Improving earlier diagnosis and the long term management of COPD: testing the case for change
NHSCANCER NHS Improvement LungDIAGNOSTICSHEARTLUNGSTROKENHS Improvement - Lung: NationalImprovement ProjectsImproving earlier diagnosis andthe long term management ofCOPD: Testing the case forchange
Contents 3NHS Improvement - Lung National Improvement Projects -Improving earlier diagnosis and the long term managementof COPD: Testing the case for changeContents4 Introduction Case studies9 Hinchingbrooke Health Care NHS Trust The introduction of direct access pulmonary function testing to support primary care in accurately diagnosing and managing respiratory patients, while reducing waiting times for clinic appointments and reducing costs10 North East, North Central London and Essex Health Innovation and Education Cluster working with Walthamstow West Primary Care Commissioning Group Validating registers and reviewing patients to ensure an accurate diagnosis of chronic obstructive pulmonary disease (COPD) and understand the region of error on GP disease registers and the variation between practices12 Imperial College Healthcare NHS Trust and Central London Community Healthcare NHS Trust An integrated respiratory team can make significant improvements across the entire COPD patient pathway14 London Community Healthcare NHS Trust and Hammersmith and Fulham Primary Care Trust Using an innovative data warehouse development to improve respiratory services18 The Leeds Teaching Hospitals NHS Trust Developing an integrated COPD disease register to support quality assured diagnosis and proactive chronic disease management20 Leicester County and Rutland PCT How good is our management of chronic obstructive pulmonary disease?21 The Victoria Practice, Aldershot, Hampshire Reducing waste and increasing adherence in use of medicines for chronic obstructive pulmonary disease23 NHS Blackpool Formalising self management planning in Blackpool25 Veor Surgery, Camborne, Cornwall A systematic approach to implementing self management action plans27 Breathe Easy North Staffordshire and NHS Stoke on Trent How support groups can impact on patients’ ability to self manage29 Acknowledgments30 References
4 IntroductionIntroductionCase for change: the current position A reduction in this variation would also The aim of the managing COPD as a longfor chronic obstructive pulmonary increase value for money of services as term condition workstream was todisease in the UK well as improving outcomes for people explore how supported self-care and with COPD in line with the Quality, regular review can best be delivered inThere are around 835,000 people Innovation, Productivity and Prevention order to improve the outcomes andcurrently diagnosed with Chronic agenda. quality of care offered to patients. TheObstructive Pulmonary Disease (COPD) aim also included related work to test thein England and an estimated 2,000,000 During the first year of project work, NHS optimisation of health resources towardspeople with COPD who remain Improvement – Lung through the ‘Earlier a reduction in emergency admissions. Anundiagnosed and are living with the Diagnosis’ and ‘Managing COPD as a important component of the workdisease1. The majority of these have mild Long Term Condition’ national incorporated medicines management byor moderate disease but if they were workstreams have focussed on ensuring all patients with COPD were ondiagnosed early, they could then take the developing services that deliver efficient the correct treatment in relation to thenecessary steps to improve the outcome and high quality care and support for severity and symptoms of their disease,of their disease and modify its patients suspected to have COPD or living and were regularly reviewed to helpprogression. The disease is progressive with the disease. This has been achieved support them to use their medicationand cannot be cured, with one person through working with and supporting correctly. Project work included testingdying every 20 minutes in England and clinical teams to identify, test and ways to develop and implement effectiveWales. However, timely and accurate implement the changes needed to self-care models and ongoing patientdiagnosis, with supportive ongoing achieve this level of care and understand review, and to identify the key challengesmanagement can help modify the impact the key components that have the and solutions for overall long termof the disease, helping people to self- greatest impact on the pathway and condition management.manage more effectively and thereby benefit to patients.reducing the need for hospital admission. This publication, which is aimed atIt is therefore vital that patients receive a The aim of the earlier diagnosis healthcare professionals, commissionersquality-assured diagnosis at the earliest workstream was to ensure that all people and other key stakeholders involved inopportunity in order to commence with suspected COPD receive an accurate respiratory health, draws together theappropriate treatment and to slow the and quality assured diagnosis sooner and evidence and learning from the past 12progression of the disease for the as a result, are placed on the correct months and highlights the workindividual. This can also reduce the treatment pathway. The aim also included undertaken by the project sites withinimpact on carers and on the burden of ensuring that patients receive appropriate both national workstreams.long term management and its related information about their condition and arecosts. added to the practice disease register. Improvement approach With the right pathway in place, it wasThe Outcomes Strategy for COPDi and hypothesised that timely and quality In July 2010, NHS Improvement - LungAsthma in England and the NCROP Auditii assured diagnosis would lead to a invited NHS organisations to work inidentified that there is significant variation reduction in service costs by optimising partnership on projects dedicated toacross England in the way in which the treatment pathway for patients and improving the COPD patient pathway andpeople are referred, diagnosed and initiating self-management at an earlier to help address the variation in care thattreated. There is significant scope to stage in the disease progression. Project patients receive. Projects plans wereimprove the quality and timeliness of work included testing service models in submitted from a number of sitesdiagnosis, treatment and management, both primary and secondary care, including acute trusts, primary care trustsincluding pharmacotherapy, and to understanding and reviewing registers (PCTs) and community organisations.organise care in a more integrated way. and the development of tools to improveThis would not only improve the quality and monitor quality.and efficiency of the service, but alsoempower patients to manage their owncondition.
