back over previous records toupdate coding as this would have beena significant amount of work formarginal benefit. This could alsohighlight an increase in exacerbationsbut will allow analysis of the proportionthat result in admission

• Recording data such as prescribingcosts for respiratory medicines on astatistical process control (SPC) chartprovides a good visual indicator of theimpact over time of regular review,optimising medication/device andimproving inhaler technique

• Information from the practice system isnow being used to evaluate the impacton admissions, medication use andcost, and potentially appointmentusage (routine vs. urgent) as the projectprogresses

Where we are now• Identifying the best pathway forpatients within primary care and how apractice team can best provide this.This includes looking at who does whatand how consistent the way of workingis between different team members, inorder to achieve best use of skills andresources for maximum patient benefit

Systematic review of patients’ inhalertechnique and medication useVictoria Practice, Aldershot, Hampshire

SPC chart: Respiratory drug costs for Victoria Practice

Improvement stories: Managing COPD 19


What we learnt• Consistent coding in primary careteams is essential in order tounderstand current performance andimpact on patient care or outcomes

• Regular consistent review of inhalertechnique is essential as some patientsdo not maintain good technique andalso for staff as they too need to beregularly updated

• The use of devices to support goodtechnique is cost effective and certainlyreinforces correct methods

• Patients need time to assimilateinformation: this team found it wasgood practice to allocate two thirtyminute appointments with an intervalof a few weeks allowing patients moretime to consider what concerns theymay have and how they are copingwith medication or their condition,rather than one 60 minuteappointment

• Longer appointments create a risk ifpatients do not attend so it is importantto plan how this can be managed

• Other factors to consider:• How many patients have correctinhaler technique? and how many inthe practice staff team?

• How much is poor inhaler techniqueaffecting patient adherence andprescribing costs? Poor techniquemay result in patients not usinginhalers because they get no benefitor it could be increasing prescribingcosts because medication is beingwasted through ineffective use

• How many exacerbations are patientsactually having and how many resultin admission? Good managementmay increase the number of recordedexacerbations but early identificationand intervention could reduce theproportion that need to be admitted

ContactClare WatsonClinical Pharmacist Victoria Practice,Medicines Management PharmacistNHS HampshireEmail: [email protected]


What were the issues?• Imperial College Healthcare NHS Trust(ICHT) is the UK's first and largestAcademic Health Science Centre. Since2005, ICHT and Hammersmith andFulham (H&F) Primary Care Trust (PCT)(now named Central LondonCommunity Healthcare NHS Trust) havebeen working in a coordinatedpartnership with the aim of improvingservices for patients with chronicobstructive pulmonary disease (COPD)and other chronic respiratory diseases

• According to the Quality and OutcomesFramework (QOF) 2007/08 there are1908 patients diagnosed with COPD inHammersmith and Fulham (H&F),representing a prevalence of only 1%

• This is below the national average(1.6%) and is thought to be asignificant underestimate; modelledprevalence predicts that the totalnumber should be in the region of7,024 representing 3.7% prevalenceoverall

• Wide variation in prevalence across allgeneral practices, ranging from 0.5%to 2.4%

• Even practices meeting 100% of theirQOF targets as regards COPD diagnosisshow low actual prevalence comparedto that predicted

• No breakdown of the known COPDpopulation by disease severity

• 28% of the local population(approximately 41,000 people) aresmokers

• Commissioners were looking for areduction in COPD hospital admissionsof 50% by 2013 and 30% reduction insecondary care outpatient attendancesby December 2011. A 10% reductionin admissions and readmissions wastargeted for July 2011

• As part of a much wider approach theredesign of the delivery of care wasscrutinised in relation to howrespiratory specialist nurses andconsultants could support primary careto deliver evidence based chronic care,anticipatory care and case managementfor patients with COPD and asthmaworking with clusters of practices

Where did we start from?To ascertain a starting point a baselineassessment was undertaken of respiratorycompetency with primary care staff whichincluded the delivery of workplace basedand modular teaching on spirometry,COPD and asthma diagnosis andmanagement. A baseline assessment wasalso established in relation to the QOF,COPD, asthma registers, and degree ofthe National Institute for Health andClinical Excellence (NICE)2010 compliancein management of COPD using thePOINTS audit system. This has shownthat management of these patients hassignificant scope for improvement.

How can respiratory specialists support primary careto improve management and reduce admissions?Imperial College Healthcare NHS Trust and Central LondonCommunity Healthcare NHS Trust


It has now been agreed with the publichealth team for them to provide therequired data to support the redesignprocess, as use of POINTS is not seen as alikely long term solution. The possibility ofcomparing data from matched practicesnot receiving RNS support has beenraised as a method of having somecontrol over the data.

Where we are nowThere has been considerable changewithin the PCT which has resulted in thelevel of administrative support not beingas originally envisaged. However despitethis we have already witnessed a 27%reduction in the number of acuteadmissions for COPD in the first half of2010 compared to 2009/10, with a 20%reduction in secondary care clinicattendances.

A significant programme of work isplanned over the next six months toestablish effective support to practiceswhich includes:

• Establishing COPD and asthma clinicsto review patients (by priority) jointlywith practice nurse/nominated GP

• Introducing the use of templates toguide COPD/asthma reviews

• Assuring smoking cessation support forthose still smoking

• The introduction of appropriate READcodes to prospectively recordexacerbations

• The use of electronic pictorial COPDand asthma self management plansand prescription of rescue medication,incentivised by local ‘QOF-plus’arrangement

• An onward referral system tocommunity pulmonary rehabilitation,incentivised by local ‘QOF-plus’arrangements

• Home review of housebound/exemptedpatients

• A review of patients post exacerbation

What we didAs this was such a large scale project, itwas imperative that efforts were targetedand measurable. Initially process mappingcommenced in relation to the openaccess spirometry and communityconsultant clinics which calculated withinthe current systems the total amount oftime it took for a patient to be referred,seen and treated could be up to 12weeks. This also identified that the realtime spent with the patient was only afew hours.

