The document summarizes work done by NHS Improvement - Lung to improve diagnosis and management of chronic obstructive pulmonary disease (COPD) in the UK. Key findings from case studies include: standardized processes reduced variation; integrated teams improved the patient pathway; and self-management support reduced emergency admissions. Emerging principles for successful COPD care include understanding current practices, integrating care across settings, and supporting patients in self-management.

1. NHS
CANCER
NHS Improvement
Lung
DIAGNOSTICS
HEART
LUNG
STROKE
NHS Improvement - Lung: National
Improvement Projects
Improving earlier diagnosis and
the long term management of
COPD: Testing the case for
change

3. Contents 3
NHS Improvement - Lung National Improvement Projects -
Improving earlier diagnosis and the long term management
of COPD: Testing the case for change
Contents
4 Introduction
Case studies
9 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 costs
10 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 practices
12 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 pathway
14 London Community Healthcare NHS Trust and Hammersmith
and Fulham Primary Care Trust
Using an innovative data warehouse development
to improve respiratory services
18 The Leeds Teaching Hospitals NHS Trust
Developing an integrated COPD disease register to support quality
assured diagnosis and proactive chronic disease management
20 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 disease
23 NHS Blackpool
Formalising self management planning in Blackpool
25 Veor Surgery, Camborne, Cornwall
A systematic approach to implementing self management action plans
27 Breathe Easy North Staffordshire and NHS Stoke on Trent
How support groups can impact on patients’ ability to self manage
29 Acknowledgments
30 References

4. 4 Introduction
Introduction
Case for change: the current position A reduction in this variation would also The aim of the managing COPD as a long
for chronic obstructive pulmonary increase value for money of services as term condition workstream was to
disease 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 in
There are around 835,000 people Innovation, Productivity and Prevention order to improve the outcomes and
currently diagnosed with Chronic agenda. quality of care offered to patients. The
Obstructive Pulmonary Disease (COPD) aim also included related work to test the
in England and an estimated 2,000,000 During the first year of project work, NHS optimisation of health resources towards
people with COPD who remain Improvement – Lung through the ‘Earlier a reduction in emergency admissions. An
undiagnosed and are living with the Diagnosis’ and ‘Managing COPD as a important component of the work
disease1. The majority of these have mild Long Term Condition’ national incorporated medicines management by
or moderate disease but if they were workstreams have focussed on ensuring all patients with COPD were on
diagnosed early, they could then take the developing services that deliver efficient the correct treatment in relation to the
necessary 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 help
progression. The disease is progressive with the disease. This has been achieved support them to use their medication
and cannot be cured, with one person through working with and supporting correctly. Project work included testing
dying every 20 minutes in England and clinical teams to identify, test and ways to develop and implement effective
Wales. However, timely and accurate implement the changes needed to self-care models and ongoing patient
diagnosis, with supportive ongoing achieve this level of care and understand review, and to identify the key challenges
management can help modify the impact the key components that have the and solutions for overall long term
of 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 at
It is therefore vital that patients receive a The aim of the earlier diagnosis healthcare professionals, commissioners
quality-assured diagnosis at the earliest workstream was to ensure that all people and other key stakeholders involved in
opportunity in order to commence with suspected COPD receive an accurate respiratory health, draws together the
appropriate treatment and to slow the and quality assured diagnosis sooner and evidence and learning from the past 12
progression of the disease for the as a result, are placed on the correct months and highlights the work
individual. This can also reduce the treatment pathway. The aim also included undertaken by the project sites within
impact 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 are
costs. added to the practice disease register. Improvement approach
With the right pathway in place, it was
The Outcomes Strategy for COPDi and hypothesised that timely and quality In July 2010, NHS Improvement - Lung
Asthma in England and the NCROP Auditii assured diagnosis would lead to a invited NHS organisations to work in
identified that there is significant variation reduction in service costs by optimising partnership on projects dedicated to
across England in the way in which the treatment pathway for patients and improving the COPD patient pathway and
people are referred, diagnosed and initiating self-management at an earlier to help address the variation in care that
treated. There is significant scope to stage in the disease progression. Project patients receive. Projects plans were
improve the quality and timeliness of work included testing service models in submitted from a number of sites
diagnosis, treatment and management, both primary and secondary care, including acute trusts, primary care trusts
including pharmacotherapy, and to understanding and reviewing registers (PCTs) and community organisations.
organise care in a more integrated way. and the development of tools to improve
This would not only improve the quality and monitor quality.
and efficiency of the service, but also
empower patients to manage their own
condition.

