Managing COPD as a long term condition: emerging learning from the national improvement projects

1. NHS
CANCER
NHS Improvement
Lung
DIAGNOSTICS
HEART
LUNG
STROKE
NHS Improvement - Lung
Managing COPD as a
Long Term Condition:
Emerging Learning from the
National Improvement Projects

2. Patients and their carers are the reason the health service exists
and therefore they should be at the heart of our services. Service
redesign and improvement generate opportunities to involve
service users who will provide a different perspective on the
service, so that we can better understand whether our service or
improvements make any difference to the patient.
Only when we understand patients’ needs – by asking them, not
second guessing – can we work in a way that meets those needs
and ensures they get maximum benefit from our service.

3. 3
Managing COPD as a Long Term Condition - Emerging
Learning from the National Improvement Projects
Contents
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 Trent
and North Staffordshire Breathe Easy Group 14
The role of secondary care in increasing consistent use of self management plans to reduce
outpatient 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 and
reduce admissions? Imperial College Healthcare NHS Trust & Central London
Community 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 through
clinical 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 to
make 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 reduce
variation 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

4. 4 Foreword
Foreword
Since July 2010, NHS Improvement – This publication contains information for
Lung has worked with a number of healthcare professionals and those
clinical teams across England as part of working in commissioning or interfacing
the Department of Health Respiratory with COPD services. This includes those
Programme. Its aim has been to support who are:
the development of patient centred,
evidenced based and clinically led services • Involved in the care of patients who
by identifying and sharing innovative require COPD services
ways to reduce variation in care and • Responsible for commissioning COPD
improve the quality and experience of services Professor Sue Hill
patients with chronic obstructive • Managing COPD services
pulmonary disease (COPD). • Local or regional leads
The national improvement projects have The project sites were encouraged to
tested approaches at key stages of the employ a range of service improvement
clinical pathways which have included: tools and techniques. These included
process mapping, demand and capacity
• Improving home oxygen services and data analysis, the application of Lean
• Early accurate diagnosis principles, process redesign and the
• Transforming acute care human dimensions of change. NHS
• Managing COPD as a long term Improvement - Lung also supported the
condition testing of new ideas and pathways
• Improving end of life care through site visits and project team peer
support. Dr Robert Winter
Following the first six months of the
improvement programme, this There are lots of practical examples within
publication signals the mid-way point in this report to support clinical teams in
the project cycle and has been written to delivering quality and productivity
share the learning from the testing phase benefits to patients and a wider range of
of the work. Through a series of case stakeholders. Over the next six months,
studies and examples, it aims to highlight NHS Improvement – Lung will continue to
areas of innovative and emerging good test the key principles for change and
practice that can be used locally to deliver implementation. As this learning
improvements for COPD patients and emerges, it will be shared with COPD
their carers. services and the wider NHS.
In order to address the paucity of current We would like to take this opportunity to
evidence, particularly around the models thank the project sites for their hard
and principles of implementation, the work, dedication and commitment and
programme will continue to adapt and look forward to the full extent of the
refine the learning. However, these improvement work as it comes to fruition.
lessons will be of value now to any team
working to improve the care it delivers
and commissions for people with COPD.
The publication contains a number of
examples that demonstrate value for Professor Sue Hill
money, increased productivity and Dr Robert Winter
approaches that can sustain Joint National Clinical Directors
improvements over the long term. for the Respiratory Programme

5. Executive summary 5
Executive summary
Chronic obstructive pulmonary disease Summary of emerging learning that issues of significance to the patient are
(COPD) is a progressive disease and cannot The early learning from the project sites to also explored, and this is highlighting the
be cured. However it can be treated, and date demonstrates some of the practical need to consider how best to provide
with the right care the impact of the disease issues around implementing those elements regular review for those patients with co-
can be modified1,2,3. In particular, effective of supported self care and good chronic morbidities. It is essential that support
management of medications, regular disease management that we already know between reviews is also optimised, and early
review, care planning and self management to be effective. This highlights not only indications are that a systematic approach
can help people cope with their disease and what works and how people are doing it, to provision of rescue medication and
reduce the need for hospital admission. but also what barriers still exist and where follow up for exacerbations can reduce
we still need to find solutions to enable demand for GP urgent appointments or
The intention of NHS Improvement - Lung’s people to adopt best practice. home visits, as well as admissions for some
workstream on Managing COPD as a Long patients. Optimising medications use, along
Term Condition is to demonstrate how self Improving people’s ability to self with systematic and opportunistic checks of
management, regular review and medicines manage: Implementing effective support inhaler technique, and regular staff training
management can best be delivered and for people to manage their condition more in how to demonstrate it, can further
how they can affect outcomes and use of effectively requires time, excellent improve patient adherence and reduce
healthcare resources. This in turn can communication and motivational waste, with cost savings of 10%
improve patients’ experience, the interviewing skills, as well as focused effort. demonstrated in one site.
progression of their disease and their need Early indications are that a comprehensive
for hospital admission when their condition consultation of at least 30 minutes – and Use data to make a difference: COPD
flares up. probably 45 to 60 minutes – is required to exacerbations are not consistently coded in
establish rapport with the patient and general practice but addressing this allows
The recently published outcomes strategy identify the issues that need to be rapid identification of patients whose
for people with chronic obstructive addressed in order to have greatest impact. condition is beginning to deteriorate and of
pulmonary disease (COPD) and asthma4 This is a challenge for teams to implement how well exacerbations are being managed.
highlights the need to focus on high quality within existing resources and ways of doing A key indicator is the proportion of
care and support, in particular the effective so need further exploration and testing. It exacerbations resulting in admission – good
management of patients with COPD using also appears that working closely with a management means exacerbations are
chronic disease management approaches. team and a group of patients appears to recognised, but early intervention should
In this initial phase of the programme, the have greater impact than a large scale roll mean fewer admissions and lower length of
projects have been exploring the reality of out of a common approach, which can take stay. Significantly more information is
making this happen – systematically taking longer to become embedded in practice. available from primary care systems than is
stock of current practice and understanding Various self management plans have been captured by practices’ Quality and
how to ensure that patients receive optimal developed and are in use, and clear Outcomes Framework (QOF) score and this
care, in a climate where there are limited documentation of a self management plan can be used to highlight how well COPD is
resources. helps ensure a consistent approach, but the being managed across primary care, the
real key is professionals’ approach to the marked level of variation that exists and the
This interim publication summarises the planning that they do with the patient, impact that this has on secondary care use
work of the projects at the mid point of rather than the plan documentation itself. and prescribing. While providing the data
their duration, and highlights the early alone does not instigate change in practice,
learning and emerging themes that will Management of COPD: Making time for it does allow a much more comprehensive
inform the next stage of work. This learning a comprehensive consultation including self picture of the current position to be
may also be helpful for both primary and management support ensures that patients’ developed and intervention to be targeted
secondary care in supporting their regular reviews are of maximum value. to drive up quality and reduce waste.
commissioning plans, with its emphasis on Various templates are becoming available to
patient centred care and delivering the support clinical checklists, but it is important
quality, innovation, productivity, prevention
(QIPP) and safety agenda.

