Chronic Obstructive Pulmonary Disease (health and wellbeing needs in South Tyneside)

Chronic Obstructive Pulmonary Disease (COPD) is the umbrella term for serious lung conditions that include chronic bronchitis[1] and emphysema[2]. COPD is usually prevalent in adults over the age of 35. As many as 3 million people suffer from COPD in the UK, of which only around a third of cases have been diagnosed. COPD is a serious lung disease for which smoking is the biggest preventable risk factor (NHS Choices).

People with COPD have difficulties breathing, primarily due to the narrowing of their airways and destruction of lung tissue. Typical symptoms include breathlessness when active, a persistent cough and frequent chest infections.

Smokers can often dismiss the early signs of COPD as a 'smoker's cough', but if they continue smoking and the condition worsens, it can greatly impact on their quality of life. Large numbers of people with COPD are unable to participate in everyday activities such as climbing stairs, housework or gardening; with many even unable take a holiday because of their disease.

If a timely diagnosis is present, COPD is a condition that can be effectively managed in a primary care setting.

Better identification of this condition is beneficial both for the patient, as a better quality of life is possible if managed effectively, and for health services with the reduction in the number of costly hospital admissions.

COPD is a specific priority for South Tyneside and is identified as such in South Tyneside Clinical Commissioning Group's Commissioning Intentions, and as part of broader work on smoking-related diseases in the Joint Health and Wellbeing Strategy.

The South Tyneside NHS RightCare Commissioning for Value (CfV) 'Where to Look' packs helped us identify the areas of greatest opportunity for improvement, with COPD being recognised as one of our key priorities. Key areas that the pack highlighted included:

• COPD was our biggest opportunity from a spend perspective.
• Local COPD prevalence is double that of the national average at 3.7%.
• There is significant variation compared to our peer group in non-elective admissions and under 75 years' mortality.

[1] Long-term inflammation of the airways

Public Health England (PHE) provide a snapshot of lung health in South Tyneside (and other local authority/ CCG areas), called Inhale (Interactive Health Atlas of Lung conditions in England). We have triangulated these data with the NHS Rightcare Commissioning for Value packs and locally produced data on respiratory disease, to identify the following key issues:

• High prevalence of smoking, and a particular legacy of smoking and heavy industry,
• High recorded prevalence of COPD (the highest in England) - 3.7% which is double the national average (1.8%) - this prevalence has been on the increase year on year, however it still falls short of our estimated prevalence (4.25%),
• High levels of non-elective admissions related to COPD, around 650 - 700 emergency COPD admissions per year- however, it's important to note that when the rate of emergency COPD admissions are adjusted for prevalence, the rate is not statistically different to the national average,
• Low capacity in pulmonary rehabilitation services relative to the size of the prevalence,
• There is an unmet need in relation to less severe cases of COPD (MRC score <3),
• Significant levels of co-morbidity in relation to COPD,
• There is a need to consider end of life pathways for patients diagnosed with COPD.

Our high-level priorities have been identified by the South Tyneside Respiratory Strategy Group and endorsed by South Tyneside Clinical Commissioning Group:

• Support a comprehensive Tobacco Control Strategy for South Tyneside
  • Particularly supporting Stop B4 Your Op pathways and a Smoke Free Hospitals Model in South Tyneside, which includes maintaining quit attempts when patients are discharged into the community,
• Clearly define the local COPD pathway (including prescribing and admission guidance) and share this with primary and secondary care,
  • Conduct biannual training sessions for primary care on the local COPD system,
• Review current community spirometry arrangements to avoid false-negative and false-positive spirometry results,
• Pilot self-care approaches to COPD, supporting individuals to better manage their own condition,
• Review pulmonary rehabilitation and design a strategy for increasing activity levels,
• Design a new in-hours pathway for COPD exacerbations (potentially community-based ambulatory care pathways),
• Review secondary care treatment options and pathways, relative to other similar CCG areas.

• NICE defines COPD as:
  • COPD is characterised by airflow obstruction that is not fully reversible. The airflow obstruction does not change markedly over several months and is usually progressive in the long term. COPD is predominantly caused by smoking. Other factors, particularly occupational exposures, may also contribute to the development of COPD. Exacerbations often occur, where there is a rapid and sustained worsening of symptoms beyond normal day-to-day variations.
• The following should be used as a definition of COPD:
  • Airflow obstruction is defined as a reduced FEV1/FVC ratio (where FEV1 is forced expired volume in 1 second and FVC is forced vital capacity), such that FEV1 / FVC is less than 0.7.
  • If FEV1 is ≥ 80% predicted normal a diagnosis of COPD should only be made in the presence of respiratory symptoms, for example breathlessness or cough.
• The airflow obstruction is present because of a combination of airway and parenchymal damage. The damage is the result of chronic inflammation that differs from that seen in asthma and which is usually the result of tobacco smoke. Significant airflow obstruction may be present before the person is aware of it.
• COPD produces symptoms, disability and impaired quality of life which may respond to pharmacological and other therapies that have limited or no impact on the airflow obstruction.
• COPD is now the preferred term for the conditions in patients with airflow obstruction who were previously diagnosed as having chronic bronchitis or emphysema.
• There is no single diagnostic test for COPD. Making a diagnosis relies on clinical judgement based on a combination of history, physical examination and confirmation of the presence of airflow obstruction using spirometry.
• Key risk groups for COPD are:
  • Current and ex-smokers,
  • Occupational exposures,
• There are other key drivers of these risk factors including:
  • Socio-economic deprivation,
  • Gender - men have traditionally smoked more than women, and men are also more likely to have worked in the heavy industries that are associated with respiratory diseases.