Introduction 5The primary aims of the projects in the Once the project teams were established, • There appears to be extensive variationtwo national workstreams were to: a period of analysis followed to allow in the quality of spirometry being teams to understand the patient pathway. undertaken and interpreted, along with• Define the patient’s pathway This also helped dispel any assumptions the quality of information being• Identify and reduce variation in the about the process, its challenges and the collected. This includes the accuracy of delivery of care solutions. Potential solutions were tested COPD registers.• Challenge the system and test the using the model for improvement and • Taking time to understand what is components of care that lead to plan-do-study-act (PDSA) cycles with happening in the current system and consistent and effective diagnosis and ongoing measurement to evaluate the identifying who is doing what may management of the condition impact of the interventions and refine mean that change can occur more• Identify the success principles that where appropriate. quickly, safely and reliably without the other organisations and teams could need for additional resources learn from and adopt Common challenges and solutions • Significant variation across primary care• Distil the learning to inform future Clinical teams at all sites have been may not be immediately apparent. ‘prototyping’ work. focussed on specific aims which have Identifying low prevalence, high included: admission rates and prescribingFocus was also given to improving the performance can help target efforts forpatient’s experience and outcomes along • Identifying the current state of practice improvementwith removing duplication and waste and any gaps, duplication, waste or • Consistent recording of data across thefrom the pathway or specific processes opportunities to improve the quality of practice team is essential to allowthrough different ways of working and care stratification, monitoring ofservice redesign. Productivity gains • Increasing the number of patients deterioration and impact of changes inachieved by sites were measured to whose treatment is optimised by care, and highlights any increasingidentify the impact of the work. identifying the right patients, providing frequency of exacerbations early in appropriate information and support, order to initiate targeted interventionDuring the ‘testing’ phase of the and ensuring they are on the right where appropriateprogramme, project teams have explored treatment path • Data is essential for improvement.the reality of making this happen by • Identifying ways to ensure that their There is plenty of it available but it istaking stock of current practice and systems for diagnosis and management important to identify what is mostunderstanding the process of are consistent and effective. useful and how best to present it.implementation to ensure patients receive Targeting patients or practices withoptimal care in a challenging Whilst each project site has worked on a high resource use can help towardsenvironment. The project sites adopted a different part of the diagnosis and demonstrating benefits more quicklysystematic approach to quality management pathway, a number of • There can be a significant impact onimprovement to ensure that any changes themes have emerged across all sites: admissions by targeting moderateimplemented were thoroughly tested and COPD patients and increasing theirmeasured. Prior to commencing the • Although clinicians understand the confidence in self management, whilework, the project sites were required to components of optimal COPD care, ensuring work is undertaken toestablish their service baseline through there is widespread variation in practice correctly identified patients’ severity inanalysis of local data and to understand in the way in which diagnosis and the first instancethe variation in services. management are provided. This includes aspects such as spirometry, support for self care and optimising treatment
6 Introduction• Where there are no formal systems in • People are motivated by different place for risk stratification, it is still things. Taking time to find out what Project Outcomes: Emerging possible to start the improvement will motivate someone to change Success Principles from Project process by exploring which patients behaviour will lead to an increased Learning account for the greatest use of chance of helping them resources – for example, appointments, • Teams may have concerns about the Through problem solving and a accident and emergency attendances, practicalities of offering longer systematic approach to admissions or medicines. Using the appointments, including the impact of improvement, all teams worked Pareto principle – the principle that patients not attending. Group sessions through a number of challenges in 20% of people or problems may for review or patient education can order to achieve their project aims. account for 80% of resources – can limit the impact on resources and may Across the sites, a number of success help target effort more effectively enhance the patient experience principles have been identified that• It is important to work together to • Taking time with patients to explore represents improvement improve the management of COPD by how the care they receive affects their opportunities towards effective both gaining common agreement with health or their ability to self-manage, service provision in the diagnosis and stakeholders, and developing using a tool such as the COPD management of COPD: integrated and consistent approaches Assessment Test (CAT) or similar, can to patient pathway management lead to improved outcomes and overall • Defining and gaining a good• Good management and self-care experience understanding of the whole support requires 30–60 minutes and a • Providing patients with information, pathway of care supported by patient-led approach. Patients with advice and contact names and numbers robust data to demonstrate more than one long term condition can result in improved management current processes, performance (LTC) may benefit from a holistic along with earlier recognition of and and variation is essential when assessment and review, which may also action on symptoms, thereby reducing embarking on improvement work. reduce total demand for healthcare the need for emergency care and This allowed organisations to resources over any twelve month admission identify priorities for change and period. Shorter appointments may • Providers should systematically address also to benchmark themselves mean there is little time to listen to the the way they work to find consistent with others locally and nationally patient and establish their needs and and sustainable pathways that deliver • Issues and challenges viewed in may lead to repeat appointments proactive and holistic care. isolation without due• Inhaler technique is a key area for consideration to the whole patient improvement in the management of pathway were less likely to lead to COPD. Many patients do not maintain sustainable improvements in care the correct technique and many staff provision may not be demonstrating correctly. • Effective working relied on the There is evidence of the cost commitment of teams in primary, effectiveness of using trainer devices to secondary and community care to improve technique, and regular improve communication across the checking can ensure patients receive patient pathway. Integrated the maximum benefit from their working helped to build positive medication relationships with health care professionals, departments and organisations, and improve the critical interface between these organisations
