This document reviews current COPD needs and services for Richmond patients and puts forward recommendations to improve the quality of care in the community.
Development of a COPD pathway remains a priority for NHS Richmond Clinical Commissioning Group (CCG), which is included in the 2015/16 Commissioning Intentions for planned care and Better Care Fund. The intention is to invest in integrated community services that provide care closer to home and reduce the number of emergency hospital admissions. COPD is one key area identified to target to achieve a reduction in avoidable admissions.
There are around 835,000 people currently diagnosed with COPD in the UK and an estimated 2,200,000 people with COPD who remain undiagnosed. Smoking is the greatest risk factor in the development of COPD. COPD is one of the most common causes of emergency admissions to hospital and one of the most costly inpatient conditions to be treated by the NHS. Ten percent of acute admissions for COPD are in people without a prior diagnosis of the condition. If these patients are identified earlier, they can be managed properly, and possibly avoid acute admission.
NICE provides comprehensive guidance on the diagnosis, treatment, and care of adults with COPD, including clinical guidelines, pathways, and quality standards. The Outcomes Strategy for COPD and Asthma (DH 2012) covers prevention, case finding, early detection and organisation of care and should be considered together with NICE to make improvements across the range of COPD services.
In 2013/14, QOF COPD prevalence in Richmond was 0.95% (London: 1.1% and England: 1.8%). There has been a decline in COPD prevalence since 2011/12, with a -2% change from 2012/13-2013/14. However, the absolute number of people on the COPD register was on the rise until 2011/12, but has remained stable since then.
There is a wide variation in the prevalence between GP Practices, ranging from 0.3% to 1.6%. In England, it is known that deprived populations have the highest prevalence and the highest under-diagnosis of COPD[i]. However, there is a weak correlation between COPD prevalence and index of multiple deprivation in Richmond, based on the deprivation score of GP Practices. This could be due to under-diagnosis of COPD in the deprived areas.
Modelled estimates (2011) for Richmond suggest that the expected prevalence of COPD for the population should be 3.35% (5,093 patients), which is more than triple the current prevalence of registered COPD patients (around 3,000 extra patients). This may be due to a proportion of patients who are currently undiagnosed; however this model may also over-estimate the number of people with COPD in Richmond.
An estimated 11.4% of adults (age 18 and over) in Richmond smoke (London: 18.4% and England: 17.3%). The prevalence is based on a survey; thus it is an estimate and not true prevalence, and the estimate has fluctuated over the last few years.
The Commissioning for Value (2014) work programme highlighted key indicators and improvement opportunities (compared to the average of 10 CCGs most similar).
Areas where NHS Richmond CCG are performing better include:
- % of COPD patients with a record of FEV1
- % of COPD patients with a review (15 months)
- <75 Mortality from bronchitis, emphysema and COPD
Areas where NHS Richmond CCG are performing worse, though not statistically significant from the average of the 10 most similar CCGs, include:
- Reported to estimated prevalence of COPD
- Non-elective spend
Admissions for COPD in Richmond are higher than would be expected for the demographic of NHS Richmond CCG. Emergency admissions and re-admissions for COPD are largely preventable through better case management. Around 30% of admissions were short stay (0 or 1 day), and a high proportion of these short stays may have been treated in their homes with appropriate support and treatment.
In Richmond, the 3-year average (2011-2013) for deaths due to COPD was 40.7 directly standardised rate (DSR) per 100,000[ii] (England: 51.5 DSR and London: 50.9 DSR. The most recent life expectancy gap analysis for Richmond shows that respiratory diseases account for 33% of the gap in life expectancy for females and 20% for males, between the most deprived quintile and the least deprived quintile[iii]. Over the period of 2010-2012, it is estimated that there were 30 excess deaths among females due to COPD in the most deprived quintile area of Richmond.
Case Finding and Early Detection
There are a number of people with undiagnosed COPD and further work around case finding and early detection is needed to identify these people and provide them with appropriate care in the community. There is potential for case finding initiatives through GP practices, community pharmacy, and stop smoking services, focusing on deprived areas with higher smoking prevalence and high risk groups.