5. Introduction 5
The primary aims of the projects in the Once the project teams were established, • There appears to be extensive variation
two 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 prescribing
Focus was also given to improving the performance can help target efforts for
patient’s experience and outcomes along • Identifying the current state of practice improvement
with removing duplication and waste and any gaps, duplication, waste or • Consistent recording of data across the
from the pathway or specific processes opportunities to improve the quality of practice team is essential to allow
through different ways of working and care stratification, monitoring of
service redesign. Productivity gains • Increasing the number of patients deterioration and impact of changes in
achieved by sites were measured to whose treatment is optimised by care, and highlights any increasing
identify the impact of the work. identifying the right patients, providing frequency of exacerbations early in
appropriate information and support, order to initiate targeted intervention
During the ‘testing’ phase of the and ensuring they are on the right where appropriate
programme, 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 is
taking stock of current practice and systems for diagnosis and management important to identify what is most
understanding the process of are consistent and effective. useful and how best to present it.
implementation to ensure patients receive Targeting patients or practices with
optimal care in a challenging Whilst each project site has worked on a high resource use can help towards
environment. The project sites adopted a different part of the diagnosis and demonstrating benefits more quickly
systematic approach to quality management pathway, a number of • There can be a significant impact on
improvement to ensure that any changes themes have emerged across all sites: admissions by targeting moderate
implemented were thoroughly tested and COPD patients and increasing their
measured. Prior to commencing the • Although clinicians understand the confidence in self management, while
work, the project sites were required to components of optimal COPD care, ensuring work is undertaken to
establish their service baseline through there is widespread variation in practice correctly identified patients’ severity in
analysis of local data and to understand in the way in which diagnosis and the first instance
the variation in services. management are provided. This
includes aspects such as spirometry,
support for self care and optimising
treatment

6. 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

7. 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 in
Many of the issues and challenges place. The challenge now is to identify
met 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 work
specialities and several of the success is also required to identify the essential
principles have been demonstrated • Sustainable and innovative service elements and most effective means to
to 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 and
areas where common principles and secondary care provision) • Planning for early intervention in the
practice meant that learning could • Models to support earlier diagnosis and event of exacerbation
be transferred across specialities. improved primary care access • Medicines management and good
• Models to support diagnosis of all inhaler technique
severities and associated conditions

8. 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 national
on demonstrating how to improve programme to deliver a QIPP reduction in
management and self care for people emergency admissions by 20%, a Catherine Blackaby
with COPD to reduce admissions, reduction in readmissions at 30 days by National Improvement Lead,
NHS Improvement – Lung
optimise medicines use and enhance 20% and reduction in prescription spend
patient 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 - Lung
This 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 - Lung
and how to implement it, to ensure that
every minute of contact is used to Phil Duncan,
maximum effect, every time. Director,
NHS Improvement - Lung
In summary, the key aims of prototype
project 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