Introduction 7 Future ‘prototyping’ work • Service models that support diagnosis• Access to and effective use of data across the whole pathway (for COPD, through collaboration between In the forthcoming year of project work Asthma, Home Oxygen and Sleep clinical and managerial staff sites will be building on the learning from Apnoea) enabled the project teams to the ‘testing’ phase of work. Sites will be • Opportunities for diagnostic bundle better understand the patient refining the components attributed to the approaches pathway and demonstrate the emerging care models and success • Workforce skills and competency impact of any change. The routine principles that demonstrated the greatest requirements. collection and review of data was impact on the patient pathway during the important in implementing past year. The prototyping work will Managing COPD as a long term sustainable improvements and define the chronic care model for patients condition workstream understanding outcomes of any with COPD, representing an efficient and It is known that patients who understand service improvements high quality care model that reflects not what to do in the event of an• Identifying the key levers and only best practice, but also demonstrates exacerbation are more confident to seek drivers in the system by integrating examples of practical approaches towards help earlier and can avoid admissions, local and national priorities into sustainable implementation. The evidence while regular medication reviews and the work such as Quality, and learning from the diagnosis inhaler technique checks can help reduce Innovation, Productivity and workstream will inform its scoping work waste in prescribing. It is also Prevention (QIPP) raised the profile prior to commencing the prototyping acknowledged that while it is critical to and priority of the project work phase. have access to tools like plans, reviews with decision makers and helped and templates to help patients manage to achieve improved engagement Earlier diagnosis workstream their condition, effective management from senior management teams Using national data currently available, needs to be underpinned by a set of• There was a need to identify and a national scoping exercise will be skills, an approach and an infrastructure understand the gaps, duplication undertaken to determine the current that will allow delivery. These and waste in the patient pathway diagnostic pathways for patients with components can be considered as: in order to make best use of suspected COPD. This will also define the available resources. It was essential optimum pathway and identify best • The resources that patients need to work and communicate with practice case study examples. Following • What professionals need to do colleagues, commissioners and analysis, service gaps between the • The infrastructure that needs to be in other stakeholders in service ‘current’ state and ‘future’ state place to facilitate to delivery. provision in order to maximise pathways, common themes and these resources and to ensure a principles, challenges and potential For patients to be effectively supported to consistent and co-ordinated solutions will be pulled together in order self care and for professionals to deliver approach to care. to inform future priorities for chronic disease management successfully improvement and prototype work. each of these components needs to be inMany of the issues and challenges place. The challenge now is to identifymet by the project teams were In summary, the key aims of the scoping how best to implement this consistently,similar to those faced in other work will be to identify: reliably and cost effectively. Further workspecialities and several of the success is also required to identify the essentialprinciples have been demonstrated • Sustainable and innovative service elements and most effective means toto be effective in other disciplines. It models (including direct access to put these into practice, including:was important for sites to recognise secondary care, GP provision andareas where common principles and secondary care provision) • Planning for early intervention in thepractice meant that learning could • Models to support earlier diagnosis and event of exacerbationbe transferred across specialities. improved primary care access • Medicines management and good • Models to support diagnosis of all inhaler technique severities and associated conditions
8 Introduction• Adequate time for regular review that • Ensure a supportive self management encompasses what is important to both approach to care that incorporates a the clinician and the patient/carer and regular structured review supports self management • Ensure a medicines management and• Skills to deliver support, education and review approach that optimises treatment. treatment.As a result the workstream will now focus It is the aspiration of the nationalon demonstrating how to improve programme to deliver a QIPP reduction inmanagement and self care for people emergency admissions by 20%, a Catherine Blackabywith COPD to reduce admissions, reduction in readmissions at 30 days by National Improvement Lead, NHS Improvement – Lungoptimise medicines use and enhance 20% and reduction in prescription spendpatient experience by prototyping: by 10% to which effective diagnosis and management can contribute. In addition,• The optimal time and components of the workstream will continue to identify an effective review from both patient the key components of care that improve and clinician perspective the overall patients’ experience and• Practical ways of implementing this and outcomes, and further develop the delivering it within existing resources learning and key success principles that• How to optimise medicines use and the support effective commissioning of impact of doing so on cost, experience respiratory services in England. and use of other health care resources• The key components that need to be in Zoë Lord place for patients to be able to Catherine Blackaby, National Improvement Lead, NHS Improvement – Lung effectively self-manage and the benefits National Improvement Lead, of doing so. NHS Improvement - LungThis will allow the production of a model Zoë Lord,that demonstrates what needs to be in National Improvement Lead,place for care to be delivered effectively NHS Improvement - Lungand how to implement it, to ensure thatevery minute of contact is used to Phil Duncan,maximum effect, every time. Director, NHS Improvement - LungIn summary, the key aims of prototypeproject sites will be to: Phil Duncan Director,• Define the exemplar model of care NHS Improvement -Lung• Demonstrate an integrated care model to identify and manage acute episodes /exacerbation• Demonstrate an approach to improving other condition management
Introduction 9Hinchingbrooke Health Care NHS TrustThe introduction of direct access pulmonary functiontesting to support primary care in accurately diagnosingand managing respiratory patients, while reducingwaiting times for clinic appointments and reducing costsProject summary • 15% classified as restrictive by GPHistorically, most patients referred to the were normalsecondary care consultant-led respiratory • 15% classified as obstructive by GPclinic via Choose and Book received were normaldetailed pulmonary function testing prior • 69% classified as normal by the P wereto their appointment with the consultant. obstructiveHowever, an audit highlighted that 30% • 54% of patients referred needed to beof referrals did not require intervention added to the practice COPD diseaseand were immediately discharged back to register and 7% needed to be removedthe GP as these patients could have been to the registerdiagnosed and managed in primary care Dr Robert Buttery, Lorraine Leech, Kelly Backler • Out of the total GP referrals which(estimated saving of £10,000). (Hinchingbrooke Hospital), Dr David Roberts (GP) were classified as obstructive, 32% of patients had their Global Initiative forThis led to the introduction of a direct Project aim Chronic Obstructive Lung Diseaseaccess service to provide full pulmonary • Improve the accuracy of diagnosis, (GOLD) disease severity changed:function testing for those GPs who especially chronic obstructive • 43% maintained their severity asrequired support diagnosing and pulmonary disease (COPD), in primary classified by GP spirometrymanaging their respiratory patients in care • 20% changed by one GOLD stageprimary care. • Ensure all patients are on the • 38% changed by two GOLD stages. appropriate management pathwaysThe new service provided detailed with appropriately identified patients Learningpulmonary function testing (spirometry, being managed in primary care, • Meaningful patient engagementstatic lung volumes, gas transfer +/- resulting in: presents valuable insights into a currentreversibility testing) for all referred • Earlier access to smoking cessation service provision. Patient engagementpatients. Where there is diagnostic • Improved access to COPD respiratory was highly beneficial resulting in acertainty, the patients receive information nurse specialists direct impact on the project:from the physiologist about the outcome • Earlier access to pulmonary improvements included the way inof their test and a British Lung rehabilitation services which the patient invitation letters areFoundation (BLF) leaflet; where this • Appropriate referrals into the hospital structured and