The process mapping also identified areasin the system which needed moredetailed analysis in order to understandwhy it took so long and where delayscould be reduced or eliminated. In orderto highlight where the greatest impactcould be achieved on reducing thenumbers of admissions in order to meetcommissioner targets local practices wererated by highest total numbers of COPDadmissions and secondary care referrals.A Pareto chart was then produced toidentify which of the six practices shouldbe first to receive respiratory nursespecialist ( RNS) support. Gantt charts forthe RNS were developed to ensure aconsistent process when supportingpractices.

Sources of support were then determinedto assist the progress of this work whichincluded using pharmaceutical industrytraining packages and POINTS for primarycare data. Apollo templates are currentlybeing used for reviews as no funding wasavailable for roll out of other versions.

Work also commenced with the localpublic health team to identify appropriateand feasible data collection. One of theareas of work underway includes theprovision of combined predictivemodelling data to primary care to supportproactive case management of patients atrisk of hospital admission.

• Case management and anticipatorycare for complex patients with onwardreferral to community consultant clinic

• A review of oxygen prescribing in thepractice and gatekeeping methods

• Providing teaching sessions and ‘virtualclinics’ at practices, delivered bycommunity respiratory consultants

What we learnt• It is important to understand what iscurrently happening, and why. Thishelped to highlight underlying problemswith the location and perception of oneof the community clinics. It has alsoassisted in targeting practices whereadditional support is required and wherethe greatest impact will be seen

• Early and sustained engagement of keystakeholders, particularly commissionersand primary care, is vital to the success ofany integrated service; without this therewouldn’t have been the investmentnecessary to move forward

• Managing change is extremely slowand can prove to be difficult. Ensuringtwo way communication throughoutthe process is essential. Changing theway the community respiratory serviceworks and communicating this toothers was very challenging

• Data is crucially important but robusttimely data is difficult to obtain; asclinicians there is a need to haveownership of data and takeresponsibility for it. There is plenty ofinformation out there, and otherpeople can help you get it and use it

• Do not reinvent wheels; there areresources already available for training,analysis and templates

• Change can sometimes be seen as hardwork and is best achieved with a team,not alone

ContactDr Irem PatelConsultant Respiratory PhysicianEmail: [email protected]


What we did• Process mapping event held resulting inan action plan

• GP champions were identified for theGuildford cluster and Thames medicalcluster

• Cluster data charts were collated• Collaboration with the medicinesmanagement respiratory lead in Surreyon GP, Quality Outcome Framework(QOF) days to market localmanagement guidelines (NICE 2010),NHS Improvement - Lung pilot andSouth East Coast respiratoryprogramme

• North west paramedic COPD championidentified

• An A4 patient held health record withessential respiratory information hasbeen developed for use across agencies(message in a bottle and hospitalpatient information systems) anddisseminated and implemented acrossnorth west and south west Surrey

What were the issues?Across Surrey there is a disparity of careand services provided, with a variance inperformance and outcomes in bothclinical and economic measures.However, there is also a widespreaddesire and shared philosophy of sharingbest practice and reducing inequalities.

The prime challenge was to avoidunnecessary and costly admissions toacute services, and to grasp theopportunity provided to ensure theprovision of high quality, efficient,equitable service is available to all acrossthe county for patients with chronicrespiratory disease, so that improvedquality of care is delivered as availablebudgets reduce.

Where did we start from?All data is shown as an actual figure forJuly 2010 and a rolling 12 monthsaverage which aims to reduce the effectof the seasonal variation.

• Admission rate (weighted for expectedCOPD prevalence) = 4 / 1000population. Rolling 12 months average= 4.75 / 1000 population

• 30 day readmission rate = 25%. Rolling12 month average = 22%

• 90 day readmission rate = 46%. Rolling12 month average = 38%

• Cost of emergency admissions =£199,536. Rolling 12 month average =£290,484

• Bed days (weighted for expected COPDprevalence) = 17 / 1000 population.Rolling 12 month average of 32 / 1000.

• Average LOS 4.2 days. Rolling 12month average = 6.7 days

• 13% of the last 12 months admissionswere accounted for by multipleattenders (2 or more attendances)

• An audit was carried out of GPsurgeries which identified team inputfor each surgery

• Agreed referral criteria• Breathe Easy information updated onproject also including the review of thenew British Lung Foundation selfmanagement literature

Earlier identification of COPD patients andpreventing inappropriate admissionsSurrey Community Healthcare

An example of the dashboard used to monitor improvement over time


Where we are now• Progress has been slower than firstexpected due to staff changes and thepolitical climate

• Issues have been uncovered aroundcoding and releasing time to undertakethe project work

• Work is ongoing to encourage andevaluate the dissemination of selfmanagement plans by the communityrespiratory team

• Further work is needed to develop linkswith primary care and identify more GPCOPD champions / leads within clusters(with a particular focus on thepathfinder consortia)

Below is an example of the dashboardused to monitor improvement over time.This can be looked at by individualpractice level and includes a South EastCoast wide comparator.