6. 6 Executive summary
Summary of projects Leicestershire County & Rutland Primary Many of the measures outlined in this
Veor Surgery, Cornwall: Trialling a Care Trust with Optimum Primary Care: document are designed to support the NHS
systematic approach to improving patients’ Understanding variation in primary care to meet the QIPP challenge, either by
recognition and management of management of COPD and using practice identifying where resources might be
exacerbations using self management data to make the case for change. released or by improving understanding of
action plans and rescue medication. the key interventions that have greatest
NHS Sheffield: Using information to effect.
NHS Blackpool: Developed a target support to practices and patients, in
comprehensive self management plan with order to reduce variation in the diagnosis Success for many of the Managing COPD
patients and tested ways to embed use in and management of COPD. projects will be indicated by their impact on
primary care. frequency or severity of exacerbation, and
Quality Innovation Productivity and the proportion of exacerbations that result
NHS Stoke on Trent & North Prevention (QIPP) and expected in admission, as well as by patient
Staffordshire Breathe Easy Group: outcomes satisfaction measures.
Exploring what impact patient support Demand for healthcare is increasing and
groups can have on people’s use of health there are areas where we could increase the Early examples of QIPP impact include:
care resources and their ability to self quality, efficiency and value for money of • A systematic approach to self
manage. services as well as improving outcomes for management and early intervention for
people with COPD. Efforts need to be exacerbation is beginning to demonstrate
Southampton University Hospitals concentrated on three components to make a reduction in the proportion of
NHS Trust: The role of secondary care in this possible. First, improving quality whilst exacerbations admitted, releasing
improving patient self management to improving productivity, using innovation capacity in secondary care
reduce outpatient attendance, emergency and prevention to drive and connect them. • In secondary care or specialist teams,
admissions and readmissions. Second, having local clinicians and targeted intervention with those patients
managers working together across who have repeated admissions is also
Victoria Practice, Aldershot: Testing the boundaries to spot the opportunities and beginning to demonstrate reduction in
impact of a practice clinical pharmacist in manage the change. Finally, to act now for admissions.
systematically reviewing patient inhaler the long term. • Similarly systematic medicines
technique and medication use to improve management, inhaler technique
outcomes and make best use of resources. The ambition is to achieve efficiency savings education and medicines review is
of up to £20 billion for reinvestment over delivering savings of 10% or around
Imperial College Healthcare & Central the next four years. This represents a very £1,000 per month on respiratory chapter
London Community Healthcare NHS significant challenge to be delivered prescribing for a practice
Trusts: Exploring how respiratory specialists through the detailed work the NHS has
can best support primary care to improve already undertaken on QIPP and the Further examples and more details are
management and reduce admissions. additional opportunities presented in Equity contained in the improvement stories.
and Excellence: Liberating the NHS.
Surrey Community Healthcare: How It is anticipated that these examples and
teams can support earlier identification of In relation to the QIPP challenge, the NHS initial phases of work will demonstrate
COPD patients and prevent avoidable has been developing proposals to improve which elements of supported self care and
admissions. the quality and productivity of its services chronic disease management for COPD are
since the challenge was first articulated in key components, and which approaches to
NHS West Sussex: Supporting people to May 2009. The challenge is to ensure that implementation are most effective.
self manage with clinical and behavioural the NHS continues to make quality happen
interventions during a period in which growth in
expenditure on the NHS will be restricted
despite increased demand.

7. Executive summary 7
Potential for future work • The optimal time and components of an
It is known that patients who understand effective review from both patient and
what to do in the event of an exacerbation clinician perspective
are more confident to seek help earlier and • Practical ways of implementing this and
can avoid admissions, while regular delivering it within existing resources
medication reviews and inhaler technique • How to optimise medicines use and the
checks can help reduce waste in prescribing. impact of doing so on cost, experience
It is also acknowledged that while it is and use of other health care resources
critical to have access to tools like plans, • The key components that need to be in
reviews and templates to help patients place for patients to be able to effectively
manage their condition, effective self-manage and the benefits of doing so Phil Duncan
Director,
management needs to be underpinned by a NHS Improvement -Lung
set of skills, an approach and an This will allow the production of a model
infrastructure that will allow delivery. These that demonstrates what needs to be in
components can be considered as: place for care to be delivered effectively and
how to implement it, to ensure that every
• The resources that patients need minute of contact is used to maximum
• What professionals need to do effect, every time.
• The infrastructure that needs to be in
place to facilitate to delivery
For patients to be effectively supported to Catherine Blackaby
self care and for professionals to deliver National Improvement Lead,
chronic disease management successfully NHS Improvement – Lung
each of these components needs to be in Catherine Blackaby
place. The challenge now is to identify how Phil Duncan National Improvement Lead,
best to implement this consistently, reliably Director, NHS Improvement - Lung NHS Improvement – Lung
and cost effectively. Further work is also
required to identify the essential elements
and most effective means to put these into
practice, including: Components for effective delivery of supported self
care and ongoing management
• Planning for early intervention in the
event of exacerbation
• Medicines management and good inhaler Person who is informed,
willing and able to self care
technique
• Adequate time for regular review that
What the person needs
encompasses what is important to both e.g. written self management plan; regular review;
the clinician and the patient/carer and rescue medication; medicines; point of contact;
supports self management knowledge; confidence; carer support
• Skills to deliver support, education and
treatment What we need to do
e.g. inhaler technique checks; annual holistic review, patient
led consultation, prescribing, listening, referral, identify risk,
As a result the workstream will now focus support smoking cessation, planning for exacerbations
on demonstrating how to improve
management and self care for people with
What needs to be in place
COPD to reduce admissions, optimise e.g. motivational interviewing skills, 30 – 60 minute appointments,
medicines use and enhance patient data and information, access to specialist support, coding of patients
experience by testing: and exacerbations, accurate diagnosis; ongoing training

8. 8 Improvement stories: Improving patients’ ability to self manage
Improvement stories: Improving
patients’ ability to self manage
Key messages
• Just giving patients a plan and telling
them what they should do probably
won’t change behaviour
• Effort, time and skills are needed to
build rapport and focus on the person’s
own goals and motivation so that they
want to do the right thing
• Different approaches work for different
people
• We think that the more time you invest
up front with people, the less frequently
you will probably see them – we are
testing how to achieve this and how to
optimise resources
“ not the plan,
It’s
but the planning
that is important.
”

