Joint Strategic Needs Assessment

The current pattern of service utilisation is not the most cost effective in particular the high rate of hospital admissions. Opportunities to reduce costs include:

• Ensuring a more systematic evidence based approach to care management in primary care in line with NICE guidance
• The continuing development of a community based COPD service. Further work is required to ensure that they are targeted at the right people, capacity is regularly reviewed, and support mechanisms are in place (including access to pulmonary rehabilitation)
  
• Based on 06/07 admission data, there were 108 admissions of two days or fewer indicating that an admission to acute hospital care was not required. The establishment of a day assessment and treatment service can offer a more cost effective alternative to hospital admission for this group of patients.
  
• Lack of targeted approach for smoking cessation services
• Inadequate access to oxygen and/or nebuliser assessment services
• Inadequate information and education available for patients

• Improve access to accredited spirometry services at diagnosis;
• Introduce a practice based template to improve the basic management of COPD patients in primary care, in accordance with NICE;
• Develop and implement Personalised Care Plans (to include better information about COPD, self management, and how to access appropriate services);
• Introduce best practice medication reviews for COPD patients;
• Improve the uptake of smoking cessation services by reviewing the appropriateness and targeting of services for COPD patients;
• Increase access to the PCT COPD Team (including pulmonary rehabilitation) by expanding the capacity of the service;
• Procure a Home Oxygen and Nebuliser Assessment Service;
• Redesign the urgent care pathway for known COPD patients to facilitate quicker access to secondary care assessment services to avoid an unnecessary admission.

The major risk factor for developing COPD is smoking – for information on those at highest risk of smoking; see the separate smoking chapter of the JSNA. High levels of deprivation are linked to high smoking and high COPD prevalence. Associated socio-economic factors such as poor diet and housing compound both the incidence of COPD and exacerbate the already poor health of patients with established respiratory conditions.

The most deprived areas of Nottingham City PCT have a rate over six times higher than the most affluent.

COPD claims around 140 deaths per year across the city. Although this accounts for only 5% of deaths overall, over 40% of these deaths are of people aged under 75 years. The rate of premature deaths in Nottingham City is approximately twice that of the County.

The estimated prevalence of COPD nationally is between 9% and 11% of the population (Thorax 2004). However the disease is generally under-diagnosed, and as shown in Figure 1 below, there are potentially two-thirds of people with COPD undiagnosed across Nottingham City.

There are 4,525 people with diagnosed COPD on GP registers (QOF Dec 08). Fig. 1 shows the numbers for the 3 largest GP clusters (using March 2007 data).

Fig.1 People with COPD on GP registers and estimated prevalence

Hospital admissions

As a chronic condition, patients with COPD are likely to have multiple admissions to hospital over time. There are up to 1,000 admissions a year across the city with a primary diagnosis of COPD, a large proportion of which are multiple admissions of the same patient (997 patients were admitted 1,900 times over two years; eleven patients were admitted 173 times between them). These figures do not include admissions where COPD was secondary to the main reason for admission and thus will underestimate the full impact of COPD.

In some practices, one or two individuals accounted for over half the admissions. In the City Central cluster, one individual accounts for 10% of the admissions: this individual was admitted 31 times with COPD as a primary cause over the two year

Analysis of a sample of postcodes of individuals admitted to NUH with COPD showed the most prominent Mosaic groups in that sample were G, H & I (Nottingham HIS 2007). Groups G (20%), H (11.6%) and I (3%) make up 34% of Nottingham’s population. I is a small group within but made up 22% of all the admissions in the sample so a considerable burden. Mosaic indexing shows that group I are nearly 3 ½ times more likely than average to be admitted with COPD. Maps showing the distribution of these groups within Nottingham can be found here.

Issues of Inequality

As discussed above, high levels of deprivation are linked to high smoking and high COPD prevalence. The most deprived areas of Nottingham City PCT have a rate over six times higher than the most affluent.

COPD Audit
An audit designed by primary and secondary care clinicians aimed at finding out whether the care provided is in line with NICE guidance was carried out looking at hospital admissions between November 2007 and March 2008. This audit also considered admission circumstances and questioned how patients were managing their condition prior to admission. The completed audit provided the PCT with a huge amount of information about the care currently provided.  Some examples of the audit headlines include:

• 41% of admitted patients had spirometry at diagnosis (enables confirmation of diagnosis and grading of the severity of disease);
• 17% of patients had self management plans;
• 44% were current smokers, 52% being ex-smokers;
• 23% of patients who met the NICE criteria had been assessed for oxygen therapy;
• Many patients were not receiving the appropriate medication and treatments or did not have supplies at home in case of an exacerbation of symptoms – work is currently being done to further interrogate the audit data;
• Peak admission times were 12 – 2pm and 6 - 8pm;
• 14% of patients felt their preferences about being treated at home or in hospital were not taken into consideration;
• 45% of patients with an MRC (Medical Research Council dyspnoea scale) grade 3 or above were offered pulmonary rehabilitation;
• 48% of patients were under the care of the PCT COPD Team (patients were more likely to have a self management plan, regular reviews and less admissions per exacerbation);
• 37% of patients felt they had enough information about the current state of their COPD.