What we learnt• Reducing admissions cannot beachieved by one part of the pathwayworking alone. Collaboration andagreed processes across the acute,community and primary care settingsand the ambulance trust are vital. If anyof these areas is disengaged or doesnot have the capacity to work tochange then the project will falter

• Information governance restrictionsmake it very difficult to shareinformation across organisations.Professionals must be aware of whatinformation they can and cannot sharewithout consent from the patient

• In the current climate professionals arebeing pressed to deliver more with lessresource; to ensure engagement youhave to give evidence that your projectis worth their time. Provide data suchas cost of emergency admissions,length of stay, readmission rates andprescribing spend

• Change takes time and commitment;changing outcomes relies on changingmindsets, not just processes

ContactVikki KnowlesCommunity Respiratory Team Lead,Consultant NurseEmail: [email protected]


• One of the initiatives which is plannedis to implement a cognitive behaviouraltherapy (CBT) group course specificallyfor people with COPD. Work has begunwith the Time to Talk team at SussexCommunity NHS Trust who will beproviding the service. So far referralcriteria for this service have beendeveloped and work is ongoing tosecure locations and publicise thisservice

• Two more initiatives, post exacerbationreviews and personalised care plans areto be delivered in primary care. FourGP practices have been identified to beinvolved in developing this further

• Another scheme is to provide selectedpatients with telehealth units which iscurrently in the process of securingfunding

What were the issues?The long term conditions programme hadundertaken a review of the admissionsand readmissions data for the PrimaryCare Trust (PCT). The data indicated thatreadmission rates remained high and thatlength of stay was prolonged. A decisionwas taken to ensure a range ofinterventions were available to all patientswith chronic obstructive pulmonarydisease (COPD) as part of their ongoingcare, to improve their ability to managetheir condition and to reducereadmissions.

Where did we start from?Quarter 2 (Q2) 09/10• Average length of stay (LOS) 8.5 days• 30 day readmission rates were at 20%• 90 day readmission rates were at 38%• 135 bed days were used per 1,000COPD population

What we did• Established the project team andworking groups

• Established links with other similarprojects in the geographical area andacross the country

• The recording of the project was set upon the NHS Improvement System to aidcommunication amongst the team aswell as project planning and trackingprogress

• Plans were developed for thepreparation phase: project plan, contactsheet, communication plan and datacollection plan

• A patient satisfaction survey wasconducted using the LTC6questionnaire amongst people withCOPD in the county to establish abaseline

• This helped identify a number of issuesto help improve care and support forpeople with COPD

Where we are nowDue to the seasonal variation associatedwith COPD where we were in July andwhere we are now in February is notcomparable. Therefore Q2 09/10 withQ2 10/11 to ensure we are comparinglike with like.

• LOS was 6.5 days for Q2 10/11, 2 dayslower than the previous years Q2

• 30 day readmission rates = 35%although this dropped to 21% for Q3

• 90 day readmission rates = 40% but aswith 30 day readmission rates this hasdropped for Q3 10/11 and now = 27%

• Using SPC analysis is helping us to seewhat is happening over time and wherewe can most effectively target ourimprovement efforts

• Bed days per 1,000 COPD populationare steadily decreasing – this is likely tobe due to the reduction in LOS

Supporting people with moderate or severe COPDto self manage through clinical and behaviouralinterventionsNHS West Sussex


What we learnt• One of the most important pieces oflearning gathered from this project wasthe use of a robust diagnostic phase.This is needed to establish the currentsituation and to discover where theunderlying problems might lie. It is alsoimportant in its use as a method ofmeasuring and demonstratingimprovements

• The solutions must be tailored topopulation and specifically for theproblem or gap identified

• It is important to identify individual(s) todrive the project forward. This isparticularly apparent in the currentstate of reorganisation in the NHS as itis needed to keep the momentum ofthe project going, keep the teamengaged and keep it a priority

• It is essential to have clear achievableobjectives

• It is sensible to take advantage ofengagement approaches that haveproven successful in the past

ContactChloe DonaldGraduate Management TraineeEmail:[email protected]

Why is data so important?If you don’t measure, how do you knowwhether what you are doing is better,worse or the same as it was last year? Orbetter, worse or the same as what everyoneelse is doing?

Data and measures are important todemonstrate that change has occurred orneeds to occur, and it also helps to focusimprovement work effectively. NHSImprovement focuses on the delivery ofquality measured improvements which arealigned to national priorities and strategies.

In line with the national Quality InnovationProductivity and Prevention (QIPP) agenda,it is essential that all system changes aremeasured and recorded. Whether thechange was a success or did notdemonstrate the anticipated outcomes, westill need to demonstrate its effect andlearn from it.

Data

Data is important for improvement projectsbecause it is not satisfactory to say “it feelsbetter”, “I think it’s better”, or “it seemsbetter”. We need to establish factual dataand measures to demonstrate what hasbeen achieved.

Data 27

What have we learned about data from the project sites?28

1. Consider a needs assessmentapproachThe overwhelming message from thesites starting improvement work was thatthere was difficulty in getting hold ofdata and information. As workcommenced, sites reported limited accessto data on their day to day activity, andvery poor access to overall informationcovering the respiratory pathway.

Fortunately, there are many resourcesavailable that can support sites tounderstand and compare their services toothers, and many of these are freely andeasily accessible.

A detailed list of data resources isavailable on the NHS Improvement - Lungwebsite. Data is available nationally onprevalence, secondary care admissionsand primary care that can be combined tobuild a picture of local services.

The Atlas of Variation, developed by MuirGray’s Right Care workstream is a goodstarting point to highlight key clinicalvariation, and the NCHOD ProgrammeBudget Atlas builds on this, providinginformation on admissions, length of stay,outcomes and overall respiratory spend,plus functionality for mapping andgraphing the information at a PCT level.