9. Improvement stories: Improving the patients’ ability to self manage 9
‘Think ABC to self manage your COPD’ - one
practice’s approach to improve patients’
management of exacerbations
Veor Surgery, Camborne, Cornwall
What were the issues? What we did
The Veor Surgery team wanted to test Initially, the team met and agreed its aims
whether chronic obstructive pulmonary and objectives; this was essential as it
disease (COPD) patients who had a self ensured all individuals stayed focused on
management plan, with courses of the task and would not get diverted into
antibiotics and steroids at home, could wider issues. Having identified the self
initiate medication early and so reduce management plan the task was then to
the need for hospital admission. identify those patients who would be
suitable for this type of patient pathway
The team already knew that early and invite those individuals for an
intervention reduces complications, but appointment. This took longer to
wanted to test whether a patient having arrange and organise and the impact of
a self management plan was sufficient patients who did not attend (DNA) was
and robust enough to enable them to significant as a longer appointment had
reliably and safely start their medication. been allocated.
Questions that arose from this initial The team were anxious to identify Once patients had committed to the
proposal included: suitable patients to test this approach. It programme they were assessed and base
• Was it safe for patients to take this was imperative to work with those line data was taken using the COPD
responsibility? individuals who would understand and Assessment Test (CAT) score. To alleviate
• Would they understand? accept the responsibility for self any patient anxieties about the risk of
• Would it create more work for the management, in order to minimise any rescue medication being inappropriately
practice? risks. used, the practice established a safety net
• Would patients feel empowered? system which entailed seeing patients
The decision was then taken to develop two days after the self initiated therapy.
Where did we start from? and adapt the existing self management This was to ensure the patients were
The team initially drew up a process map, plan which had been generated by the managing and that there were no existing
involving all team members and patient local hospital respiratory nurse. or further problems.
representation, to determine what
currently happens along the patient
journey. This highlighted the need to
identify which patients were being Process mapping to understand what currently happens on the patient’s journey
admitted and who provides what type of
care at each stage, particularly following
admission. The practice computer
records provided the register of COPD
patients required and in order to include
house bound patients the community
matron was invited to be involved within
the team. It was found that the practice
records provided plenty of baseline data
to initially start the project and it was
agreed that this was an accurate source
of information.

10. 10 Improvement stories: Improving the patients’ ability to self manage
A recording system was initiated in order • Can patients understand the plan? If • Keep numbers small and manageable
to identify major and minor significant not, why not? • Try and involve carers in the
events; it was also an opportunity to • Why don’t they follow the plan? consultation so they know and
highlight that the self management plans • Does early intervention increase or understand what to do and why. It can
were working and working safely. Once reduce practice work load? be frightening for the carer when their
data started to accumulate they were • Are self management plans cost partner is unwell so ensure they know
then in a position to reflect back on the effective? who to contact when, and what to
previous year’s exacerbations and for • Does early intervention reduce hospital look out for
each current year for a patient as it arose. admission? • Having a contact person and/or number
• Are patients happy with managing their that is not the GP can encourage
As time went on, they worked through own conditions? people to get in touch. They may not
several amendments to the plan, as • Have we done good or harm with self want to trouble the GP with their
changes were identified based on management plans? query, but might feel happier talking to
patients’ experience and feedback. a nurse, especially one they know deals
What have we learnt? with them when they are well
Where are we now? • Projects need to be flexible and be
The practice are now seeing patients adaptive as they are tried out in real life Above all try and answer the
shortly after they have self medicated and • It is essential to have a close working
question you have proposed
are ensuring that they have used the self team who understands the aim of the
management plan appropriately. It has project in order to be its driving force at the start of the project.
been noted that some patients do not and to seek further improvement
contact the practice after starting • Keeping focused on the aim of the Contact
medication and when questioned explain project can be challenging, particularly Dr Peter Perkins, GP
that this is because they are feeling better as projects generate lots of data and Angie Bennetts, Advanced Nurse
now and did not want to bother the then lots more questions Practitioner, Veor Surgery, Cornwall
doctor/nurse. As a single practice, the • Which of these questions need Email:
numbers are small so it is difficult to answering and which are for new angie.bennetts@veor.cornwall.nhs.uk
quantify or prove the impact on projects?
admissions, but the team is confident • Coding in a consistent manner is
they have avoided admissions for some fundamental and recording of data on
patients. For example, one patient who the computer system is paramount
had several admissions over the previous • Finding time to explain plans is
four months successfully managed an challenging, but important, to ensure
exacerbation at home just before that all patients understand the
Christmas which was very rewarding for implications of a self management plan
the team. • Safety nets are essential
• Record all eventualities including
Work so far has identified other questions successes and failures in order to learn
that arise from initiating self management from them
action plans:

11. Improvement stories: Improving the patients’ ability to self manage 11
Embedding the use of effective self
management approaches in primary care
NHS Blackpool
What were the issues?
Blackpool has a relatively high recorded
prevalence of chronic obstructive
pulmonary disease (COPD) at 2.6%, an
estimated prevalence of 5.9%, a smoking
rate of 31% and the 15th highest
mortality rate for COPD out of 152
Primary Care Trusts (PCTs). COPD makes
a significant contribution to the area’s
lowered life expectancy and as such was
recognised as an area for improvement.
While Blackpool has the highest total
spend per 100,000 weighted population
of English PCTs, the proportion of spend
in primary care is relatively low. All these
factors suggested that there was
significant scope to improve care
planning approaches in primary care with
a view to increasing patients’ ability to
self manage and so reduce unplanned
admissions.
Where did we start from?
• In 2007/08, there were 599 COPD What we did Patients also particularly liked the colour
non-elective admissions costing The team developed a self management charts for sputum which they felt would
£1.26 million plan through the respiratory steering help them to identify problems quickly
• There was no formalised self group, which includes patient input as and the visual aid colour chart was
management plan or approach in well as clinical representatives from reported as easy and simple to use. Local
routine use across the PCT area. primary and secondary care and from a contact numbers and services were also
• As part of a more integrated approach range of different disciplines. added as a specific request from both
to COPD care, the team wanted to The self management plan was tested in patients and clinicians.
improve both patient and clinician four practices with the ‘Breathe Easy
education in order to establish self Group’ and adaptations were made Patients named the plan ‘My Breathing
management and embed it within based on feedback before rolling out Book’ and it is coloured blue to make it
primary care so patients are able to more widely. easily identifiable.
manage their disease
This highlighted issues around A series of educational events for
terminology as well as identifying the stakeholders was provided, to ensure
time and commitment required to there was good level of awareness and
implement it. For example, patients understanding with regards to the self
requested they change ‘MRC scale’ to management approach and plan before
‘breathlessness scale’, and ‘sputum’ rolling it out.
rather than using the term ’phlegm’.