9. Introduction 9
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 costs
Project summary • 15% classified as restrictive by GP
Historically, most patients referred to the were normal
secondary care consultant-led respiratory • 15% classified as obstructive by GP
clinic via Choose and Book received were normal
detailed pulmonary function testing prior • 69% classified as normal by the P were
to their appointment with the consultant. obstructive
However, an audit highlighted that 30% • 54% of patients referred needed to be
of referrals did not require intervention added to the practice COPD disease
and were immediately discharged back to register and 7% needed to be removed
the GP as these patients could have been to the register
diagnosed 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 for
This led to the introduction of a direct Project aim Chronic Obstructive Lung Disease
access 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 as
required support diagnosing and pulmonary disease (COPD), in primary classified by GP spirometry
managing their respiratory patients in care • 20% changed by one GOLD stage
primary care. • Ensure all patients are on the • 38% changed by two GOLD stages.
appropriate management pathways
The new service provided detailed with appropriately identified patients Learning
pulmonary function testing (spirometry, being managed in primary care, • Meaningful patient engagement
static lung volumes, gas transfer +/- resulting in: presents valuable insights into a current
reversibility testing) for all referred • Earlier access to smoking cessation service provision. Patient engagement
patients. Where there is diagnostic • Improved access to COPD respiratory was highly beneficial resulting in a
certainty, 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 in
of their test and a British Lung rehabilitation services which the patient invitation letters are
Foundation (BLF) leaflet; where this • Appropriate referrals into the hospital structured and written along with the
certainty does not exist, patients receive respiratory clinics for specialist guidance information leaflets that are given out
more general information about lung (a reduction in unnecessary referrals for to patients at the time of their tests
health, 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 volume
Function Tests, with chest physician • To create a measurable effect on GPs’ referrers. Only providing written
guidance as necessary. Depending on the decision to refer a patient to hospital information about a new service does
outcome of the tests, patients no longer clinics with the aim to reduce referrals not instigate a change in referral
automatically see the consultant by 25%. patterns. Newsletters, emails and letters
respiratory physician, although advice have a limited effect. Building
may be given to refer the patient in to the Highlights and achievements relationships and using personal
respiratory clinic where deemed Reduction in unnecessary consultant mediums of communication like
appropriate. 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: rbuttery@nhs.net

10. 10 Case studies
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 practices
Project summary
North East, North Central London and Quality of COPD diagnosis measures at practice level
Essex Health Innovation and Education
Cluster (NECLES HIEC) have been working
with nine practices in Walthamstow West
Primary Care Commissioning Group with
support from GlaxoSmithKline UK to
quantify the region of error in the
diagnosis of COPD and the recording of
information 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

11. 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: gabluc@aol.com
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 O'Malley
diagnosis highlighted 50% of patients Respiratory Nurse Specialist
had a confirmed diagnosis of COPD
and 50% did not have COPD. Kirsty Barnes
HIEC Fellow
Learning Email: kirstybarnes@hiec.org.uk
• 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. 12 Case studies
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 pathway
Project summary • To support patients post discharge after
A consultant led integrated respiratory acute exacerbation
team in Hammersmith and Fulham (H&F), • To improve communication and joint
working across Imperial College working by clinicians looking after
Healthcare NHS Trust (ICHT) and Central COPD patients in primary, secondary
London Community Healthcare NHS Trust and community teams.
(CLCH) has been working to improve the
quality of services for patients with COPD Highlights and achievements
and other long term respiratory • Improvements across the patient
conditions. pathway have led to a reduction of
admissions by 19% and readmissions
The project was part of a broader review by 66%
to reconfigure and re-commission services • Reduction in first and follow up Learning
to deliver an integrated COPD patient outpatient appointments equating to • Shared aims and joint working across
pathway, supported by the primary care approximately £170k savings primary, secondary and community
trust and local stakeholders. The project • Reduction in the proportion of patients care, with engagement of
was commenced after a gap analysis presenting with an acute exacerbation commissioners is critical to the success
showed that H&F had among the worst of COPD who do not have a previous of an integrated service
outcomes for COPD patients in London, GP diagnosis • Changing traditional patterns of
with high admissions costing over £1m • 145 patients have had a quality review working is challenging and takes time
per year and an estimated 5,000 patients with a respiratory specialist as a result to implement
with as yet undiagnosed COPD. of which: • Data is crucially important; robust
• Quality of recording of FEV1, timely data is difficult to obtain and
Service developments have included exacerbations and breathlessness clinicians need to take ownership and
specialist support to primary care have improved in line with National responsibility for it
delivering quality assured spirometry, Institute for Health and Clinical • Managing change can be slow and
workplace based training and quality Excellence (NICE) quality standards in difficult. Communication
reviews; community based pulmonary a practice audit exercise throughout the process is vital
rehabilitation; a COPD discharge bundle • 30% additional referrals to • Implementation of the chronic care
with community follow-up; and smoking cessation advice were made model in COPD pathway can deliver
community clinics. • 41% of patients received rescue improved outcomes. Working across
medication packs traditional boundaries to deliver an
Project 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: irempatel@nhs.net
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