2. VariationA key message from the sites is how tounderstand the variation within their localsystems, and to understand why therecould be a difference in admissions,length of stay, or cost, between localareas, GPs and healthcare providers, inorder to improve the care for patients.

Much of the variation may be for validand explainable reasons. Often,socioeconomic factors, such as smokingrates, can greatly influence the levels ofhealthcare need between different areas.Yet, it cannot explain all the variation.

However the key learning is that often wedo not know this variation exists, andthat by using the data more informationis being uncovered about what ishappening in the site.

Analysts may be able to support and offerstandardised data, which accounts forsocial status, age and sex factors, to showthe variation with control applied forthese factors.

Projects are working to understand thereasons behind variation by asking thequestion "why" there is a difference.This helps us better understand theprocesses and provision of our services.

Within the projects in Southampton, afunnel plot and mapping technique wasapplied to show which practices hadsignificantly higher rates of admissioncompared to peers. It was found thatthese practices were located in areas of

What have we learned about datafrom the project sites?

National Programme Budget Interactive Atlas – http://nww.nchod.nhs.uk (NHS Network connections only)

high social deprivation, and that theteams were generally less likely to engagewith patients in these areas for fear ofcrime. The team agreed to explore whatother ways there may be to accesspatients in these areas.

3. Prescribing savingsThere have been significant financialsavings demonstrated from simpleapproaches to medicines review.

Respiratory medicines information can beobtained from the ePact system. Thereports generated by this system havebeen used by pharmacy advisors workingwith practices to monitor monthlyspending, and reductions in costs havebeen shown. Examples of how this isbeing used by Victoria Practice inHampshire are covered in theirimprovement story on page 19.

4. Data sharing: localagreements neededThe importance of sharing informationand data across the health communityhas been a key message from ourimprovement projects. Integrated carewill give the best outcome for patients,but this message also applies to data.Without the sharing of information it isnot possible to show the whole pictureand what is involved in the care of thepatient. Healthcare providers need thedata for the whole pathway tounderstand how their improvement workis benefiting the patient.

Hospital admissions data can be freelyobtained from sources such as HES(Hospital Episode Statistics), NHSComparators or in performance reports;however this is often aggregatedinformation, and can be up to threemonths old. The detail and timelinessrequired for improvement projects impliesthat sites should explore how to accessthe data locally, collaborating with theirlocal data teams.


Having local access to HES, or theadmissions providers collect prior tosubmission to HES, would be valuable tomonitoring service improvement over

short time periods. For example, length ofstay could be monitored on a per patientbasis.

Example of statistical process control (SPC) chart – Charting can show processinformation, such as the length of stay, in a way that offers more detail than typicalperformance measures such as averages can offer

Example of NHS Comparators mapping functionality

5. Primary care data doesn’t need tobe impossiblePrimary care data is often seen as adifficult area to extract, and some of thesites found it difficult to access primarycare data at first. However, a number ofresources are easily available which canprovide a picture of primary care which isvaluable for improvement work.

QOF data is useful, particularly forbuilding evidence and understandingaround the diagnosis and communityparts of the patient pathway. QOF data isparticularly valuable when compared toother indicators for COPD, such asadmissions, or expected prevalence.Comparing the proportion of patientspredicted to have COPD against actualreported COPD on QOF may highlightareas of unmet need, find missingpopulations, and suggest where to targetsupport and future work.

It is important that sites using QOF reviewany exception reports, as it is possible toexclude patients.

NHS Comparators has been muchdeveloped in the last year, and sites wereimpressed with the information itprovided, which helped provide basicbenchmarking and comparison forprimary care.

Local investigation may reveal moreinformation. Project sites have foundvalue in interrogating the informationheld within primary care systems. Theimportance of accurate coding has beenemphasised by project sites, as they havelearned more about the exacerbations oftheir patients by ensuring coding iscorrect.


Example of QOF data

NHS Comparators mapping example

Primary care data can be explored usingthe reporting functions built into primarycare systems, or using external tools,examples of which include the POINTSaudit tool from GSK, and the OptimumPatient Care (OPC) tool used by theLeicestershire project (see page 34 ).Details on how to access these resourcesare in the data guide on the NHSImprovement website.

Access to practice information is alsoessential for projects involved in End ofLife (EOL) care work, as it is estimatedthat 14% of EOL registers may be COPDpatients. Ensuring that this information isaccessible, coded well, and used willsupport the EOL care pathway.

The NHS Information centre is planningto improve access to GP informationthrough the development of a nationalGP data extraction service. For furtherinformation visit the information centrewebsite at www.ic.nhs.uk

6. Using primary care data to supportpatient managementThe Veor Surgery in Cornwall extractedinformation using a locally created report,which provided information for allpatients who appeared to have had anadmission for COPD or respiratorydisease. Patient notes were compared tothe extracted information from thepractice system, and discrepancies werefound with the numbers of exacerbationsand the coding of patients.

The site looked into why the coding wasincorrect and the processes used toidentify COPD patients. This led toimproved coding practice within thepractice, improving how they identifiedCOPD patients, ensuring that allexacerbations of COPD were monitored.

The importance of accurate coding wasemphasised by this site, as they learnedmore about the exacerbations of theirpatients by ensuring coding was correct.

The Leicestershire project reviewed a vastrange of primary care indicators acrossthe majority of GP practices inLeicestershire County. This illustrateddifferent approaches to care, anddifferent outcomes. It did not addresswhy there was a difference, butencouraged further investigation andchange to practice.