12. 12 Improvement stories: Improving the patients’ ability to self manage
Where we are now
The plan is initially being used to target
those most at risk of admission and the
combined predictive model is being used
to look for the most vulnerable group of
patients. It has been adopted so far by
all 22 practices and while it is too early to
say what impact it has had on admission
rates overall, one GP dedicated three
educational sessions to a patient who had
frequent problems in the previous 12
months. This has now prevented at least
one admission and embedded an
apparent change in understanding and
behaviour for that patient.
One practice is now testing group
sessions for patients as a means to
minimise the impact of any failures to
attend and to enhance the potential for
people to share experiences and provide
support.
Presently 40 plans are in place from the
original pilot with another 100 initiated
and data is still coming in from some of
the practices. It is also being used by
pulmonary rehabilitation, community
matrons, and the acute Trust.
To ensure that the self management plans
are being delivered appropriately and
uniformly, in order to underpin clinical
effectiveness and promote change.
changes to the way clinicians have
traditionally delivered learning are being
tested, including approaches used in
diabetes structured education.
To do this effectively clinicians need skills few practices. Standardisation in the
Some key aspects of this are: in setting measurable goals, negotiation, consistent use of Read codes has been
• To find out what is important to the and the ability to build rapport with the agreed with all practices in order to
patient, not what you think is patients. facilitate data capture and analysis. This
important for them in order to establish will also allow tracking of unplanned
meaningful goals and life style changes To determine what impact the plan is admissions for patients who have been
• For every piece of information you give, having, the team is currently monitoring given a self management plan and to
make sure you get some information admission rates on a high level. However, explore and identify reasons in gaps in
back to be meaningful the impact needs to be service or highlight any common trends.
• Try not to solve problems for people identified at a more personal level so
but encourage them to solve problems work is currently being undertaken with a
for themselves

13. Improvement stories: Improving the patients’ ability to self manage 13
By focusing on these few practices the Similarly, the time required to deliver
team will also be able to quantify the effective care planning for self
time required to plan effectively with management is significant. For practices
patients and evaluate the impact on total and other teams to take on this approach
contact time as well as secondary care it requires compelling evidence that it
admissions. does pay dividends, as well additional
guidance on how to do it with existing
What we learnt resources.
Involving all associated stakeholders,
including patients in developing the plan Contact
ensures it has greater relevance to them Ros Ince
and therefore there is greater Project Lead/Lead Nurse -
commitment to its value and use. The Diabetes and Respiratory
testing process allowed clinicians to Email: rosalyn.ince@blackpool.nhs.uk
experience the potential of the plan, and
to share knowledge and expertise with
colleagues at the launch of the project,
which was more powerful than just
providing research data or evidence. The
GP chair of the PBC endorsed the self
management plan and was actively
engaged in its launch and in promoting it
to all practices in Blackpool. One clinician
reported that investment in time was
essential in order to reap the rewards.
Clinical education is a vital component if
this approach is to be properly embedded
in practice. Just providing the self
management plans to patients will not
ensure its success. Clinicians need the
skills and confidence to take a different,
longer term approach in order to develop
rapport and instigate behaviour change
with patients.

14. 14 Improvement stories: Improving the patients’ ability to self manage
How can support groups increase patients’
ability to self manage?
NHS Stoke on Trent and North Staffordshire Breathe Easy Group
What were the issues?
The Primary Care Trust (PCT) is rated 11th
highest for COPD risk nationally with
people 38% more likely to be admitted
to hospital with COPD than elsewhere in
the UK. Stoke on Trent is an area of high
significant deprivation where the public
are less likely to engage with statutory
authorities, to initiate change in lifestyle,
or engage in effective self care. Working
with the British Lung Foundation and the
local Breathe Easy North Staffordshire
(BENS) patient support group offered a
different route to increase self care and
promote healthy activity. It was also a
way to evaluate how support groups can
best add value for patients.
Where did we start from? Members of the community respiratory team joining Breathe Easy North Staffordshire at
• 2% recorded prevalence with estimated a chronic obstructive pulmonary disease (COPD) awareness raising event in October 2010
prevalence of 5% (rising to 6.3% by
2020)
• Smoking prevalence of 30% compared
to national average of 21% • A health care professional from the • Monthly recording was implemented in
• Approximately 20 people from Stoke specialist community respiratory service order to capture the number of
on Trent attended BENS meetings each provides regular input to BENS group members attending Breathe Easy North
month at outset meetings to answer questions and offer Staffs meetings and the number of new
• There was significant variation in additional advice members
referral to/attendance at the local • Testing the impact of including referral • The Breathe Easy Group was involved in
Breathe Easy group by practice to the group as part of active care the official launch of the community
• Little knowledge and understanding of planning and self management for a respiratory service where they had a
who attends groups, why people don’t group of patients who have had workshop to raise awareness of the
attend, what is of greatest value to exacerbations group amongst healthcare professionals
patients who do attend and no formal • Establishing impact measures on the
recording of the benefits people get patient’s health status and confidence Where we are now
from being part of a group • Capacity was built in within the Breathe • The attendance of a health care
Easy group in order to support the professional at group meetings has
BENS did not monitor how those committee which included a new venue highlighted how many concerns people
attending find out about the group or the and better opportunities to promote have, and their reluctance to approach
numbers of new members joining. the group via the community or voice these in ordinary consultations.
respiratory service and at pulmonary Currently a list of frequently asked
What we did rehab questions are being determined from
• Established which practices do and do • The development of a Breathe Easy the meetings to identify any common
not refer to the group and working to welcome pack to be given out to new themes and how they might be tackled
raise awareness of the potential impact members, and formalised the process • Group members now have a slot on the
peer support can have for their for recording new members and where pulmonary rehabilitation programme to
patients, and how this can be tested they found out about the group highlight BENS group and the
• Developed protocols to allow easy data additional support they can provide
capture around membership