written along with thecertainty does not exist, patients receive respiratory clinics for specialist guidance information leaflets that are given outmore general information about lung (a reduction in unnecessary referrals for to patients at the time of their testshealth, based upon leaflets from the BLF. patients who can be managed in • GP engagement can be challenging.GPs receive fully interpreted Pulmonary primary care) Use data to target high volumeFunction Tests, with chest physician • To create a measurable effect on GPs’ referrers. Only providing writtenguidance as necessary. Depending on the decision to refer a patient to hospital information about a new service doesoutcome of the tests, patients no longer clinics with the aim to reduce referrals not instigate a change in referralautomatically see the consultant by 25%. patterns. Newsletters, emails and lettersrespiratory physician, although advice have a limited effect. Buildingmay be given to refer the patient in to the Highlights and achievements relationships and using personalrespiratory clinic where deemed Reduction in unnecessary consultant mediums of communication likeappropriate. appointments by 78% for those patients face-to-face meetings can have a referred in to the service: positive effect. • Saving of £144 per patient who does not require a consultant appointment Contact • Reduction in waiting times – from eight Dr Robert Buttery weeks to one week Consultant Respiratory Physician, • 32% of patients have had their Papworth Hospital and diagnosis changed following detailed Hinchingbrooke Hospital Pulmonary Function Tests: Email: email@example.com
10 Case studiesNorth East, North Central London and Essex Health Innovation andEducation Cluster working with Walthamstow West Primary CareCommissioning GroupValidating registers and reviewing patients to ensure anaccurate diagnosis of chronic obstructive pulmonarydisease (COPD) and understand the region of error onGP disease registers and the variation between practicesProject summaryNorth East, North Central London and Quality of COPD diagnosis measures at practice levelEssex Health Innovation and EducationCluster (NECLES HIEC) have been workingwith nine practices in Walthamstow WestPrimary Care Commissioning Group withsupport from GlaxoSmithKline UK toquantify the region of error in thediagnosis of COPD and the recording ofinformation on disease registers.Project aim• Quantify the region of error in diagnosis of COPD, by understanding the proportion of patients with an incorrect diagnosis (following National Institute for Health and Clinical Excellence (NICE) 2010 guidelines for confirming COPD diagnosis) Practice 1 Practice 2 Practice 3 Practice 4 Practice 5• Quantify the variation between practices Practice 6 Practice 7 Practice 8 Practice 9• Establish a comprehensive and accurate disease registers that capture all elements of the diagnostic and severity assessment, enabling healthcare Highlights and achievements • Up to 36% of records on the registers professionals to take a proactive • A baseline from the practices was had no documented spirometry which approach to the identification and extracted using GSK POINTS tool along would suggest that spirometry has not management of people with COPD, in with a list of COPD patients on each been performed or the result had not line with the NICE COPD guideline disease register been documented on the register 2010 • Any patient without a recorded • Between 3% and 100% of records in• Reduction in waste, improved spirometry result or with an FEV1/Ratio the nine surgeries had incomplete productivity and quality of services recorded >0.7 was invited for a review spirometry results which could indicate provided locally, by reducing with the respiratory nurse specialist – that these patients have not had a inappropriate administration of using NICE COPD 2010 guidelines. The validated diagnosis and that there is the medicines review was based on and included a possibility that these patients are not• Prevent inappropriate treatment due to full patient history and spirometry with being treated effectively inaccurate diagnosis or incorrect reversibility testing • 18% to 100% of records in the nine assessment of severity. • Following a clinical review, the practice practices did not document ‘percentage registers were updated and the GP of predicted FEV1’ to assess severity of informed. If any medication changes the disease and monitor disease were necessary, the patient notes were progression over time also updated along with dialogue with • Between 21% and 47% of records had the GP a ‘FEV1/FVC ratio ≥ 0.7’ which could indicate that the patient does not suffer from COPD and there is an issue with poor technique or interpretation of spirometry results
Case studies 11• Four out of the nine practices had 60% Contact or more patients with a dual diagnosis Dr Gabby Ivbijaro of asthma GP Waltham Forest• Evidence from the practices confirmed Email: firstname.lastname@example.org that patients on both COPD and Asthma registers receive two reviews Professor Mike Roberts which is costly to the health service and HIEC Facilitator confusing to patients Email: c.m.roberts@QMUL.ac.uk• Results following a review with the respiratory nurse specialist to confirm Anne OMalley diagnosis highlighted 50% of patients Respiratory Nurse Specialist had a confirmed diagnosis of COPD and 50% did not have COPD. Kirsty Barnes HIEC FellowLearning Email: email@example.com• A standardised register which incorporates the requirements for Quality Outcomes Framework (QOF) and NICE diagnosis and management is required to drive up quality• Variation occurs in the patient information collected on the practice templates. This occurrence is due to different software companies (EMIS, VISION etc) and variations within each version of the software• Education and training for practice staff is imperative to the quality of COPD diagnosis and the recording of information. Both individual and group education and training session are required ensure all new diagnoses are quality assured and the correct information is added to the COPD register• A standardised register would assist l earning for healthcare professional who are new to COPD• Collecting data is time consuming but important to understand the current reality and the variation in clinical practice so that action can be taken to improve quality and patient care.
12 Case studiesImperial College Healthcare NHS Trust and Central LondonCommunity Healthcare NHS TrustAn integrated respiratory team can make significantimprovements across the entire COPD patient pathwayProject summary • To support patients post discharge afterA consultant led integrated respiratory acute exacerbationteam in Hammersmith and Fulham (H&F), • To improve communication and jointworking across Imperial College working by clinicians looking afterHealthcare NHS Trust (ICHT) and Central COPD patients in primary, secondaryLondon Community Healthcare NHS Trust and community teams.(CLCH) has been working to improve thequality of services for patients with COPD Highlights and achievementsand other long term respiratory • Improvements across the patientconditions. pathway have led to a reduction of admissions by 19% and readmissionsThe project was part of a broader review by 66%to reconfigure and re-commission services • Reduction in first and follow up Learningto deliver an integrated COPD patient outpatient appointments equating to • Shared aims and joint working acrosspathway, supported by the primary care approximately £170k savings primary, secondary and communitytrust and local stakeholders. The project • Reduction in the proportion of patients care, with engagement ofwas commenced after a gap analysis presenting with an acute exacerbation commissioners is critical to the successshowed that H&F had among the worst of COPD who do not have a previous of an integrated serviceoutcomes for COPD patients in London, GP diagnosis • Changing traditional patterns ofwith high admissions costing over £1m • 145 patients have had a quality review working is challenging and takes timeper year and an estimated 5,000 patients with a respiratory specialist as a result to implementwith as yet undiagnosed COPD. of which: • Data is crucially important; robust • Quality of recording of FEV1, timely data is difficult to obtain andService developments have included exacerbations and breathlessness clinicians need to take ownership andspecialist support to primary care have improved in line with National responsibility for itdelivering quality assured spirometry, Institute