This project used the services of OPC. Thiscompany supported the sites in extractingprimary care information, andsupplemented this with patientquestionnaires. This detailed informationhighlighted where there was scope toimprove practice, patients for whomtreatment could be optimised and thevariation in treatment offered acrosspractices.

7. Know/love your analystMany of the project sites haveemphasised the benefits from gettingearly support from a dedicated dataanalyst. This has helped projects inobtaining baseline information,supporting process mapping, andongoing support to monitorimprovement.

The key tips for getting and keepinganalysts involved in projects are:

• Get your analyst involved earlySites that included analyst support fromthe beginning had a head start withdata, and rapidly built the evidencebase and understanding for the servicechange. Those sites without analystsupport struggled to understand theimportance of data, and later expressedregret as data revealed challenges ormisunderstandings which could havebeen addressed sooner. Earlyinvolvement helps ensure that you andthe analyst have a sharedunderstanding of the project.

• Involving analysts closely with theproject, rather than an externalfunctionThis close involvement ensured theanalysts had a greater understanding ofthe purpose of the projects, and theanalyst could input into the projectgoals to ensure the aims aremeasurable and achievable. It is alsovaluable, as it may reveal other sourcesof information or approaches whichmay be unknown to the project team.


GSK POINTS audit tool

• Seek formal support from theanalyst and managerAnalysts are often seen as a valuableresource, and as such their time may beprotected. Some sites have founddifficulties in maintaining analystsupport in projects due to competingpressures elsewhere in the organisation.Sites have recommended that youensure management support is in placefor the improvement work andensuring that analyst time is madeavailable to support your work.

• Look widely for your supportPeople with access and expertise todata may not always be in analyst roles.Sites looking for information may wishto contact performance managers,clinical coders, data managers andcontract managers, who exist in avariety of roles, supporting themanagement of Primary Care Trustsand provider trusts, with access to databeing a core part of their roles.

• Be clear on data requirements toinformation departmentsIt helps to explain what you are tryingto measure or demonstrate, as theymay be able to suggest alternativeindicators. As well as informationanalysts, involve all those involved indelivering care to contribute to a datacollection plan.


Key messages• Code consistently, or you won’t be able

to measure• You don’t need new data sources as

there are plenty already available• Choose your measures of effectiveness

carefully• Don’t be a victim of paralysis by

analysis; use what you have, even if it isimperfect

• Know what you are trying to achieveand what will indicate whether or notyou are getting there. If it doesn’t tellyou anything useful, don’t measure it.

• Tools like ‘driver diagrams’, which wereoriginally developed by the IHI5, canhelp you determine what you need tomeasure and why, as illustrated in theexamples on the following pages. Moreinformation on ‘driver diagrams’ isavailable via the NHS Improvementwebsite at:www.improvement.nhs.uk/lung

Improvement stories: Turning datainto information for improvement

Not everythingthat can becounted counts,and noteverything thatcounts can becounted.

“

”Albert Einstein

Improvement stories: Turning data into information for improvement 33


What were the issues?Leicestershire County & Rutland PrimaryCare Trust (PCT) wanted to reduce thenumber of admissions and readmissionsfor chronic obstructive pulmonary disease(COPD). While national projections gavesome indication of need and demand, ithad become clear that there was littleunderstanding of how COPD was beingmanaged across primary care, and whatimpact this was having on admissions. Itwas difficult to know where efforts toimprove management and focusintervention would best be targeted. Theproject therefore aimed to create an initialbaseline of current performance whichwould allow personalised care plans to bedeveloped for each patient, to supportimproved management in primary careand so reduce admissions andreadmissions.

Where did we start from?• The PCT had the second lowestrecorded prevalence in the UK of 1.3%(ERPHO predicted prevalence: 2.6%)

• There were 2,200 admissions for COPDin 2010 of which 600 werereadmissions and the number wasrising

• Six out of 41 practices were achievinghigher QOF rates for all COPDmeasures

• An initial pilot survey indicated markedvariation in recording of FEV1, COPDseverity, exacerbation recording,smoking history, medication use,referral for pulmonary rehabilitation &other aspects of COPD care

• This reinforced the recognition thatthere was no real corporateunderstanding of the issues aroundvariation between ‘best’ and ‘worst’performing practices or the impact thiswas having on secondary care orprescribing. Existing data sets gaveonly a limited understanding of whatwas happening across practices

Understanding variation in primary caremanagement of COPD - using practicedata to make the case for changeLeicestershire County & Rutland PCT in conjunctionwith Optimum Patient Care (OPC)

xxxxxxx xxxxx

100

90

80

70

60

50

40

30

20

10

0FEV1% Predicted

>80%FEV1% Predicted

50 - 79%Overall

%o

fC

OPD

pat

ien

ts

Appropriate therapy Inappropriate therapy


What we did• The PCT worked with Optimum PatientCare (OPC), a not for profitorganisation, using their software toolsto collect practice clinical data

• OPC’s clinical review service uses theDOSE index to identify those peoplewith COPD who are at highest risk ofexacerbation and hospitalisation usingroutinely recorded practice data andquestionnaire responses

• The data extracted was alsoautomatically compared with PCTagreed COPD rule sets based onNational Institute for Health andClinical Excellence (NICE) standards

• Discrepancies between currentmanagement and agreed optimal carewere automatically recorded andformed the basis of individualisedpatient reports that were fed back intothe computer system

• The next patient review can now bebased on the personalised specificrecommendations for that patient thatappear in their care plan

• 50% (41) practices participated in theproject

Where we are now• Information on patients from 41practices has been analysed andindividual patient reports provided tothose practices