Community Services

• Variable levels of spirometry provision in primary care
• Community based case management service (community matrons) for patients with more than one long-term condition and complex needs using Combined PARR risk modelling tool to identify patients with highest risk
• Community COPD service comprising specialist nurses, respiratory physiotherapists, occupational therapist and community support workers, currently supporting around 150 patients (also using Combined PARR risk modelling tool to identify patients with highest risk)
• Pulmonary rehabilitation programme, available at venues across the City with unexpected under-utilisation

Telephone outreach service
The PCT is also currently commissioning a large scale pro-active telephone based care management service for people with long term conditions, in the first instance focusing on diabetes and COPD but with a view to including other diseases or other areas eg obesity.

Issues raised by Equality Impact Assessment
Community COPD service is not accessible equally across the city, nor are they currently targeted at highest levels of need

Notable changes since JSNA April 08
Combined PARR predictive risk modelling tool implemented

Case management services more embedded into mainstream services

Procurement of the Telephone Outreach service to improve self-management of Long Term Conditions (to be in place 2009/10)

Addressing the identified under-diagnosis of this disease and ensuring a more systematic approach to management will lead to an increased demand on community services over the next 3-10 years. However, early diagnosis and effective interventions and treatment by primary care and enhanced community services should in time lead to a decrease in the demand on acute hospital care.

There are NICE guidelines for the management of COPD in the community and clinically proven ways of adjusting therapy to reduce hospital admissions. A National Service Framework for COPD is expected to be released before the end of 2008.

• British Thoracic Society Guidelines. Standards for Clinical Care. (2004)
• NICE COPD Guidelines. Standards for Clinical Care. Clinical Guidelines 12 (February 2004)
• The National Service Framework for COPD is due to be published in early 2009; it is anticipated it will highlight the following: Reduce inequalities in COPD care; Reduce healthcare utilisation costs; Develop a patient focused care pathway; Provide outcome measures for monitoring and measuring progress.
• Our Health, Our Care, Our Say (DH 2006) – highlights the importance of the movement of specialist care into a primary care setting, which is a key driver for the development of COPD services.
• Supporting People with Long-Term Conditions (DH 2005)
• British Lung Foundation - Invisible Lives. Chronic Obstructive Pulmonary Disease (COPD) – finding the missing millions (November 2007)

COPD stakeholder event July 2008
The results of the COPD audit were presented at a stakeholder event on the 10th July 2008. Feedback was collated and the event’s recommendations have shaped the recommendations for commissioning.

The current pattern of service utilisation is not the most cost effective in particular the high rate of hospital admissions. Opportunities to reduce costs include:

• Ensuring a more systematic evidence based approach to care management in primary care in line with NICE guidance

• The continuing development of a community based case management service. Further work is required to ensure that they are targeted at the right people, capacity is regularly reviewed, and support mechanisms are in place.
  
• Based on 06/07 admission data, there were 108 admissions of two days or fewer indicating that an admission to acute hospital care was not required. The establishment of a day assessment and treatment service can offer a more cost effective alternative to hospital admission for this group of patients.

• Improve access to accredited spirometry services at diagnosis;
• Introduce a practice based template to improve the basic management of COPD patients in primary care, in accordance with NICE;
• Develop and implement Personalised Care Plans (to include better information about COPD, self management, and how to access appropriate services);
• Introduce best practice medication reviews for COPD patients;
• Improve the uptake of smoking cessation services by reviewing the appropriateness and targeting of services for COPD patients;
• Increase access to the PCT COPD Team (including pulmonary rehabilitation) by expanding the capacity of the service;
• Procure a Home Oxygen and Nebuliser Assessment Service;
• Redesign the urgent care pathway for known COPD patients to facilitate quicker access to secondary care assessment services to avoid an unnecessary admission.

The COPD audit will be repeated for hospital admissions during the winter period of 2009/10 which will inform the PCT of the impact of implementation of the recommendations and provide further evidence of service issues.

Shirley Smith, Assistant Director of Commissioning Community Services, Nottingham City PCT, Shirley.smith@nottinghamcity-pct.nhs.uk
Dr Rashbal Ghattaora, GPwsI Public Health, Nottingham City PCT, Rashbal.ghattaora@nottinghamcity-pct.nhs.uk
Sharan Jones, Health and Wellbeing Manager, Nottingham City Council, sharan.jones@nottinghamcity.gov.uk