for Health and Clinical • Managing change can be slow andworkplace based training and quality Excellence (NICE) quality standards in difficult. Communicationreviews; community based pulmonary a practice audit exercise throughout the process is vitalrehabilitation; a COPD discharge bundle • 30% additional referrals to • Implementation of the chronic carewith community follow-up; and smoking cessation advice were made model in COPD pathway can delivercommunity clinics. • 41% of patients received rescue improved outcomes. Working across medication packs traditional boundaries to deliver anProject aim • 23% of patients were referred to integrated pathway is one way to• To review practice disease registers and pulmonary rehabilitation achieve these outcomes and deliver support primary care clinicians to • 44% of patients underwent value for money. confidently diagnose and manage changes to prescribed respiratory patients pharmacotherapy Contact• Ensure all reviews include quality • 5% of patients had their diagnosis Dr Irem Patel assured spirometry to confirm changed from Asthma to COPD. Consultant Respiratory Physician, diagnosis, with an assessment of • A real time ‘COPD Report’ tool has Integrated Care disease severity, and patients receive been developed in liaison with Public Email: firstname.lastname@example.org written information about their Health to capture patient and practice diagnosis level data on COPD care and outcomes• To support patients to self manage and to monitor progress of the• To facilitate NICE standard pathway. pharmacological and non pharmacological management of COPD and asthma
Case studies 13Example of the GP practice reports and progress made PRACTICE A PRACTICE B PRACTICE CNumber of admissions by patients who are on and not on the GP COPD disease register Patient on GP condition register Patient not on GP condition register
14 Case studiesLondon Community Healthcare NHS Trust andHammersmith and Fulham Primary Care TrustUsing an innovative data warehouse developmentto improve respiratory servicesProject summary ‘COPD’ or ‘asthma’ report at patient, • Data is automatically extracted from GPIn all quality improvement projects, access practice or Primary Care Trust (PCT) level practices and aggregated by Apolloto data is a crucial part of identifying the as required which also can track Softwareareas for improvement and for improvements over time. A key • The data is then downloaded frommonitoring progress. component of this is measuring Apollo and linked into the PCT data compliance with locally agreed and warehouseAn integrated respiratory team in National Institute for Health and Clinical • The data warehouse combinesHammersmith and Fulham working Excellence (NICE) standard care, rather individual patient level data fromacross Imperial College Healthcare NHS than Quality Outcomes Framework (QOF) Secondary Uses Service (SUS), the localTrust and Central London Community targets, and focusing on important data RIO database and the extract fromHealthcare NHS Trust started their such as smoking prevalence in the primary care, matching patients on NHSimprovement project by working with respiratory population. numberlocal GP practices. Using the • An innovative, interactive document isGlaxoSmithKline POINTS (GSK) audit tool Project aim produced for viewing and sharing theto assess the quality of chronic • Improve joint working across primary, data, using Tableau software. Tableauobstructive pulmonary disease (COPD) secondary and community care to software provides an intuitivemanagement in their area, a respiratory deliver and monitor an integrated dashboard style interface that enablesspecialist team worked with practices to pathway practices to have an overview of thereview COPD and asthma patients to • Improve the collection and analysis of key measures for their practice, anddeliver workplace based training aimed at primary and secondary care data to click into the detail for patient levelprimary care clinicians. Data from support local services and the decision information if they requireenhanced COPD and asthma reviews was making processes • This data is shared with practices andentered on read code linked templates • Improve monitoring of the local the integrated respiratory team toand progress was followed up with a integrated COPD pathway, through facilitate appropriate intervention andsecond audit. monthly monitoring across primary monitor progress. care and secondary careSignificant improvements were made to • Improve local monitoring of asthma Highlights and achievementsreduce the variation between practices patients • This innovative approach enables theand improve the quality of diagnosis and • Provide greater feedback on admissions PCT to access and merge the data frommanagement. To sustain the data to local GP practices the local acute services and generalimprovement in the area, a multi • Create useful performance measures to practices to provide a whole systemdisciplinary team from Central London support clinicians and managers in the picture of the care received by COPDCommunity Healthcare NHS Trust, area. and asthma patients in the areaHammersmith and Fulham Primary Care • Data is collected on compliance withTrust (PCT) and General Practice initiated Data extraction and matching process locally agreed and NICE standards ofa project to build a near a real-time audit A multidisciplinary team made up of an care as opposed to QOF targets (e.g.tool. integrated care consultant, primary and stop smoking support, pulmonary community clinicians, public health rehabilitation referrals etc)The tool can baseline and monitor specialists and commissioners built the • The architecture of the data warehouseinformation recorded on practice warehouse based on primary and is owned by the PCT and is available forcomputer systems, monitor out patient secondary care read codes relevant to other healthcare providers to use andappointments, admissions and re- COPD and asthma. The 30 practices in implement in their local area. Noadmissions, along with highlighting those NHS Hammersmith and Fulham agreed to additional software is required as theadmissions coded as COPD or asthma share a generic monthly extract of data warehouse is based on the commonlywho are not on the GP practice disease from their practice systems to the PCT. used Microsoft SQL databaseregister. This then generates a local
Case studies 15• The database structure and definitions Learning of the read code extractions are • There is a cost associated with available to share with other PCTs or extracting data using Apollo, which is clinical commissioning groups low when considered on a per extract• The extracts from Apollo software are basis, but may limit implementation in automated for the practices and the larger PCTs over longer periods PCT. No further user input is required • The reports are dependent on the once the extract is set up quality of coded data. The data• Matching the data from GP practices to extracted is very useful, but data coding secondary care allows for some useful issues can sometimes report measures to be calculated. For unexpected results, which require local example, each month the PCT reviews investigation the COPD and asthma patients who • Risk stratification has been difficult have had an admission for their from the initial extracts due to an respiratory condition who do not have incorrect level of read code data, but a diagnosis in Primary Care and are not there are plans to fix this in future on the practice disease register extracts.• The practice list data is refreshed monthly, compared to the previous Contact annual QOF practice list which the David Sayers practice received Public Health Intelligence Analyst• Practices receive admissions and re- Email: email@example.com admissions data on a monthly basis• The data is obtained from the practices Dr Irem Patel each month providing a timely update Consultant Respiratory Physician, on performance unlike annual data Integrated Care sources such as QOF Email: firstname.lastname@example.org• The tableau interface provides a tailored approach depending on the Alide Petri audience’s requirements; it can output Consultant in Public Health Medicine to a pdf or word document, or using Email: email@example.com the tableau browser interface. This enables practices to drill-down to the Dr Clare Graley individual patient level data General Practitioner• Transferability – current work has Email: firstname.lastname@example.org piloted reports for COPD and asthma. The same data warehouse could be used for other disease areas.