• Of recorded COPD patients, 12.5%(525 patients) were of unknownseverity and 14.5% (609) patientswere, on the basis of recorded clinicalinformation, unlikely to actually haveCOPD. 2711 patients had no FEV orFVC values within two years ofdiagnosis

• Optimal therapy is not consistent acrosspractices. Approximately 10% of thosewith a recorded diagnosis of COPD didnot have COPD on spirometric criteria

Long term therapy costs formisdiagnosed COPD patients couldamount to £86k, a potential saving;depending on what their accuratediagnosis would be. Approximately10% of the remainder were on notherapy and 30% required optimisationof prescribed therapy

• Key information from this approachthat can help prompt improvement andinform commissioning includes:• Moderate (FEV1 %50 – 79) andsevere (30 – 49%) patients accountfor significant numbers ofadmissions; improved managementefforts for this group could havemarked impact. 50 patients withCOPD of moderate severityaccounted for 101 admissions, while38 patients with severe diseaseaccounted for 73 admissions

• Although smoking cessation is a highimpact intervention for COPDmanagement, referral for support isnot consistent

Appropriateness of therapy by COPD severity(patients with only COPD diagnosis, not concurrent asthma and COPD)

• The data analysis identified 35patients with COPD diagnosiswho have had a hospitaladmission and for whom therewas a therapy recommendationof a LABA, LAMA, ICS orICS/LABA

• These 35 patients haveexperienced a combined total of62 admissions

• If these therapy recommendationslead to a possible 20% reductionin admissions – or 12 admissions -at an estimated cost of£1,641.60 per admission thiscould equate to a saving of£19,699.20

What we learnt• Providing information on performancealone does not instigate significantchange; primary care requires practicalinput to support change

• To provide a review covering all thepoints in the report requires at least 45minutes and practices are likely to needsupport to be able to deliver this

• Primary care data can provide a farmore meaningful picture than throughQuality Outcomes Framework (QOF)alone and can be used to supportcommissioning and education plans aswell as to target intervention withpractices more accurately, to improvemanagement and reduceadmissions/manage exacerbations

• Next steps are to identify how topresent this information for maximumimpact and which elements are mostsignificant to different audiences. Alsohow to best support practices to deliverbetter care with the use of educationalsupport and how to ensurecommissioning plans take account ofidentified needs so funds can bedirected accordingly

ContactDermot RyanCOPD Lead, Leicestershire County andRutland PCT, Woodbrook Medical Centre,Loughborough LE11 1NHEmail: [email protected]

100

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H&B(308)

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Percentage of active smokers offered smoking cessation advice in the last year



What were the issues?Chronic obstructive pulmonary disease(COPD) is a top priority for NHS Sheffieldand forms part of their AchievingBalanced Health Strategy 3 (ABH), withpotential to reduce avoidable hospitaladmission and reduce the mortality andinequalities gap. Identified ‘hot spot’areas in Sheffield have a greaterprevalence of COPD, and there issignificant early mortality with a 14 yearmortality gap between the most affluentareas and the most deprived. As part ofa large scale service redesign the teamwanted to look at how to target supporteffectively to those areas where there wasevidence of greatest need, and reducevariation across the city. For example,Yorkshire and Humber Public HealthObservatory report that Quality OutcomeFramework rates for patients receiving alung function test every 15 months rangefrom 34% to 100% across the city.

Where did we start from?In 2008/09, 15% of patients with COPDhad an emergency admission, a rate alittle higher than the national average of14%. Strategic analysis had highlightedthe ‘hot spot’ areas and identified that67% of admissions profiled were firstadmissions. GP practice profiling hadhelped in identifying that certain practiceshad higher risk and higher levels ofadmission, but further work was neededto understand how COPD patients werebeing diagnosed and managed, in orderto identify what support was needed toimprove care.

Work had already been undertaken insome parts of Sheffield using Navigatorsoftware to interrogate GP systems as itwas felt that this could be targeted at the‘hot spot’ areas to help improvemanagement.

Using information to target support to practices andpatients, in order to reduce variation in diagnosisand management of COPDNHS Sheffield

Graph quadrant example of how practices were identified though MOSAIC types(risk stratification) and plotted admissions of practices within a consortium

Practice performance

The upper right hand quadrant identifies greatest risk of hospital admission; patients withCOPD are three and four times more likely to be admitted to hospital, plotted against high ratesof admission.


What we didHaving identified the key practices wherethere was greatest scope forimprovement, lead nurses approachedthem for agreement to install Navigatorsoftware which would allow analysis oftheir COPD patient population and whereto target effort.

The software could then be used toidentify patients who were at a high levelof risk of re-admission and those whoneeded a review, based on a range ofindicators (see table below).

The project nurses worked with thepractices to provide clinical support andadvice and to ensure patients werereviewed and referred appropriately.They were then in a position to be able toprovide easy to read data that illustratedto the practices what the areas toprioritise were, and why, and were alsoable to provide examples from practicesin other areas of the difference thisapproach had made.