13. Case studies 13
Example of the GP practice reports and progress made
PRACTICE A
PRACTICE B
PRACTICE C
Number 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. 14 Case studies
London Community Healthcare NHS Trust and
Hammersmith and Fulham Primary Care Trust
Using an innovative data warehouse development
to improve respiratory services
Project summary ‘COPD’ or ‘asthma’ report at patient, • Data is automatically extracted from GP
In all quality improvement projects, access practice or Primary Care Trust (PCT) level practices and aggregated by Apollo
to data is a crucial part of identifying the as required which also can track Software
areas for improvement and for improvements over time. A key • The data is then downloaded from
monitoring progress. component of this is measuring Apollo and linked into the PCT data
compliance with locally agreed and warehouse
An integrated respiratory team in National Institute for Health and Clinical • The data warehouse combines
Hammersmith and Fulham working Excellence (NICE) standard care, rather individual patient level data from
across Imperial College Healthcare NHS than Quality Outcomes Framework (QOF) Secondary Uses Service (SUS), the local
Trust and Central London Community targets, and focusing on important data RIO database and the extract from
Healthcare NHS Trust started their such as smoking prevalence in the primary care, matching patients on NHS
improvement project by working with respiratory population. number
local GP practices. Using the • An innovative, interactive document is
GlaxoSmithKline POINTS (GSK) audit tool Project aim produced for viewing and sharing the
to assess the quality of chronic • Improve joint working across primary, data, using Tableau software. Tableau
obstructive pulmonary disease (COPD) secondary and community care to software provides an intuitive
management in their area, a respiratory deliver and monitor an integrated dashboard style interface that enables
specialist team worked with practices to pathway practices to have an overview of the
review COPD and asthma patients to • Improve the collection and analysis of key measures for their practice, and
deliver workplace based training aimed at primary and secondary care data to click into the detail for patient level
primary care clinicians. Data from support local services and the decision information if they require
enhanced COPD and asthma reviews was making processes • This data is shared with practices and
entered on read code linked templates • Improve monitoring of the local the integrated respiratory team to
and progress was followed up with a integrated COPD pathway, through facilitate appropriate intervention and
second audit. monthly monitoring across primary monitor progress.
care and secondary care
Significant improvements were made to • Improve local monitoring of asthma Highlights and achievements
reduce the variation between practices patients • This innovative approach enables the
and improve the quality of diagnosis and • Provide greater feedback on admissions PCT to access and merge the data from
management. To sustain the data to local GP practices the local acute services and general
improvement in the area, a multi • Create useful performance measures to practices to provide a whole system
disciplinary team from Central London support clinicians and managers in the picture of the care received by COPD
Community Healthcare NHS Trust, area. and asthma patients in the area
Hammersmith and Fulham Primary Care • Data is collected on compliance with
Trust (PCT) and General Practice initiated Data extraction and matching process locally agreed and NICE standards of
a 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 warehouse
information recorded on practice warehouse based on primary and is owned by the PCT and is available for
computer systems, monitor out patient secondary care read codes relevant to other healthcare providers to use and
appointments, admissions and re- COPD and asthma. The 30 practices in implement in their local area. No
admissions, along with highlighting those NHS Hammersmith and Fulham agreed to additional software is required as the
admissions coded as COPD or asthma share a generic monthly extract of data warehouse is based on the commonly
who are not on the GP practice disease from their practice systems to the PCT. used Microsoft SQL database
register. This then generates a local

15. 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: d.sayers@nhs.net
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: irempatel@nhs.net
• 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: alide.petri@inwl.nhs.uk
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: clare.graley@nhs.net
piloted reports for COPD and asthma.
The same data warehouse could be
used for other disease areas.

