Commissioning a pulmonary rehabilitation service for patients with COPD

Nearly 900,000 people in the UK have been diagnosed as having chronic obstructive pulmonary disease (COPD), and half as many again are thought to be living with COPD without the disease being diagnosed. The symptoms of the disease usually develop insidiously, making it difficult to determine the incidence. Most patients are not diagnosed until they are in their fifties.

COPD is the sixth most common cause of death in England and Wales killing more than 30,000 a year; and morbidity is high with patients needing frequent primary and secondary care input. The population prevalence of COPD is expected to increase over time due to ageing of the population, and the cumulative effect of smoking.

In 2004, NICE published clinical guideline CG12 for the care of people with COPD that highlighted the importance of pulmonary rehabilitation in improving patients' quality of life. The guideline provides recommendations on the core components to include when setting up a rehabilitation programme, but methods of provision can vary between community settings and secondary care.

See the NICE clinical guideline CG12 and the full guideline on chronic obstructive pulmonary disease for the recommendations on the management of COPD, and the evidence on which they are based.

Benefits

The potential benefits of robustly commissioning an effective pulmonary rehabilitation service for patients with COPD include:

• improving health related quality of life, patients' functional and maximum exercise capacity, and reducing dyspnoea
• developing and improving support in the community
• reducing the length of hospital stays.

Key clinical issues

The key clinical issues, as identified in the NICE guideline on the management of COPD, are:

• offering pulmonary rehabilitation to patients who consider themselves functionally disabled by COPD (usually dyspnoea of MRC [Medical Research Council] grade 3 and above), but noting that pulmonary rehabilitation is not suitable for patients who are unable to walk, have unstable angina or have had a recent myocardial infarction
• offering pulmonary rehabilitation at times and venues suitable for the patient within a reasonable time of referral
• providing programmes that are multicomponent, multidisciplinary and tailored to the individual patient's needs.

National priorities

National priorities and initiatives relevant to commissioning services for patients with COPD include:

• ‘World class commissioning'.
• ‘The NHS in England: The operating framework for 2009/10'.
• Meeting the diagnostic pathway milestones.
• 'Delivering the 18 week patient treatment pathway'.
• ‘Improving chronic disease management'.
• The ‘Care closer to home' initiative outlined in chapter 6 of the white paper ‘Our health, our care, our say'.
• Considering the impact of patient choice.
• The ‘Expert patients programme'.
• Meeting targets for key diagnostic service indicators, which are core standards within the Healthcare Commission's annual health check.
• Implementation of NICE clinical and public health guidelines. These are currently core standards, and performance against these standards will be assessed by the Care Quality Commission in line with ‘Standards for better health'.

Although many or all of these priorities may be relevant to the services nationally, your local service redesign may address only one or two of them.