The nurses’ role then was to help thepractices identify their strengths anddevelopment areas, to enhance capabilityin house. This included:

1. Practice protocol for managing peoplewith COPD

2. Qualitative measures as identified byAssessment of RespiratoryManagement (ARM) questionnaire.

3. Identifying QOF data gaps, e.g. lungfunction tests recorded in last 15months, spirometry, immunisations,inhaler technique

4. For patients admitted to hospital,assessing suitability for pulmonaryrehabilitation and follow up in primarycare or community clinic

5. Reviewing the number of patients with3+ exacerbations and how they weremanaged

6. Identification of patients suitable forpulmonary rehabilitation followingMedical Research Council guidance(level 3 and above)

Total COPD Admissions per 1000population

Inhaled corticosteroids

Indicators of risk and need usedby Navigator

• Correct / quality assuredspirometry measured andrecorded (i.e. VC, FVC, FEV1,FVC/FEV1, VC/FEV1, actual valuesand percent of predicted, post-bronchodilator)

• Assessment and documentationof COPD symptoms (exertionalbreathlessness, chronic cough,sputum production, winterbronchitis, wheeze)

• Patients treated outside NICEpharmacological guidelines andNHS Sheffield formulary

• People at high risk ofexacerbation (previous admission,steroid & antibiotic courses, lowFEV1, MRC 3+ etc)

• Risk stratification by severity• People with COPD with writtenindividualised care plan


Where we are nowEarly measures show a reduction inadmissions for COPD, suggesting that theinterventions are targeting patients andpractices successfully.

The nurses have successfully establishedlinks with key hot spot practices identifiedfor this phase of work. They are nowable to use the information extracted tomake recommendations on andcontribute to further learning andsupport, including developing practicaltraining in areas such as spirometry, theuse of Navigator software to support bestpractice, self management planning andthe use of Map of Medicine and clinicaltemplates. At a very practical level theycan promote and assist in the referral tokey services, including smoking cessation,active programmes, communityrespiratory team, oxygen assessment,mental health support and end of lifesupport, based on the picture that theNavigator software provides of whereimprovement is needed. This is indicatedby an increase in referral to and uptake ofpulmonary rehabilitation and communityclinics. 50% more patients are gainingaccess to group programmes and 50%more are accessing domiciliaryrehabilitation.

Next steps will include developing abooklet outlining key support for healthcare professionals as a reference tool topromote ongoing good practice.

What we learntIt took considerable time to engage thepractices in the more deprived and at riskareas. It is likely that dedicated projectmanagement support would have helpedprogress this, particularly in the light ofsignificant staffing challenges andorganisational change that occurred inthe early stages of the project.

GP clinical leadership for the project hashelped drive change locally.

Using stories and examples from otherpractices and patients helped to make thecase for using the software and what itcould do to make a difference in practice.

“One gentleman who went topulmonary rehabilitation hasgone back to work”

Nurses reported that they thought theircare was good, but this approach hasshown them there is still significant roomfor improvement.

The reports from the system were very apowerful tool to highlight what wasactually going on in the practice and whythere was a need to work differently. Thefact that help was available from a projectteam, from people who could build on anestablished relationship with the practiceteam, probably made it easier to move onto the next stage of actuallyimplementing change.

ContactSue ThackrayDeputy Head of Development Nursing –Respiratory Project LeadEmail: [email protected]

Patient reviews• You can have significant impact on

admissions by targeting your moderateCOPD patients and increasing theirconfidence in self management. Youneed to ensure you have correctlyidentified patients’ severity to be able todo this

• If you have no other system for patientrisk stratification, look at who accountsfor most use of resources e.g.appointments, Accident & Emergencyattendances, admissions, medicines. Usethe Pareto principle to target effort; 20%of people or problems may account for80% of resources

• Allow enough time for a review – thiscould be 45 to 60 minutes. Shorterappointments mean you will not havetime to listen to the patient and find outwhat they want and need to know,rather than what you want to tell them.If you get this right, you may avoidrepeat appointments

Top tips for COPD management projects

• People are motivated by different things.If you take time to find out what willmotivate someone to change behaviour,you have a better chance of helpingthem

• Group sessions for review or patienteducation can limit the impact if patientsdo not attend

• Find out from patients what differenceyour care makes to their ability tomanage or their evaluation of their ownhealth using the CAT score or other tool.If what you are doing isn’t helping them,it’s not their fault. Find out what wouldwork for them

Top tips for COPD management projects40


Data and documentation• Record exacerbations consistently, using

agreed Read codes. This will helpidentify when people’s condition isdeteriorating and will help you evaluatewhether more people are managing theirexacerbations without being admitted.If you do not do this, you will not findthe right patients when you search yoursystem

• Do not just focus on the documentationfor self management or care planning.The time and the skills are mostimportant

• How good is your current system or thecare you give? Look for indicators thatactually tell you what is happening, notwhat you think is or should behappening

Medicines management• Liaise with your pharmacist colleagues to

label rescue medication clearly so thatpeople know what it is for, when to takeit and what to do afterwards

• Check all patients’ inhaler technique atevery opportunity, and always beforechanging medication that does notappear to be working for them. It isessential to first check that you and allyour team are demonstrating inhalertechnique correctly; experience suggeststhat most people are not

Organisation• If capacity is a problem, look at demand

and capacity or Lean approaches to seehow you can use existing resources moreefficiently or to quantify the gap

• Templates are available for reviews andself management plans. You do notneed to develop these from scratch, butyou might want to adapt for local use toensure commitment from yourstakeholders

• Every project needs someone to takeoverall ownership; even if they are notformally called a ‘project manager’

• Be clear about what your aim is and youroverall objectives. Articulate what is youwant to achieve, by when, how muchand why, and make sure that everyonehas the same understanding whichavoids creeping outside the scope ofwhat you have originally agreed

• Do not rush to implement a solutionbefore you have truly understood theproblem or the issue. Take time tounderstand what really goes on atpresent and why. Process mapping andanalysis can help with this stage

• Engage your patients in the project andvalue their engagement. Patients shouldbe at the heart of every improvementproject

• Measure your baseline to determinewhere you are starting from. What areyou aiming for? Make the recording ofmeasurement easy so that it is doneroutinely. Use SPC (statistical processcontrol) or run charts to highlight thevariation in your current system overtime. If you do not measure, how willyou know whether you have made animprovement or not?