- HRCH Respiratory Care Team (RCT)- provides a respiratory specialist service in the community for adult patients with long-term respiratory conditions
- Stop smoking- one of the most important and cost effective components of management and support is available through community pharmacies, GPs, the dedicated stop smoking service ‘Kick It’ and outreach clinics
- Physical activity- promote regular physical activity in all people with COPD and refer to appropriate physical activity services
- Pulmonary Rehabilitation- The RCT provides pulmonary rehabilitation, comprising individualised exercise programmes and education
- Immunisations- offer annual flu vaccine and one off pneumococcal vaccination
- Medicines optimisation- for local prescribing advice, based upon national guidelines and local Trust formularies, refer to NHS Richmond CCG Medicines Optimisation Team COPD Briefing Sheet
- Patient review- review people with mild/moderate COPD at least once a year and those with very severe COPD at least twice a year, in line with NICE guidance
- Psychological therapy- clinicians should assess and address co-morbid mental health problems in patient reviews, and refer to Richmond Wellbeing Service
- Patient Support Group- weekly group, ‘Breathe for Life,’ for people with respiratory conditions, providing an opportunity to discuss and share experiences
- Self-management- support people to self-manage their condition through self-treatment at home, Expert Patient Programme, and health improvement services.
- Richmond Response and Rehabilitation Team- health and social care support packages to regain independence and wellbeing, for prevention of hospital admission, hospital discharge, or community rehabilitation
- Managing exacerbations- prescription for emergency exacerbation medication provided following diagnosis and identification of being at risk of exacerbations
- Oxygen Therapy- provision is for more advanced cases and is managed by RCT
- Enhanced Service for Avoiding Unplanned Admissions- practices identify patients at high risk of admission and manage them using risk stratification tools, a case management register, personalised care plans and same day telephone access.
- GRASP-COPD- audit tool that can support GP practices with case finding, early detection, and management of their COPD patients
Because of the chronic nature of COPD, the terminal phase is often not detected by clinicians until death is imminent. As a result, people who are dying and their carers frequently do not receive appropriate care. The Richmond End of Life Care target is to increase the proportion of people who die in their usual place of residence from 39% in 2012-13 to 44% in 2015-16[iv]. Patients with end-stage COPD, their family, and carers should be informed of the full range of information on end of life care services.
These recommendations were developed in consultation with key stakeholders:
Primary and Community Care
- Identify patients with COPD early through pro-active case finding
- Ensure all newly diagnosed COPD patients have access to community respiratory care, through referral to HRCH Respiratory Care Team
- Health care professionals support self-management, refer to appropriate services, and develop self-management plans
3a. Promote regular physical activity in all people with COPD and refer to appropriate services
3b. Refer to Psychological Therapies
3c. Refer to Expert Patient Programme
3d. Promote AirTEXT service for information on air quality
- Ensure changes/updates to provider contracts (completed action)
4a. Incorporate recent evidence based guidance within provider contracts
4b. Monitor equalities data in provider contracts
Community Based Specialist Care and Acute Care
- Reduce avoidable emergency hospital admissions
- Develop a local respiratory care group to improve coordinated care
End of Life Care
- Assess people with COPD for end of life care needs and refer for appropriate treatment and support
7a. Identify people at risk of deteriorating health and dying, using the Supportive and Palliative Care Indicators Tool (SPICT™)
7b. Adapt end of life care pathway for COPD specific patients (NHS Improvement), reflecting local provision for COPD patients
7c. A focus on personalisation and choice at the end of life, including improved information regarding different service options and the types of support available
The COPD Care Pathway Review will be presented and discussed at the Richmond & Barnes Clinical Network and Teddington, Twickenham, and Hampton Clinical Network in November 2015. NHS Richmond CCG will lead on taking forward recommendations, with support from Public Health. Additionally, relevant stakeholders will be included to inform planning and delivery of the recommendations.
[i] Department of Health, An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England, July 2011.
[iii] LBRuT Public Health, JSNA Newsflash: Segmenting Life Expectancy Gaps, January 2015.
[iv] London Borough of Richmond upon Thames and NHS Richmond CCG, Better Care Fund planning template – Part 1, July 2014.
Topic Lead: Usman Khan, Public Health Principal
Date of publication: September 2015