15. Improvement stories: Improving the patients’ ability to self manage 15
• Personal health budgets are currently
BENS membership by postcode - August 2010 being tested to see what impact they
7 have on supporting a person with
COPD to self manage
6
Number of members
5 What we learnt
• This is not a quick fix as the group only
4
meet once a month and it can take
3 time to witness changes. Measuring
the impact has taken longer than
2
anticipated because of time factors and
1 issues around data access. Evidence on
the group’s effectiveness depends both
0
Area A Area B Area C Area D Area E Area F Area G Area H Area I Other
on patient feedback (for example
around confidence and health status)
Home postcode of members
and measures of use of health care
resources, such as appointments in
primary care, and self management of
Referral source for members
exacerbation. In order for this to
6
succeed strong links and two way
5 communication must be present with
Number of members
primary care and patient consent
4 • Patients are more likely to raise
3
concerns in an informal environment
than in a formal consultation, which
2 may highlight issues relating to clinical
1
care elsewhere in the system
• While groups are not for everyone,
0 more patients could benefit from
Respiratory Newspaper Matron Rehab Hospital Not given
Physiology participation if professionals are aware
Potteries
Shopping
From
another
From a
friend
GP surgery Nurse
of their existence and consistently
Referral source promote theses groups within patient
support information
• It is proposed that further work over
Group membership by Stoke on Trent practice the next six months will define how
support groups can enhance patient
6
engagement with self management
5 and will specifically target one or two
Number of members
key practices to focus work with
4
patients whose condition is more
3 difficult to manage.
2 Contact
1
Becky Gowers, Project Manager
Email: becky.gowers@blf-uk.org
0
1 2 3 4 5 6 7
Sharon Maguire, Project Lead
Practice Email: sharon.maguire@stoke.nhs.uk

16. 16 Improvement stories: Improving the patients’ ability to self manage
The role of secondary care in increasing consistent
use of self management plans to reduce out patient
attendance and emergency admission
Southampton University Hospitals NHS Trust
What were the issues?
Self management plans were not widely
established across Southampton
University Hospitals Trust and the Primary
Care Trust (PCT). Previously approaches
were variable, with disparate initiatives
and lack of overall coordination. Patients
were confused about how to access care
appropriately, particularly during
exacerbations. The goal was to work with
commissioners and other local providers
to agree a uniform approach and a
common plan.
Where did we start from?
• High prevalence of chronic obstructive
pulmonary disease (COPD) modelled at
6% with the PCT identified as a
‘hotspot’ for the highest rate of COPD
admissions in the south of England
• Less than 10% of COPD patients under
the hospital COPD team had active self
management plans
A discharge support plan was also The possibility of developing a local,
What we did developed which included a variety of comprehensive integrated service which
We analysed attendance and admission measures that should be in place for all includes the hospital, community, primary
data for COPD patients using codes D39 COPD patients admitted. This work will care, social and emergency services is
and D40 (admission with acute also allow evaluation of how easy it is to now being examined. The benefits of
exacerbation of COPD) and route of entry implement and the impact it can have on implementing this type of service would
to hospital. readmissions. provide a patient centred approach
focusing on supported self management
This identified a group of 34 patients Where we are now with access to an array of support
who accounted for 176 admissions in a A simple self management plan has been services via a single point 24/7.
12 month period. Each of these patients developed for local use which it is hoped
had a one hour appointment with a can be more widely adopted.
consultant and respiratory nurse, often in How best to bring psychological therapy
their own home to help the team input into the pathway is now being
understand why they were attending. It explored as part of the patient
was also an opportunity to help the assessment or follow up.
patient to understand their condition Having identified a group of patients who
better and what to do in the event of an frequently use urgent care, work has now
exacerbation. They were offered a begun with the local ambulance service in
bespoke range of complex interventions order to improve use of oxygen alert
and support in self management. These cards, emergency oxygen therapy and
patients have subsequently only had eight general communication around patients
admissions in 12 months, a reduction of at risk of readmission.
90%.

17. Improvement stories: Improving the patients’ ability to self manage 17
What we learnt
Establishing the baseline data was time
consuming, but was essential to
understand:
• Who is being admitted most frequently
• Why they are being admitted,
particularly from their point of view
• What is happening in the course of an
admission to explain variation in length
of stay and readmission
• Time spent with patients to explain
their condition and understand their
concerns pays dividends
• There are gaps and overlaps in the
patient journey that need to be
understood in order to make best use
of available resources
• Ensuring a consistent discharge plan
may reduce readmissions
It is also vital to work with colleagues,
commissioners and other partners
involved in service provision, to maximise
the resources already in place to ensure a
consistent and coordinated approach
both to self management and to
exacerbation management.
Contact
Dr Tom Wilkinson
Respiratory Physician
Email: t.wilkinson@soton.ac.uk

18. 18 Improvement stories: Managing COPD
Improvement stories:
Managing COPD
Key messages
• Consistent recording of data across the • It is important to work together to
practice team is essential to allow improve management of COPD and
stratification, monitoring of deterioration develop consistent and reliable
and impact of changes in care approaches
• Inhaler technique is a key area for • Understanding the current system and
improvement in management – many why things do or don’t work well is
patients do not maintain correct important before you start
technique and many staff may not be • Change is slow and depends on people
demonstrating correctly. There may be working together
evidence of the cost effectiveness of • Data is essential. There is plenty of it
using trainer devices to improve available but it is important to identify
technique what is most useful and how best to
• Take time to understand what is present it. Targeting patients or practices
happening in your current system and with high resource use can help show
who is doing what. You may be able to benefits more quickly
do things more quickly, safely and
reliably without additional resources
• Significant variation across primary care
may not be immediately apparent.
Identifying low prevalence, high
admission rates and prescribing
performance can help target efforts
for improvement

19. Improvement stories: Managing COPD 19
Systematic review of patients’ inhaler
technique and medication use
Victoria Practice, Aldershot, Hampshire
What were the issues? • Common coding has been agreed for
The Victoria Practice is a five partner all practice team members in order to
practice of 8,352 patients based in identify and record exacerbations of
Aldershot. The practice was already COPD more accurately. It was decided
actively managing its chronic obstructive not to go back over previous records to
pulmonary disease (COPD) patients, but update coding as this would have been
wanted to ensure it was making best use a significant amount of work for
of available resources to deliver consistent marginal benefit. This could also
high quality care. Evidence from a highlight an increase in exacerbations
previous project on the Isle of Wight but will allow analysis of the proportion
suggested inhaler technique and that result in admission
medication adherence could help improve • Recording data such as prescribing
patient experience and reduce frequency costs for respiratory medicines on a
or severity of exacerbation, and use of statistical process control (SPC) chart
health care resources. The practice provides a good visual indicator of the
wanted to explore how best to do this, impact over time of regular review, Where we are now
using existing skills within the practice, optimising medication/device and • Identifying the best pathway for
including their clinical pharmacist. improving inhaler technique patients within primary care and how a
• Information from the practice system is practice team can best provide this.
Where did we start from? now being used to evaluate the impact This includes looking at who does what
• Prescribing costs for respiratory on admissions, medication use and and how consistent the way of working
medicine of £11,000 per month cost, and potentially appointment is between different team members, in
• Practice COPD prevalence: 1.58% (15.8 usage (routine vs. urgent) as the project order to achieve best use of skills and
cases/1000 patients.) progresses resources for maximum patient benefit
• Admission rate for COPD 10.6% (14
admissions in last 12 months)
• Four patients had two or more
admissions in previous 12 months SPC chart: Respiratory drug costs for Victoria Practice
• Four patients accounted for nine
admissions (out of a total from the
practice of 14)
• Inhaler technique baseline: 66 patients
with GOOD technique (663H) ; Ten
with POOR (663I)
What we did
• The practice systematically checked
inhaler technique and medication
review during the COPD annual check
• Patients now complete a COPD
Assessment Test (CAT) score at the start
of their planned review and at recall
after four weeks, where medication has
been changed, to see what impact the
change has had for them