Top tips for service improvement

• Focus your effort; you can not doeverything at once. Driver diagrams canhelp you identify which factors will helpmove you towards your goal and Paretoanalysis can help you target your effortswhere they will have greatest impact

• Communication is vital to ensure thatthe project team know what ishappening and what their role is, and tomaintain momentum and support.Choose appropriate means and intervalsthat fit the team you are working with,and include other stakeholders too

• Document your progress. This does notneed to be complicated but will providea record of what, why, when and howyou did things that will be a usefulreference as time goes on, and captureslessons learned and best practice forfuture projects. It also helps you keeptrack of what has been achieved to date.This is especially helpful whenchange is incremental as it demonstrateshow much progress has in fact beenmade

Top tips for service improvement42


• Test innovation and change on a smallscale initially. We suggest using the Plan,Do, Study, Act (PDSA) cycle approach, asthis minimises disruption if anintervention does not work, and helps tobuild commitment and sustainability if itdoes

• Do not be afraid to ask for help or tofully utilise offers of support andresource

You can find more information on theimprovement tools mentioned above, andother techniques to help manage yourproject and deliver change, on the NHSImprovement website at:www.improvement.nhs.uk

Veor Surgery, Camborne, Cornwall“Think ABC to manage your COPD” – onepractice’s approach to improve patients’management of exacerbations

Angie Bennetts, Advanced NursePractitionerDr Peter Perkins, GPTelephone: 01209 611 199Email: [email protected]

NHS BlackpoolEmbedding the use of effective selfmanagement approaches in primary care

Ros InceProject Lead / Lead Nurse – Diabetes andRespiratoryTelephone: 01253 651316Email: [email protected]

NHS Stoke on Trent & NorthStaffordshire Breathe Easy GroupHow can support groups increase patients’ability to self manage?

Becky Gowers, Project ManagerPhone: 0116 249 5780Email: [email protected]

Sharon Maguire, Project LeadPhone: 01782 298286Email: [email protected]

Southampton University HospitalsNHS TrustThe role of secondary care in increasingconsistent use of self management plans toreduce OP attendance and emergencyadmission

Dr Tom WilkinsonRespiratory PhysicianTelephone: 02380 795341Email: [email protected]

Contact details

Victoria Practice, Aldershot, HampshireSystematic review of patients’ inhalertechnique and medication use

Clare WatsonClinical Pharmacist, Victoria Practice /Medicines Management Pharmacist, NHSHampshireTelephone: 07789 271953Email: [email protected]

Imperial College Healthcare NHS Trust &Central London Community HealthcareNHS TrustHow can respiratory specialists supportprimary care to improve management andreduce admissions?

Dr Irem PatelConsultant Respiratory PhysicianTelephone: 020 3311 7160Email: [email protected]

Surrey Community HealthcareEarlier identification of COPD patients andpreventing avoidable admissions

Vikki KnowlesCommunity Respiratory Team lead,Consultant NurseTelephone: 01483 782000Email: [email protected]

NHS West SussexSupporting people with moderate or severeCOPD to self manage through clinical andbehavioural interventions

Chloe DonaldGraduate Management TraineeTelephone: 01903 708513Email: [email protected]

Leicestershire County & Rutland PCTUnderstanding variation in primary caremanagement of COPD – using practice datato make the case for change

Dermot RyanCOPD lead LCR PCT, Woodbrook MedicalCentre, Loughborough LE11 1NHTelephone: 01509 239166Email: [email protected]

NHS SheffieldInformation to help target support topractices and patients, to reduce variation indiagnosis and management of COPD

Sue ThackrayDeputy Head of Development NursingTelephone: 07773 790915Email: [email protected]

NHS Improvement - LungCatherine BlackabyNational Improvement LeadEmail:[email protected]: www.improvement.nhs.uk/lung

Contact details44

NHS Improvement - Lung would like to thank all the national improvement project sites fortheir contribution both to the ongoing work to improve care for people with COPD and tothis document.

Thanks also go to Alex Porter, Senior Analyst at NHS Improvement and other members ofthe NHS Improvement - Lung team, for their expert input and to those project teammembers on the editorial team who produced this guide:

Rachel Collins, Programme Manager, South East CoastChloe Donald, Graduate Management Trainee, NHS West SussexRachel Haffenden, Respiratory Service Clinical Lead, Central London Healthcare NHS TrustDr Irem Patel, Consultant Respiratory Physician, Imperial College Healthcare NHS TrustDr Peter Perkins, GP, Veor Surgery, Camborne, Cornwall

For more information please contact Catherine Blackaby, National Improvement Lead:[email protected]

Acknowledgements

Acknowledgements 45

1 Calverley PM, Anderson JA, Celli B, et al. Salmeterol and fluticasone propionateand survival in chronic obstructive pulmonary disease. N Engl J Med007;356:775e89.

2 Sutherland ER, Allmers H, Ayas NT, et al. Inhaled corticosteroids reduce theprogression of airflow limitation in chronic obstructive pulmonary disease:a meta-analysis. Thorax 2003;58:937e41.

3 Adams SG, Smith PK, Allan PF, et al. Systematic review of the chronic care model inchronic obstructive pulmonary disease prevention and management. Arch Intern Med2007;167:551e61.

4 An outcomes strategy for people with chronic obstructive pulmonary disease (COPD) andasthma in England, Department of Health 2011 www.orderline.dh.gov.uk

5 Institute for Healthcare Improvement www.ihi.org

References

Contact details46

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managing copd as a long term condition: emerging learning from the national improvement projects

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