16. 16 Case studies
Example of COPD and asthma reports produced for GP practices

17. Case studies 17

18. 18 Case studies
The Leeds Teaching Hospitals NHS Trust
Developing an integrated COPD disease register to
support quality assured diagnosis and proactive
chronic disease management
Project summary • Enables assessment of the impact of Contact
The 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 to
Obstructive Pulmonary Disease (COPD) progression over time to identify the request to use the register in your area
register designed to proactively support indications for all interventions with the contact:
diagnosis and chronic disease impact on the patient and their chronic
management across both Primary and disease Dr Doychin Dimov
Secondary Care. • Consistent with the current clinical Consultant Physician in
evidence and the recommendations of Respiratory Medicine
Project aim the national and international Email: doytchin.dimov@leedsth.nhs.uk
To produce an integrated standardised guidelines
register to ensure all the necessary patient • Data format will be compatible with Further information including the register
information 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/lung
communication and information flow • The process of collecting, recording and
between Primary and Secondary Care analysing the data will be acceptable
which is highly beneficial for both patient and feasible for both patients and
outcomes and efficiency, and to act as a health care organisations
platform where diagnostic information • Support continuous audit of all
(e.g. current smoking status) triggers requirements of Quality and Outcomes
patient referral for treatment (e.g. Framework (QOF), Quality Standards
smoking 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 process
Benefits of using this disease register of engagement and decision making is
include: 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

19. 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: doytchin.dimov@leedsth.nhs.uk
More documents are available on the NHS Improvement at: www.improvement.nhs.uk/lung

20. 20 Case studies
Leicester County and Rutland PCT
How good is our management of chronic
obstructive pulmonary disease?
Project summary Highlights and achievements Learning
Leicester County and Rutland Primary OPC software was used to extract Existing data sets and Quality Outcomes
Care Trust worked with Optimum Primary routinely recorded data from participating Framework measures give only a limited
Care (OPC) using software to extract practices. The data is automatically understanding of quality. The marked
primary care data. In order to target compared with the National Institute for variation in recording of FEV1, COPD
education and intervention appropriately Health and Clinical Excellence (NICE) severity, exacerbation recording, smoking
an evaluation was conducted to COPD rule sets to identify any history, medicines use, referral for
determine how well asthma and chronic discrepancies between current and pulmonary rehabilitation and other
obstructive pulmonary disease (COPD) suggested optimal care for each patient. aspects of care potentially indicates
were being diagnosed and managed. This is automatically fed back into the significant difference in quality of care
Following the results of this evaluation it practice system forming personalised and related impact on secondary care and
was evident that a significant variation in recommendations for that patient; this prescribing. Making this visible helps to
quality and consistency existed, which information will also inform the patient’s target appropriate intervention to
was 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 severe
Project 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: dermotryan@doctors.org.uk
• 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.

21. Case studies 21
The Victoria Practice, Aldershot, Hampshire
Reducing waste and increasing adherence in use of
medicines for chronic obstructive pulmonary disease
Project summary
Victoria practice employed a clinical Change in consecutive CAT score by patient
pharmacist to conduct reviews for asthma
and COPD patients that has reduced 35
prescribing costs and improved patient's
30
COPD assessment test (CAT) scores.
25
Project 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 10
Highlights and achievements
Patient
The pharmacist sees COPD and asthma
patients routinely for review. These Original CAT Score Second CAT Score
consultations are specifically structured
around previous National Prescribing
Centre (NPC) concordance training, using
open questions which help to understand Patients complete a CAT at their first
the patients' current attitude to their appointment with the pharmacist which CAT scores
medicines and to set realistic goals for is then repeated at follow up where an The COPD assessment test (CAT) is
improvement 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 measures
During these consultations inhaler outcomes. Patients who do not need a the impact of COPD on the person’s
technique is evaluated and an InCheck face to face follow up appointment are life. A high score indicates the
Dial trainer device is also used in order to contacted by phone two to three weeks condition is having greater impact
determine that patients are achieving the after their appointment. Where a on the person’s life; a low score
optimal inspiratory flow for their device. significant intervention such as change of indicates less impact. Patients are
Patients 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 allows
device and advised to check their showed reductions in CAT score of them to express themselves in a
inspiratory flow once a month at home. between 5 and 17 points. way that permits a common
understanding of the issues
The pharmacist is an independent affecting them. Ongoing use and
prescriber, who holds COPD and clinical comparison of consecutive scores
pharmacy diplomas. This ensures that can reveal whether impact is
the pharmacist is able to review and changing over time, providing a
revise current medication, but working in useful framework for discussion to
the practice she also has the opportunity help optimize treatment.
to discuss any significant concerns with
the practice's lead GP. More information is available at
www.catestonline.co.uk/hcpbenefits
.htm