20. 20 Improvement stories: Managing COPD
What we learnt Contact
• Consistent coding in primary care Clare Watson
teams is essential in order to Clinical Pharmacist Victoria Practice,
understand current performance and Medicines Management Pharmacist
impact on patient care or outcomes NHS Hampshire
• Regular consistent review of inhaler Email: clare.watson2@nhs.net
technique is essential as some patients
do not maintain good technique and
also for staff as they too need to be
regularly updated
• The use of devices to support good
technique is cost effective and certainly
reinforces correct methods
• Patients need time to assimilate
information: this team found it was
good practice to allocate two thirty
minute appointments with an interval
of a few weeks allowing patients more
time to consider what concerns they
may have and how they are coping
with medication or their condition,
rather than one 60 minute
appointment
• Longer appointments create a risk if
patients do not attend so it is important
to plan how this can be managed
• Other factors to consider:
• How many patients have correct
inhaler technique? and how many in
the practice staff team?
• How much is poor inhaler technique
affecting patient adherence and
prescribing costs? Poor technique
may result in patients not using
inhalers because they get no benefit
or it could be increasing prescribing
costs because medication is being
wasted through ineffective use
• How many exacerbations are patients
actually having and how many result
in admission? Good management
may increase the number of recorded
exacerbations but early identification
and intervention could reduce the
proportion that need to be admitted

21. Improvement stories: Managing COPD 21
How can respiratory specialists support primary care
to improve management and reduce admissions?
Imperial College Healthcare NHS Trust and Central London
Community Healthcare NHS Trust
What were the issues?
• Imperial College Healthcare NHS Trust
(ICHT) is the UK's first and largest
Academic Health Science Centre. Since
2005, ICHT and Hammersmith and
Fulham (H&F) Primary Care Trust (PCT)
(now named Central London
Community Healthcare NHS Trust) have
been working in a coordinated
partnership with the aim of improving
services for patients with chronic
obstructive pulmonary disease (COPD)
and other chronic respiratory diseases
• According to the Quality and Outcomes
Framework (QOF) 2007/08 there are
1908 patients diagnosed with COPD in
Hammersmith and Fulham (H&F),
representing a prevalence of only 1%
• This is below the national average
(1.6%) and is thought to be a
significant underestimate; modelled
prevalence predicts that the total
number should be in the region of
7,024 representing 3.7% prevalence • As part of a much wider approach the
overall redesign of the delivery of care was
• Wide variation in prevalence across all scrutinised in relation to how
general practices, ranging from 0.5% respiratory specialist nurses and
to 2.4% consultants could support primary care
• Even practices meeting 100% of their to deliver evidence based chronic care,
QOF targets as regards COPD diagnosis anticipatory care and case management
show low actual prevalence compared for patients with COPD and asthma
to that predicted working with clusters of practices
• No breakdown of the known COPD
population by disease severity Where did we start from?
• 28% of the local population To ascertain a starting point a baseline
(approximately 41,000 people) are assessment was undertaken of respiratory
smokers competency with primary care staff which
• Commissioners were looking for a included the delivery of workplace based
reduction in COPD hospital admissions and modular teaching on spirometry,
of 50% by 2013 and 30% reduction in COPD and asthma diagnosis and
secondary care outpatient attendances management. A baseline assessment was
by December 2011. A 10% reduction also established in relation to the QOF,
in admissions and readmissions was COPD, asthma registers, and degree of
targeted for July 2011 the National Institute for Health and
Clinical Excellence (NICE)2010 compliance
in management of COPD using the
POINTS audit system. This has shown
that management of these patients has
significant scope for improvement.

22. 22 Improvement stories: Managing COPD
What we did It has now been agreed with the public • Case management and anticipatory
As this was such a large scale project, it health team for them to provide the care for complex patients with onward
was imperative that efforts were targeted required data to support the redesign referral to community consultant clinic
and measurable. Initially process mapping process, as use of POINTS is not seen as a • A review of oxygen prescribing in the
commenced in relation to the open likely long term solution. The possibility of practice and gatekeeping methods
access spirometry and community comparing data from matched practices • Providing teaching sessions and ‘virtual
consultant clinics which calculated within not receiving RNS support has been clinics’ at practices, delivered by
the current systems the total amount of raised as a method of having some community respiratory consultants
time it took for a patient to be referred, control over the data.
seen and treated could be up to 12 What we learnt
weeks. This also identified that the real Where we are now • It is important to understand what is
time spent with the patient was only a There has been considerable change currently happening, and why. This
few hours. within the PCT which has resulted in the helped to highlight underlying problems
level of administrative support not being with the location and perception of one
The process mapping also identified areas as originally envisaged. However despite of the community clinics. It has also
in the system which needed more this we have already witnessed a 27% assisted in targeting practices where
detailed analysis in order to understand reduction in the number of acute additional support is required and where
why it took so long and where delays admissions for COPD in the first half of the greatest impact will be seen
could be reduced or eliminated. In order 2010 compared to 2009/10, with a 20% • Early and sustained engagement of key
to highlight where the greatest impact reduction in secondary care clinic stakeholders, particularly commissioners
could be achieved on reducing the attendances. and primary care, is vital to the success of
numbers of admissions in order to meet any integrated service; without this there
commissioner targets local practices were A significant programme of work is wouldn’t have been the investment
rated by highest total numbers of COPD planned over the next six months to necessary to move forward
admissions and secondary care referrals. establish effective support to practices • Managing change is extremely slow
A Pareto chart was then produced to which includes: and can prove to be difficult. Ensuring
identify which of the six practices should two way communication throughout
be first to receive respiratory nurse • Establishing COPD and asthma clinics the process is essential. Changing the
specialist ( RNS) support. Gantt charts for to review patients (by priority) jointly way the community respiratory service
the RNS were developed to ensure a with practice nurse/nominated GP works and communicating this to
consistent process when supporting • Introducing the use of templates to others was very challenging
practices. guide COPD/asthma reviews • Data is crucially important but robust
• Assuring smoking cessation support for timely data is difficult to obtain; as
Sources of support were then determined those still smoking clinicians there is a need to have
to assist the progress of this work which • The introduction of appropriate READ ownership of data and take
included using pharmaceutical industry codes to prospectively record responsibility for it. There is plenty of
training packages and POINTS for primary exacerbations information out there, and other
care data. Apollo templates are currently • The use of electronic pictorial COPD people can help you get it and use it
being used for reviews as no funding was and asthma self management plans • Do not reinvent wheels; there are
available for roll out of other versions. and prescription of rescue medication, resources already available for training,
incentivised by local ‘QOF-plus’ analysis and templates
Work also commenced with the local arrangement • Change can sometimes be seen as hard
public health team to identify appropriate • An onward referral system to work and is best achieved with a team,
and feasible data collection. One of the community pulmonary rehabilitation, not alone
areas of work underway includes the incentivised by local ‘QOF-plus’
provision of combined predictive arrangements Contact
modelling data to primary care to support • Home review of housebound/exempted Dr Irem Patel
proactive case management of patients at patients Consultant Respiratory Physician
risk of hospital admission. • A review of patients post exacerbation Email: irempatel@nhs.net