16 Case studiesExample of COPD and asthma reports produced for GP practices
18 Case studiesThe Leeds Teaching Hospitals NHS TrustDeveloping an integrated COPD disease register tosupport quality assured diagnosis and proactivechronic disease managementProject summary • Enables assessment of the impact of ContactThe Leeds Teaching Hospitals NHS Trust the disease on the patient To receive a copy of the register,developed a standardised Chronic • Facilitates assessment of disease supplementary documentation or toObstructive Pulmonary Disease (COPD) progression over time to identify the request to use the register in your arearegister designed to proactively support indications for all interventions with the contact:diagnosis and chronic disease impact on the patient and their chronicmanagement across both Primary and disease Dr Doychin DimovSecondary Care. • Consistent with the current clinical Consultant Physician in evidence and the recommendations of Respiratory MedicineProject aim the national and international Email: email@example.comTo produce an integrated standardised guidelinesregister to ensure all the necessary patient • Data format will be compatible with Further information including the registerinformation is collected and recorded in the different information technology is also available on the following website:one system. Thus improving the systems used in NHS www.improvement.nhs.uk/lungcommunication and information flow • The process of collecting, recording andbetween Primary and Secondary Care analysing the data will be acceptablewhich is highly beneficial for both patient and feasible for both patients andoutcomes and efficiency, and to act as a health care organisationsplatform where diagnostic information • Support continuous audit of all(e.g. current smoking status) triggers requirements of Quality and Outcomespatient referral for treatment (e.g. Framework (QOF), Quality Standardssmoking cessation). for COPD and National Institute for Health and Clinical Excellence (NICE)Highlights and achievements standard CG101.• Development of an integrated register• A decision making pathway has been Learning developed to sit alongside the register • The consultation with patients was and support a care planning invaluable to understand their consultation experiences, expectations and needs of• Fully implemented register in Leeds a COPD service Teaching hospitals with work ongoing • Support from the primary care to convert the register into an computer systems is of paramount electronic format for primary care. importance for the full implementation of the integrated register. The processBenefits of using this disease register of engagement and decision making isinclude: slow and requires perseverance• Standardised register for both primary • A barrier to the implementation of a and secondary care disease register is the lack of widely• Standardised collection of data accepted and robust standards for• Mechanism for improved management of patients with COPD. communication between primary and QOF has limited clinical value, however, secondary care this disease register can facilitate the• Improved the information flow establishment of such standards. between primary and secondary care• Supports the assessment of severity of disease
Case studies 19 Disease Register for COPD - Leeds Teaching Hospitals NHS Trust Summary of thre consultation: Patient’s goals: (enter in patient’s own words) The Disease Register for COPD is developed in the department of Respiratory Medicine at Leeds Teaching Hospitals NHS Trust Correspondence: Dr Doytchin Dimov, Consultant Physician in Respiratory Medicine, St Jamesʼs University Hospital,Beckett Street, Leeds LS9 7TF Tel: +44 113 2064523 Fax: +44 113 2064158 E-mail: firstname.lastname@example.orgMore documents are available on the NHS Improvement at: www.improvement.nhs.uk/lung
20 Case studiesLeicester County and Rutland PCTHow good is our management of chronicobstructive pulmonary disease?Project summary Highlights and achievements LearningLeicester County and Rutland Primary OPC software was used to extract Existing data sets and Quality OutcomesCare Trust worked with Optimum Primary routinely recorded data from participating Framework measures give only a limitedCare (OPC) using software to extract practices. The data is automatically understanding of quality. The markedprimary care data. In order to target compared with the National Institute for variation in recording of FEV1, COPDeducation and intervention appropriately Health and Clinical Excellence (NICE) severity, exacerbation recording, smokingan evaluation was conducted to COPD rule sets to identify any history, medicines use, referral fordetermine how well asthma and chronic discrepancies between current and pulmonary rehabilitation and otherobstructive pulmonary disease (COPD) suggested optimal care for each patient. aspects of care potentially indicateswere being diagnosed and managed. This is automatically fed back into the significant difference in quality of careFollowing the results of this evaluation it practice system forming personalised and related impact on secondary care andwas evident that a significant variation in recommendations for that patient; this prescribing. Making this visible helps toquality and consistency existed, which information will also inform the patient’s target appropriate intervention towas not routinely visible through the next review as well as creating improve management.current standard measures and reports. aggregated reports. Those patients with a recorded diagnosis of COPD of As patients with moderate or severeProject aim approximately 10% did not have COPD disease account for significant numbers• Develop an accurate baseline of current on spirometric criteria: of admissions, there is scope for improved performance in primary care management of these patients to have• Provide practices with individualised • Over 50% of patients had no FEV considerable impact on acute activity. patient reports on their system to (Forced Expiratory Volume) or FVC support improved management (Forced Vital Capacity) values within Contact• Stratification of patients by disease two years of diagnosis. The cost of Dermot Ryan severity therapy for misdiagnosed COPD COPD Lead• Identification of high risk patients patients could amount to £86k pa – Leicestershire County and Rutland PCT/• Assist in the planning of service this represents a potential saving, Woodbrook Medical Centre development depending on what their accurate Email: email@example.com• Identify scope for targeted intervention diagnosis would be to optimise therapy and reduce • 30% of patients required optimisation admissions. of therapy, which could reduce the likelihood of admission • Approximately 7% of patients were identified as high risk patients using the DOSE index. The DOSE index The DOSE index (MRC Dyspnoea Scale, airflow obstruction, smoking status and exacerbation frequency) is a simple, validated tool for assessing the severity of COPD and guiding management, for use in routine clinical settings.