22. 22 Case studies
Victoria Practice prescribing costs
The practice has demonstrated a Ensuring that repeat prescriptions for Contact
sustained 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 Pharmacist
group were showing an increase. increases the reliability of patients having NHS Hampshire
the medication and taking it correctly. Email: clare.watson2@nhs.net
Learning
Allowing 30 minute appointments Process mapping at the practice has
provides sufficient time with the patient revealed scope to work more closely with
so all aspects of the consultation can be the local pharmacies to reduce potential
covered. Making this time available for waste in repeat prescribing systems.
the patient is important to establish a
rapport with the patient. Enhancing the skill mix in the practice
To reduce ‘do not attends’ (DNAs) the team has brought more general
receptionists phones the patient the day knowledge and sharing into the practice
before their appointment with a such as an increased awareness of
reminder; this also allows time to contact medication costs, benefits waste of
other patients if there is a cancellation. different medication and additional cover
within the team.
Looking at the total prescribing picture
for the patient can help identify waste.

23. Case studies 23
NHS Blackpool
Formalising self management
planning in Blackpool
Project summary
With high prevalence of chronic
obstructive pulmonary disease (COPD)
within the region along with high rates of
smoking, high mortality and high
spending, improving care planning and
patients' ability to self manage were seen
as priorities by the Primary Care Trust
(PCT). At that time there was no
formalised self management plan in use
locally so a format was developed in
conjunction with patients. This initiative is
now in use across all 22 Primary Care
teams and in the acute unit, with over
1000 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 patient's 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. 24 Case studies
The impact is being evaluated by a
patient questionnaire, approved by
Clinical Governance and funded by
Partnerships and Patient Engagement
through local commissioners.
Learning
Strong links and good personal working
relationships help build bridges and
develop a consistent approach to delivery.
Clinical education is important to ensure
the plan is used properly and consistently
and to promote both behavioural and
cultural change. Pulmonary rehabilitation
referral rates improved with
implementation of the plan, with
awareness of the educational component
and additional time staff can offer
patients.
A simplified version of a written self
management plan is useful for those
patients or carers who are less confident
or literate.
It can be difficult to evaluate or attribute
impact in the short term. Information
governance issues made it difficult to
track impact by NHS number as originally
planned. Alternative process measures
may help in the interim, or individual sites
may be able to monitor their own
patients, but it is important to get
acknowledgement that impact on high
level admission data will take longer to
work through. Total resource use per
patient per year may be a better indicator
of integrated care that includes self
management planning. Self management Contact
planning may be best seen as an integral Ros Ince
component of a care bundle approach to Lead Nurse Respiratory NHS Blackpool
delivering holistic, best practice care. Tel: 01253 651316
Email: rosalyn.ince@blackpool.nhs.uk
It takes time!

25. Case studies 25
Veor Surgery, Camborne, Cornwall
A systematic approach to implementing
self management action plans
Project summary Consultations included discussing with
To ensure all chronic obstructive the patient general health and wellbeing
Think ‘ABC’ to self-manage
pulmonary disease (COPD) patients could (using a COPD computer template), what
your COPD
recognise 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 and
management 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 completion
significant rise in exacerbations, the in advance.
Coughing up coloured
proportion of reported exacerbations
sputum or phlegm?
resulting in admission was only 5% that Patients were encouraged to start
winter compared to 8% the previous antibiotics in line with local guidelines
Don’t delay, start your
year, 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 their
condition. Exacerbations during the severe winter
period were 117 (60 in previous year) but
Project 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
0.8
Highlights and achievements Seen by doctor Seen by nurse
The team reviewed existing resources and 0.7
re-allocated time to set up 20 specific 0.6
Percentage
COPD self management clinics, each 0.5
offering six 30 minute appointments.122
patients were reviewed for the project, 0.4
and 100 patients agreed self 0.3
management action plans during a three
0.2
month period.
0.1
Receptionists contacted patients the day 0
before their appointment with a reminder October 2009 - March 2010 October 2010 - March 2011
to reduce the chance of them not Year
attending.