23. Improvement stories: Managing COPD 23
Earlier identification of COPD patients and
preventing inappropriate admissions
Surrey Community Healthcare
What were the issues? What we did
Across Surrey there is a disparity of care • Process mapping event held resulting in
and services provided, with a variance in an action plan
performance and outcomes in both • GP champions were identified for the
clinical and economic measures. Guildford cluster and Thames medical
However, there is also a widespread cluster
desire and shared philosophy of sharing • Cluster data charts were collated
best practice and reducing inequalities. • Collaboration with the medicines
management respiratory lead in Surrey
The prime challenge was to avoid on GP, Quality Outcome Framework
unnecessary and costly admissions to (QOF) days to market local
acute services, and to grasp the management guidelines (NICE 2010),
opportunity provided to ensure the NHS Improvement - Lung pilot and
provision of high quality, efficient, South East Coast respiratory
equitable service is available to all across programme
the county for patients with chronic • North west paramedic COPD champion
respiratory disease, so that improved identified • An audit was carried out of GP
quality of care is delivered as available • An A4 patient held health record with surgeries which identified team input
budgets reduce. essential respiratory information has for each surgery
been developed for use across agencies • Agreed referral criteria
Where did we start from? (message in a bottle and hospital • Breathe Easy information updated on
All data is shown as an actual figure for patient information systems) and project also including the review of the
July 2010 and a rolling 12 months disseminated and implemented across new British Lung Foundation self
average which aims to reduce the effect north west and south west Surrey management literature
of the seasonal variation.
• Admission rate (weighted for expected
COPD prevalence) = 4 / 1000 An example of the dashboard used to monitor improvement over time
population. Rolling 12 months average
= 4.75 / 1000 population
• 30 day readmission rate = 25%. Rolling
12 month average = 22%
• 90 day readmission rate = 46%. Rolling
12 month average = 38%
• Cost of emergency admissions =
£199,536. Rolling 12 month average =
£290,484
• Bed days (weighted for expected COPD
prevalence) = 17 / 1000 population.
Rolling 12 month average of 32 / 1000.
• Average LOS 4.2 days. Rolling 12
month average = 6.7 days
• 13% of the last 12 months admissions
were accounted for by multiple
attenders (2 or more attendances)

24. 24 Improvement stories: Managing COPD
Where we are now What we learnt
• Progress has been slower than first • Reducing admissions cannot be
expected due to staff changes and the achieved by one part of the pathway
political climate working alone. Collaboration and
• Issues have been uncovered around agreed processes across the acute,
coding and releasing time to undertake community and primary care settings
the project work and the ambulance trust are vital. If any
• Work is ongoing to encourage and of these areas is disengaged or does
evaluate the dissemination of self not have the capacity to work to
management plans by the community change then the project will falter
respiratory team • Information governance restrictions
• Further work is needed to develop links make it very difficult to share
with primary care and identify more GP information across organisations.
COPD champions / leads within clusters Professionals must be aware of what
(with a particular focus on the information they can and cannot share
pathfinder consortia) without consent from the patient
• In the current climate professionals are
Below is an example of the dashboard being pressed to deliver more with less
used to monitor improvement over time. resource; to ensure engagement you
This can be looked at by individual have to give evidence that your project
practice level and includes a South East is worth their time. Provide data such
Coast wide comparator. as cost of emergency admissions,
length of stay, readmission rates and
prescribing spend
• Change takes time and commitment;
changing outcomes relies on changing
mindsets, not just processes
Contact
Vikki Knowles
Community Respiratory Team Lead,
Consultant Nurse
Email: vikkiknowles@nhs.net

25. Improvement stories: Managing COPD 25
Supporting people with moderate or severe COPD
to self manage through clinical and behavioural
interventions
NHS West Sussex
What were the issues?
The long term conditions programme had
undertaken a review of the admissions
and readmissions data for the Primary
Care Trust (PCT). The data indicated that
readmission rates remained high and that
length of stay was prolonged. A decision
was taken to ensure a range of
interventions were available to all patients
with chronic obstructive pulmonary
disease (COPD) as part of their ongoing
care, to improve their ability to manage
their condition and to reduce
readmissions.
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 1,000
COPD population
• One of the initiatives which is planned Where we are now
What we did is to implement a cognitive behavioural Due to the seasonal variation associated
• Established the project team and therapy (CBT) group course specifically with COPD where we were in July and
working groups for people with COPD. Work has begun where we are now in February is not
• Established links with other similar with the Time to Talk team at Sussex comparable. Therefore Q2 09/10 with
projects in the geographical area and Community NHS Trust who will be Q2 10/11 to ensure we are comparing
across the country providing the service. So far referral like with like.
• The recording of the project was set up criteria for this service have been
on the NHS Improvement System to aid developed and work is ongoing to • LOS was 6.5 days for Q2 10/11, 2 days
communication amongst the team as secure locations and publicise this lower than the previous years Q2
well as project planning and tracking service • 30 day readmission rates = 35%
progress • Two more initiatives, post exacerbation although this dropped to 21% for Q3
• Plans were developed for the reviews and personalised care plans are • 90 day readmission rates = 40% but as
preparation phase: project plan, contact to be delivered in primary care. Four with 30 day readmission rates this has
sheet, communication plan and data GP practices have been identified to be dropped for Q3 10/11 and now = 27%
collection plan involved in developing this further • Using SPC analysis is helping us to see
• A patient satisfaction survey was • Another scheme is to provide selected what is happening over time and where
conducted using the LTC6 patients with telehealth units which is we can most effectively target our
questionnaire amongst people with currently in the process of securing improvement efforts
COPD in the county to establish a funding • Bed days per 1,000 COPD population
baseline are steadily decreasing – this is likely to
• This helped identify a number of issues be due to the reduction in LOS
to help improve care and support for
people with COPD

