To challenge the existing theoretical construct in COPD management through implementing NICE Guidance in a joint working arrangement between Walthamstow West Locality, Waltham Forest PCT and GSK to improve COPD healthcare.
This example was originally submitted to demonstrate implementation of NICE guideline CG101. The guideline has now been updated and replaced by NG115. The example has been amended to reflect this and remains consistent with the updated guideline. NG115 should be referred to if seeking to replicate any aspects of this example.
Aims and objectives
Our high level aspiration was focused in a measured way by challenging the existing assumptions around COPD management and treatment, enhancing what we did well and replacing it with a new model of care based on National Institute of Care Excellence (NICE) guidance.
Our vision was to raise the aspiration of the local NHS, its partners and the public to close the gap in life expectancy by 2 years to improve health outcomes, comparable to the top performers, for this and future generations. Embodying this aspiration, was improving health by identifying and targeting the population at risk and to reduce the unmet health need.
The vision was that this pilot would contribute to reducing the mortality rate and those causes amenable to healthcare. Mortality from bronchitis, emphysema and other chronic obstructive pulmonary disease required special attention. Through pathway development, our aspiration was to increase access to personalised services and choice improving patient satisfaction at least to the national average. Reducing inequalities across Walthamstow locality by raising the standards of COPD management in primary care reported from the Quality Outcome Framework (QOF) to NICE standard of care. This should positively impact both diagnosed and undiagnosed patients and have a downstream benefit on hospital related costs from COPD. Our value streams are focused on an integrated approach to COPD management through continuous improvement in clinical education, personalised care and improving quality of life as well as optimising the management of patients with COPD in Waltham Forest. The COPD management pilot had multiple clinical and not clinical objectives which supported by primary and secondary objectives. It was intended to permeate across the COPD care pathway. It was recognised early on, that knowledge and understanding of the wider determinants of COPD, primary prevention, early detection, primary care, secondary/tertiary care and continuous support were all important considerations. T
he primary objectives were:
- To significantly improve reported experience of COPD reviews measured by quality of life survey.
- To increase awareness and understanding of their condition and treatment options as stipulated by NICE, comparable to the local baseline.
- Improve understanding and access to appropriate services and medicines as defined by local andnational guidelines.
- Increase the number of newly diagnosed COPD patients measured by the POINT audit tool, comparable to the local baseline.
- Reduce COPD exacerbations and improve data recording measured by POINTS and comparable to the national standard.
- To engage Healthcare Professionals and ensure adherence to the evidenced based care pathway and treatment protocols.
- Up skill Walthamstow West Group Healthcare Professionals understanding and management of COPD measured through local feedback and attendance of Professor Mike Roberts's educational meetings.
The secondary objectives were to decrease follow-up referrals and non-elective admissions to secondary care for COPD measured by the Hospital Episode Statistics (HES) data. Decrease in Length of Stay, Visits, Discharge into the community service. As well as reduce the number of inappropriate referrals to secondary care measured by reviewing read codes. Maximise the appropriate use of the intermediary service measured through reviewing the patient review data versus capacity.
Reasons for implementing your project
Understanding the health needs and demographics of the local population as outlined in the Joint Strategic Needs Assessment (JSNA) was the starting point. We undertook a baseline assessment of NHS Waltham Forest and the locality and found that performance was lower than average for prevalence for diagnosed COPD patients during 2007/2008. Although epidemiological data suggest that the actual prevalence should be much higher. The UK average prevalence was 1.4%, London, 0.9%, Waltham Forest 0.9%. However, the modelled prevalence suggests it should be 4.23% leading to a negative variance of 3.33%.
We considered the wider determinants indicated by demographic factors. Walthamstow has a transient, diverse population that is 41% non-white, relatively young population with high levels of tuberculosis, high levels of deprivation with expected reduced life expectancy. We accepted that the quality of health intelligence was an area for development that rapidly required reassessment because there was a gap between what were reported and actual health outcomes. NHS Waltham Forest ranked 148 out of 152 PCTs nationwide for COPD, while the QoF data indicated that health outcomes are positive.
The health burden on the local economy was significant as measured through Length of Stay, the number of emergency admissions and the number of emergency bed days for patients with COPD.
An assessment of the provider landscape of complimentary health services revealed poor integration and poor utilisation of the Pulmonary Rehabilitation Service. There was a gap in service provision because there was no intermediate care service that was adequately supporting COPD.
Our main acute provider performed extremely poorly in the national outpatient survey indicating that the patient experience was not satisfactory. We recognised that this position presented opportunities to improve efficiency, cost savings and productivity as well as the patient experience.
How did you implement the project
During 2008, Dr Gabriel Ivbijaro and Professor Mike Roberts, Whipps Cross Hospital Chest Consultant, believed that there was clear clinical justification to implementing changes based on empirical evidence and epidemiological data in Waltham Forest. Walthamstow had one of the worst reported COPD performances in the country. Through clinical leadership Dr Gabriel Ivbijaro mobilised support from the10 participating practices. He was able to commit all stakeholders to periodic mandatory training sessions as part of their internal governance arrangements to tackle clinical issues and share best practice. Coincidently, GSK was seeking to develop COPD education in Walthamstow West Locality to improve the level of care in COPD management at that time. GSK had an innovative bottom-up approach that applied their Patient Outcome Information Service (POINTS) auditing tool. It supported GP consultation by enabling structured patients reviews and providing customisable reports. Walthamstow West expected that there would be positive outcomes for patients outside the scope of the pilot to include Asthma patients.
An education programme for HCPs and patients was developed and implemented over the course of the project. The programme was delivered by a local secondary care Chest Consultant, Professor Mike Roberts and a Specialist Respiratory Nurse named Anne O'Malley. Anne was responsible for upskilling the HCPs in delivering of high quality patient care and equips patients with more information about their condition, options and treatment. This involved protected learning time at the practice level for regular HCP training and development.
An intermediate care service was set up to run two and half days per week managed through Anne O'Malley. An examination room was made available at the health centre. A dedicated practice GP lead and nurse from the participating practices ran respiratory clinics in their respective practices.
The results of the pilot are indicated in the supported material.
Progress was regularly monitored through periodic clinical reports and mandatory training sessions. The ten practices were given the opportunity to make recommendations regarding their key issues and challenges and this was incorporated into the service redesign. An outline of the main clinical results as reported in the supporting material:
- Significant improvements in NICE compliance
- Significant improvements in recording Exacerbations
- Significant improvements in recording FEV1
- Significant improvements in recording COPD Reviews
- Significant improvements in recording Breathlessness
- Significant improvements in clinical data quality
- Significant improvements in drug therapy
- Redesign of clinical pathway in line with best practice
- Significant reduction in Length of Stay by 186 days 27%
- Significant cost saving in year for non-elective admissions by £35,000
- Opportunity to make cost savings of £500,000 over 3 years
- Significant improvements in the patient experience measured by the Quality of Life survey
- Upskilling of GPs and Health Care Professionals
- Collaborative working across all providers
Key learning points
- Clinical leadership
- Focus on building sustainability
- Develop GP and HCP accreditation programme
- Review appropriate on-going practice level support
- Build health intelligence model
- Apply matrix working approach
GlaxoSmithKline UK worked in partnership by supporting the implementation of the COPD pilot by facilitating educational sessions, resources and making available the Patient Outcome and Information Service (POINTS) intelligence tool.