26. 26 Case studies
Learning
Inviting patients to discuss self Patient exacerbation pathway
management in August and September
meant there was less likelihood of illness BEFORE
or bad weather affecting patients’ ability
to attend.
Urgent Start Review after
Exacerbation Prescription medication
appointment two weeks
The professional conducting the review
should be able to prescribe antibiotics
and steroids, and be confident to
examine and assess the patient, including Delay and stress when patient is unwell
distinguishing between exacerbation and
heart failure. This helps avoid additional
referrals back to the GP.
NOW
Allowing 30 minute appointments gives
Start Review with
adequate time to address the patient’s Annual review
Prescription Exacerbation nurse
wih plan medication
concerns and ensures their understanding practitioner
when discussing self management.
Setting up specific clinics to reach all
patients initially was time consuming, but Prompt access to advice and treatment
did not create the backlog of other work
that the nurses had expected. Once the
system is established, new patients can
be booked in for appropriate
appointments on diagnosis.
Contact
Angie Bennetts,
Advanced Nurse Practitioner
Email:
angie.bennetts@veor.cornwall.nhs.uk

27. Case studies 27
Breathe Easy North Staffordshire and NHS Stoke on Trent
How support groups can impact on
patients’ ability to self manage
Project summary Highlights and achievements
NHS 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 better
how patient support groups can be understanding of their condition since 75% said they felt more confident
integrated into the patient pathway, with joining the group in managing their condition
a 25% increase in attendance at the local • A member of the local community
group and 70% of members reporting respiratory team attends each meeting 88% indicated they felt more
greater awareness of what to do when to answer questions and concerns, and hopeful about the future
they become unwell. The area has high to promote relevant self management
deprivation along with high smoking and messages. If any common themes are 94% said they had a better
COPD prevalence; increasing patients’ identified this can then be addressed at understanding of their lung
understanding of how to manage their an organisational level condition
own health is an important part of the • Enquiries and membership have
local 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 practices
sufferers cope with their and ensuring that Breathe Easy and 76% felt they had more
illness has made me feel British Lung Foundation (BLF) support awareness of the support
are highlighted at diagnosis available to people living with a
that I can do the things I • Information packs on the local support lung disease
previously felt I could not.” group and BLF are provided to practices
to give to patients on diagnosis and
Project 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. 28 Case studies
Learning
• 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.
Contact
Rebecca Gowers
Development Officer,
Midlands Region (BLF)
Email: becky.gowers@blf-uk.org
Sharon Maguire
Service Improvement and
Development Manager,
Long Term Conditions
(NHS Stoke on Trent)
Email: sharon.maguire@stoke.nhs.uk

29. Acknowledgements 29
Acknowledgments
NHS Improvement - Lung would like to
thank all national improvement project
sites for their hard work and dedication
to improve quality and care for people
with COPD, and for their contributions to
this document.
In addition, the following people have
provided a source of expertise and
support and their help is gratefully
acknowledged:
Phil Duncan, Director,
NHS Improvement - Lung
Ore Okosi, National Improvement Lead,
NHS Improvement - Lung
Catherine Thompson, National
Improvement Lead, NHS Improvement -
Lung
Alex Porter, Senior Analyst,
NHS Improvement - Lung
For more information please
contact: Catherine Blackaby,
National Improvement Lead, NHS
Improvement - Lung, Email:
catherine.blackaby@improvement.nhs.uk
or Zoë Lord, National Improvement Lead,
NHS Improvement - Lung, Email:
zoe.lord@improvement.nhs.uk

30. 30 References
References
iAn Outcomes Strategy for Chronic
Obstructive Pulmonary Disease (COPD)
and Asthma in England, Department of
Health, July 2011
iiThe National COPD Resources and
Outcomes Project Final Report, Clinical
Effectiveness & Evaluation Unit, Royal
College of Physicians, London, May 2009

32. NHS
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DIAGNOSTICS
HEART
LUNG
STROKE
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