26. 26 Improvement stories: Managing COPD
What we learnt
• One of the most important pieces of
learning gathered from this project was
the use of a robust diagnostic phase.
This is needed to establish the current
situation and to discover where the
underlying problems might lie. It is also
important in its use as a method of
measuring and demonstrating
improvements
• The solutions must be tailored to
population and specifically for the
problem or gap identified
• It is important to identify individual(s) to
drive the project forward. This is
particularly apparent in the current
state of reorganisation in the NHS as it
is needed to keep the momentum of
the project going, keep the team
engaged and keep it a priority
• It is essential to have clear achievable
objectives
• It is sensible to take advantage of
engagement approaches that have
proven successful in the past
Contact
Chloe Donald
Graduate Management Trainee
Email:
chloe.donald@westsussexpct.nhs.uk

27. Data 27
Data
Why is data so important? Data is important for improvement projects
If you don’t measure, how do you know because it is not satisfactory to say “it feels
whether what you are doing is better, better”, “I think it’s better”, or “it seems
worse or the same as it was last year? Or better”. We need to establish factual data
better, worse or the same as what everyone and measures to demonstrate what has
else is doing? been achieved.
Data and measures are important to
demonstrate that change has occurred or
needs to occur, and it also helps to focus
improvement work effectively. NHS
Improvement focuses on the delivery of
quality measured improvements which are
aligned to national priorities and strategies.
In line with the national Quality Innovation
Productivity and Prevention (QIPP) agenda,
it is essential that all system changes are
measured and recorded. Whether the
change was a success or did not
demonstrate the anticipated outcomes, we
still need to demonstrate its effect and
learn from it.

28. 28 What have we learned about data from the project sites?
What have we learned about data
from the project sites?
National Programme Budget Interactive Atlas – http://nww.nchod.nhs.uk (NHS Network connections only)
1. Consider a needs assessment The Atlas of Variation, developed by Muir However the key learning is that often we
approach Gray’s Right Care workstream is a good do not know this variation exists, and
The overwhelming message from the starting point to highlight key clinical that by using the data more information
sites starting improvement work was that variation, and the NCHOD Programme is being uncovered about what is
there was difficulty in getting hold of Budget Atlas builds on this, providing happening in the site.
data and information. As work information on admissions, length of stay,
commenced, sites reported limited access outcomes and overall respiratory spend, Analysts may be able to support and offer
to data on their day to day activity, and plus functionality for mapping and standardised data, which accounts for
very poor access to overall information graphing the information at a PCT level. social status, age and sex factors, to show
covering the respiratory pathway. the variation with control applied for
2. Variation these factors.
Fortunately, there are many resources A key message from the sites is how to
available that can support sites to understand the variation within their local Projects are working to understand the
understand and compare their services to systems, and to understand why there reasons behind variation by asking the
others, and many of these are freely and could be a difference in admissions, question "why" there is a difference.
easily accessible. length of stay, or cost, between local This helps us better understand the
areas, GPs and healthcare providers, in processes and provision of our services.
A detailed list of data resources is order to improve the care for patients.
available on the NHS Improvement - Lung Within the projects in Southampton, a
website. Data is available nationally on Much of the variation may be for valid funnel plot and mapping technique was
prevalence, secondary care admissions and explainable reasons. Often, applied to show which practices had
and primary care that can be combined to socioeconomic factors, such as smoking significantly higher rates of admission
build a picture of local services. rates, can greatly influence the levels of compared to peers. It was found that
healthcare need between different areas. these practices were located in areas of
Yet, it cannot explain all the variation.

29. What have we learned about data from the project sites? 29
high social deprivation, and that the
teams were generally less likely to engage Example of NHS Comparators mapping functionality
with patients in these areas for fear of
crime. The team agreed to explore what
other ways there may be to access
patients in these areas.
3. Prescribing savings
There have been significant financial
savings demonstrated from simple
approaches to medicines review.
Respiratory medicines information can be
obtained from the ePact system. The
reports generated by this system have
been used by pharmacy advisors working
with practices to monitor monthly
spending, and reductions in costs have
been shown. Examples of how this is
being used by Victoria Practice in
Hampshire are covered in their
improvement story on page 19.
4. Data sharing: local Having local access to HES, or the short time periods. For example, length of
agreements needed admissions providers collect prior to stay could be monitored on a per patient
The importance of sharing information submission to HES, would be valuable to basis.
and data across the health community monitoring service improvement over
has been a key message from our
improvement projects. Integrated care
will give the best outcome for patients, Example of statistical process control (SPC) chart – Charting can show process
but this message also applies to data. information, such as the length of stay, in a way that offers more detail than typical
Without the sharing of information it is performance measures such as averages can offer
not possible to show the whole picture
and what is involved in the care of the
patient. Healthcare providers need the
data for the whole pathway to
understand how their improvement work
is benefiting the patient.
Hospital admissions data can be freely
obtained from sources such as HES
(Hospital Episode Statistics), NHS
Comparators or in performance reports;
however this is often aggregated
information, and can be up to three
months old. The detail and timeliness
required for improvement projects implies
that sites should explore how to access
the data locally, collaborating with their
local data teams.

30. 30 What have we learned about data from the project sites?
5. Primary care data doesn’t need to
be impossible Example of QOF data
Primary care data is often seen as a
difficult area to extract, and some of the
sites found it difficult to access primary
care data at first. However, a number of
resources are easily available which can
provide a picture of primary care which is
valuable for improvement work.
QOF data is useful, particularly for
building evidence and understanding
around the diagnosis and community
parts of the patient pathway. QOF data is
particularly valuable when compared to
other indicators for COPD, such as
admissions, or expected prevalence.
Comparing the proportion of patients
predicted to have COPD against actual
reported COPD on QOF may highlight
areas of unmet need, find missing
populations, and suggest where to target
support and future work. NHS Comparators mapping example
It is important that sites using QOF review
any exception reports, as it is possible to
exclude patients.
NHS Comparators has been much
developed in the last year, and sites were
impressed with the information it
provided, which helped provide basic
benchmarking and comparison for
primary care.
Local investigation may reveal more
information. Project sites have found
value in interrogating the information
held within primary care systems. The
importance of accurate coding has been
emphasised by project sites, as they have
learned more about the exacerbations of
their patients by ensuring coding is
correct.