Case studies 21The Victoria Practice, Aldershot, HampshireReducing waste and increasing adherence in use ofmedicines for chronic obstructive pulmonary diseaseProject summaryVictoria practice employed a clinical Change in consecutive CAT score by patientpharmacist to conduct reviews for asthmaand COPD patients that has reduced 35prescribing costs and improved patients 30COPD assessment test (CAT) scores. 25Project aim CAT Score• Review asthma and COPD patients use 20 of medicines• Identify opportunities to improve 15 quality and reduce waste in prescribing 10• Evaluate the cost effectiveness of a clinical pharmacist as part of the 5 primary care team. 0 1 2 3 4 5 6 7 8 9 10Highlights and achievements PatientThe pharmacist sees COPD and asthmapatients routinely for review. These Original CAT Score Second CAT Scoreconsultations are specifically structuredaround previous National PrescribingCentre (NPC) concordance training, usingopen questions which help to understand Patients complete a CAT at their firstthe patients current attitude to their appointment with the pharmacist which CAT scoresmedicines and to set realistic goals for is then repeated at follow up where an The COPD assessment test (CAT) isimprovement for the future. intervention has been made in order to a simple validated test of 8 measure and document the effects and questions that objectively measuresDuring these consultations inhaler outcomes. Patients who do not need a the impact of COPD on the person’stechnique is evaluated and an InCheck face to face follow up appointment are life. A high score indicates theDial trainer device is also used in order to contacted by phone two to three weeks condition is having greater impactdetermine that patients are achieving the after their appointment. Where a on the person’s life; a low scoreoptimal inspiratory flow for their device. significant intervention such as change of indicates less impact. Patients arePatients using metered dose inhalers medication was made during the course encouraged to complete it(MDIs) are also given a 2Tone Trainer of the project, 8 out of 10 patients independently, as the test allowsdevice and advised to check their showed reductions in CAT score of them to express themselves in ainspiratory flow once a month at home. between 5 and 17 points. way that permits a common understanding of the issuesThe pharmacist is an independent affecting them. Ongoing use andprescriber, who holds COPD and clinical comparison of consecutive scorespharmacy diplomas. This ensures that can reveal whether impact isthe pharmacist is able to review and changing over time, providing arevise current medication, but working in useful framework for discussion tothe practice she also has the opportunity help optimize treatment.to discuss any significant concerns withthe practices lead GP. More information is available at www.catestonline.co.uk/hcpbenefits .htm
22 Case studies Victoria Practice prescribing costsThe practice has demonstrated a Ensuring that repeat prescriptions for Contactsustained reduction in prescribing costs of different medications are synchronized in Clare Watson£1300 per month on respiratory chapter terms of quantity prescribed can reduce Clinical Pharmacist Victoria Practice,medicines when other practices in its over or under ordering. This also Medicines Management Pharmacistgroup were showing an increase. increases the reliability of patients having NHS Hampshire the medication and taking it correctly. Email: firstname.lastname@example.orgLearningAllowing 30 minute appointments Process mapping at the practice hasprovides sufficient time with the patient revealed scope to work more closely withso all aspects of the consultation can be the local pharmacies to reduce potentialcovered. Making this time available for waste in repeat prescribing systems.the patient is important to establish arapport with the patient. Enhancing the skill mix in the practiceTo reduce ‘do not attends’ (DNAs) the team has brought more generalreceptionists phones the patient the day knowledge and sharing into the practicebefore their appointment with a such as an increased awareness ofreminder; this also allows time to contact medication costs, benefits waste ofother patients if there is a cancellation. different medication and additional cover within the team.Looking at the total prescribing picturefor the patient can help identify waste.
Case studies 23NHS BlackpoolFormalising self managementplanning in BlackpoolProject summaryWith high prevalence of chronicobstructive pulmonary disease (COPD)within the region along with high rates ofsmoking, high mortality and highspending, improving care planning andpatients ability to self manage were seenas priorities by the Primary Care Trust(PCT). At that time there was noformalised self management plan in uselocally so a format was developed inconjunction with patients. This initiative isnow in use across all 22 Primary Careteams and in the acute unit, with over1000 plans distributed by October 2011.Project aim• Develop consistent written self management care plans for all patients, as a key component of an integrated COPD pathway• Develop patient education materials and/or programmes together with Highlights and achievements Plans were distributed to all GP practices, educational support for clinicians A comprehensive plan was developed in community matrons, case workers, adopting new ways of working conjunction with patients and adopted pulmonary rehabilitation, acute trust,• Identify and promote the evidence base across primary and secondary care. The early supported discharge team and the for self management plans to gain plan was tested with clinicians and relief nursing team. When a plan is issued clinical commitment for their use patients to check terminology, content in secondary care, the named contact in• Agree an integrated approach to and the process of delivery before rolling the patients practice is informed to implementation, including promotion out, which both improved quality and facilitate seamless follow up. The plan of the plans and embedding their use increased buy-in from clinicians. also formed part of the Commissioning in clinical and social care practice and for Quality and Innovation (CQUIN) other care settings Training and education sessions were payment framework with the acute trust• Develop structured education provided to participating practices to to help embed its use as best practice. programmes appropriate to local needs ensure that the plan was delivered This helped reduce confusion for patients and skilling healthcare professional to appropriately and consistently, to by standardising the information they deliver the plan maximise effectiveness. were given and also helped assure• Evaluate the impact on patient continuity. confidence and outcomes. Educational events and training sessions supported the roll out of the plan which Training sessions were also run for social embedded the ethos and methodology care workers to equip them with necessary to deliver it successfully. additional skills to support patients in Training included the whole team so that their own homes by using My Breathing everyone was aware of and engaged in Book as an information tool. Community the process. pharmacists also have access to the plan as a reference tool.
24 Case studiesThe impact is being evaluated by apatient questionnaire, approved byClinical Governance and funded byPartnerships and Patient Engagementthrough local commissioners.LearningStrong links and good personal workingrelationships help build bridges anddevelop a consistent approach to delivery.Clinical education is important to ensurethe plan is used properly and consistentlyand to promote both behavioural andcultural change. Pulmonary rehabilitationreferral rates improved withimplementation of the plan, withawareness of the educational componentand additional time staff can offerpatients.A simplified version of a written selfmanagement plan is useful for thosepatients or carers who are less confidentor literate.It can be difficult to evaluate or attributeimpact in the short term. Informationgovernance issues made it difficult totrack impact by NHS number as originallyplanned. Alternative process measuresmay help in the interim, or individual sitesmay be able to monitor their ownpatients, but it is important to getacknowledgement that impact on highlevel admission data will take longer towork through. Total resource use perpatient per year may be a better indicatorof integrated care that includes selfmanagement planning. Self management Contactplanning may be best seen as an integral Ros Incecomponent of a care bundle approach to Lead Nurse Respiratory NHS Blackpooldelivering holistic, best practice care. Tel: 01253 651316 Email: email@example.comIt takes time!
Case studies 25Veor Surgery, Camborne, CornwallA systematic approach to implementingself management action plansProject summary Consultations included discussing withTo ensure all chronic obstructive the patient general health and wellbeing Think ‘ABC’ to self-managepulmonary disease (COPD) patients could (using a COPD computer template), what your COPDrecognise and respond appropriately to to look out for when becoming unwell,any worsening of their condition the prescribed medicines and their use, Able to do usual activities ?practice wanted to discuss a self inhaler technique, spirometry check andmanagement action plan with each of recording a COPD Assessment Test (CAT) Bit more breathless than usual ?them before winter set in. In spite of a score, sent to the patient for completionsignificant rise in exacerbations, the in advance. Coughing up colouredproportion of reported exacerbations sputum or phlegm?resulting in admission was only 5% that Patients were encouraged to startwinter compared to 8% the previous antibiotics in line with local guidelines Don’t delay, start youryear, and patients made greater use of and to contact the practice for advice and tablets today.planned appointments and telephone follow up.support to manage changes in theircondition. Exacerbations during the severe winter period were 117 (60 in previous year) butProject aim admissions and GP appointments• Ensure every COPD patient is reviewed remained stable. Patients made more use and has discussed self management of telephone consultations and planned action for exacerbations in the run up nurse appointments rather than urgent to the winter period contacts, indicating early intervention• Issue antibiotics and steroids in line gave better control and outcomes. with local guidelines to all appropriate patients• Evaluate the safety and impact of issuing rescue medication to patients in Proportion of exacerbations seen by GP or nurse relation to untoward incidents, admissions and use of primary care. 0.9 0.8Highlights and achievements Seen by doctor Seen by nurseThe team reviewed existing resources and 0.7re-allocated time to set up 20 specific 0.6 PercentageCOPD self management clinics, each 0.5offering six 30 minute appointments.122patients were reviewed for the project, 0.4and 100 patients agreed self 0.3management action plans during a three 0.2month period. 0.1Receptionists contacted patients the day 0before their appointment with a reminder October 2009 - March 2010 October 2010 - March 2011to reduce the chance of them not Yearattending.
26 Case studiesLearningInviting patients to discuss self Patient exacerbation pathwaymanagement in August and Septembermeant there was less likelihood of illness BEFOREor bad weather affecting patients’ abilityto attend. Urgent Start Review after Exacerbation Prescription medication appointment two weeksThe professional conducting the reviewshould be able to prescribe antibioticsand steroids, and be confident toexamine and assess the patient, including Delay and stress when patient is unwelldistinguishing between exacerbation andheart failure. This helps avoid additionalreferrals back to the GP. NOWAllowing 30 minute appointments gives Start Review withadequate time to address the patient’s Annual review Prescription Exacerbation nurse wih plan medicationconcerns and ensures their understanding practitionerwhen discussing self management.Setting up specific clinics to reach allpatients initially was time consuming, but Prompt access to advice and treatmentdid not create the backlog of other workthat the nurses had expected. Once thesystem is established, new patients canbe booked in for appropriateappointments on diagnosis.ContactAngie Bennetts,Advanced Nurse PractitionerEmail:firstname.lastname@example.org
Case studies 27Breathe Easy North Staffordshire and NHS Stoke on TrentHow support groups can impact onpatients’ ability to self manageProject summary Highlights and achievementsNHS Stoke on Trent and Breathe Easy • 75% of members say they are more Since joining Breathe Easy…North Staffordshire (BENS) demonstrated confident and 90% have a betterhow patient support groups can be understanding of their condition since 75% said they felt more confidentintegrated into the patient pathway, with joining the group in managing their conditiona 25% increase in attendance at the local • A member of the local communitygroup and 70% of members reporting respiratory team attends each meeting 88% indicated they felt moregreater awareness of what to do when to answer questions and concerns, and hopeful about the futurethey become unwell. The area has high to promote relevant self managementdeprivation along with high smoking and messages. If any common themes are 94% said they had a betterCOPD prevalence; increasing patients’ identified this can then be addressed at understanding of their lungunderstanding of how to manage their an organisational level conditionown health is an important part of the • Enquiries and membership havelocal strategy to address this. increased, with a 25% increase in 70% felt they had more attendance at meetings, as a result of knowledge of what to do if they“…seeing the way other making the referral process more become unwell consistent across a number of practicessufferers cope with their and ensuring that Breathe Easy and 76% felt they had moreillness has made me feel British Lung Foundation (BLF) support awareness of the support are highlighted at diagnosis available to people living with athat I can do the things I • Information packs on the local support lung diseasepreviously felt I could not.” group and BLF are provided to practices to give to patients on diagnosis andProject aim increase the reliability of referral to the• Analyse current membership of groups group. Information is also included in and referral sources to identify gaps discharge information packs• Increase the total number of patients • BENS members now provide input to involved in the group and the local pulmonary rehabilitation representation from a wider group of programme, promoting the role of the practices by raising awareness and local support group clarifying referral routes • Representation from BLF at the local• Develop effective patient and carer respiratory implementation group has information to support self enhanced understanding and management awareness of what Breathe Easy and• Increase patients’ healthy behaviour BLF can offer to enhance patient and confidence to self manage by experience and self management providing appropriate messages, • A quarterly newsletter and a welcome information and support pack are provided to members.• Identify the impact that group • Group members completed a membership has on patient outcomes. questionnaire on the impact of the group on their confidence and self management (see box).
28 Case studiesLearning• If health professionals are to consistently promote membership of a local support group, they need to be convinced that the programme and advice it offers are appropriate and valuable. This can be achieved through engagement at both a strategic and operational level• Personal contact with local practices can help raise awareness of the support available via the local group and increase referrals to the group. This is helpful because patients often report receiving only limited information at diagnosis, whereas referral to the BLF / Breathe Easy group can provide another early source of information and support, to enhance the opportunities for understanding their condition and what they can do to manage it• It is not easy to measure impact on health care resource use for small group numbers, but patient-reported measures and personal stories emphasise the value of group support in enhancing quality of life and confidence which provides a powerful message.ContactRebecca GowersDevelopment Officer,Midlands Region (BLF)Email: email@example.comSharon MaguireService Improvement andDevelopment Manager,Long Term Conditions(NHS Stoke on Trent)Email: firstname.lastname@example.org
Acknowledgements 29AcknowledgmentsNHS Improvement - Lung would like tothank all national improvement projectsites for their hard work and dedicationto improve quality and care for peoplewith COPD, and for their contributions tothis document.In addition, the following people haveprovided a source of expertise andsupport and their help is gratefullyacknowledged:Phil Duncan, Director,NHS Improvement - LungOre Okosi, National Improvement Lead,NHS Improvement - LungCatherine Thompson, NationalImprovement Lead, NHS Improvement -LungAlex Porter, Senior Analyst,NHS Improvement - LungFor more information pleasecontact: Catherine Blackaby,National Improvement Lead, NHSImprovement - Lung, Email:email@example.com Zoë Lord, National Improvement Lead,NHS Improvement - Lung, Email:firstname.lastname@example.org
30 ReferencesReferencesiAn Outcomes Strategy for ChronicObstructive Pulmonary Disease (COPD)and Asthma in England, Department ofHealth, July 2011iiThe National COPD Resources andOutcomes Project Final Report, ClinicalEffectiveness & Evaluation Unit, RoyalCollege of Physicians, London, May 2009