History of Industries in South Tyneside

The 2007 Joint Strategic Needs Assessment provides an overview of South Tyneside's industrial heritage. The section can be accessed here.

South Tyneside is an area which has seen a decline in its traditional industry and suffers from significant socio-economic deprivation. South Tyneside's main industries historically were shipbuilding and coal mining, however the last shipbuilder (Redheads) closed in 1984 and the last coalmine (Westoe Colliery) closed in 1991. In 2001 the service industry was the largest sector of the local economy employing 63% of all workers. The graph below outlines the proportion of workers within each of the industries re-organised to the categories used in the 2001 key statistics.

• The need for services for local people has been highlighted in several Department of Health documents in recent years. NICE^[1] recommends pulmonary rehabilitation as an important part of COPD management, in conjunction with optimal treatment and smoking cessation.
• The registered practice population of South Tyneside in July 2016 was 156,546.
• The QOF data 2014 / 15 for South Tyneside shows that 3.7% of the registered population has a confirmed diagnosis of COPD (all ages)^[2]; some 5,700 people. However the estimated prevalence of COPD (all ages) is 4.25%, which is around 6,500.
• In July 2016, 2,305 individuals had a recorded MRC score of 3 or above (eligible target patients for acute based pulmonary rehabilitation)^[3].
• In 2015 - 16 there were 706 admissions for COPD and 186 readmissions within 90 days.^[4]
• Chart 1, provides a breakdown of MRC scores as at 31-07-2016, for all patients registered In South Tyneside aged 16 years or over with COPD.

Pulmonary Rehabilitation

Pulmonary rehabilitation should be made available to all patients who consider themselves functionally disabled by COPD (usually MRC grade 3 and above). Pulmonary rehabilitation programmes should include multicomponent, multidisciplinary interventions, which are tailored to the individual patient's needs. The rehabilitation process should incorporate a programme of physical training, disease education, nutritional, psychological and behavioural intervention.

• The national NHS Pulmonary Rehabilitation service specification states "A community based service would focus on engaging patients with an MRC 3 or more". ^[5]
• In South Tyneside, this is the inclusion criteria for the acute based service. Chart 1 above shows there are 2,305 patients who are eligible to access the acute pulmonary rehabilitation service within South Tyneside.
• The above chart also shows that on the MRC scale of 1 - 5, MRC 2 has the most individuals recorded against this level of severity. Based on the current acute specification, 3,387 patients (MRC 1 & 2) are therefore not eligible for the current service, representing a considerable unmet need. Moreover, the respiratory health of many of these people may deteriorate, placing additional burdens on the system.
• Data obtained from local GP practices (from the Better Outcomes Scheme - practice incentive scheme) found that fewer than 50% of the patients attending the service were referred from primary care (the majority of referrals were from other local referring agencies or from self-referrals). In 2014 / 15 almost as many patients declined the course as attended. In 2015 / 16 more than three times as many patients declined the course as actually attended. Locally we have high rates of patients declining pulmonary Rehabilitation.
• It is important to raise that the patients who are not accessing the service (over the years of 2012 - 2016), are potentially having a significant impact on the system.
• According to the Better Outcomes Scheme data from 2014 - 2016, there were 1443 patients referred from GP practices who did not receive pulmonary rehabilitation, 256 of whom were deemed unsuitable and 1187 of whom declined to attend a course. Both these groups will use other services to treat their respiratory condition. Of those who declined to attend a course there will be many who could learn to self-manage, potentially reducing demand for other, more costly services.

• There is no clear model for a Smoke Free South Tyneside Hospital,
• There isn't a clear pathway to help people stop smoking prior to elective surgery in South Tyneside,
• There is no pulmonary rehabilitation provision for patients with an MRC score of < 3,
• Community-based support for people with acute exacerbations and advice/ support on immediate response and "rescue" medications,
• Support to help people (and carers) self-care and manage their conditions,
• There is a fragmented COPD care model in South Tyneside and clearer connections between different elements of the pathway need to be made,
• Lack of capacity in the pulmonary rehabilitation programme, and the pathways out of pulmonary rehabilitation into community-based services for exercise / wellness,
• GP practices have highlighted a gap in clinical care for housebound patients with COPD. This was identified through a recent audit of GP practices as part of the Better Outcomes Scheme.

Not only is lung disease the UK's third biggest killer disease area - after cardiovascular disease and non-respiratory cancers - but relatively little progress has been made in tackling it in the last 10 years. Whereas the number of people dying from cardiovascular disease has fallen significantly, the number of people dying from lung disease has barely changed. According to the British Lung Foundation, the UK now has the fourth highest lung disease mortality rate in Europe.

• By 2020 it is estimated that the prevalence of COPD in South Tyneside will rise to 4.3%, which equates to approximately a 1,000 additional people with COPD - this is a 17% increase,
• This increase is likely to place a significant pressure on the existing COPD care system leading to large increases in prescribing and admission costs. The system will have to adapt considerably to better manage this projected demand,
• Smoking prevalence continues to fall with South Tyneside now at 17%, statistically similar to that of the England average. Tobacco consumption has been found to be strongly predictive of COPD mortality.
• There is an estimated time-lag of approximately 15 years for males and 20 years for females between smoking and a COPD diagnosis,[1] therefore the legacy of high smoking prevalence in South Tyneside may continue to drive health care needs into the future.

• Locally there is a Breathe Easy Group run by the British Lung Foundation,
• A Better U Selfcare programme,
• Increasing Access to Psychological Therapies,
• Inhaler Technique training is available to South Tyneside staff online and we will be designing videos for HealthPathways that professionals can also use,
• Most direct COPD care is provided through General Practice and South Tyneside NHS Foundation Trust,
• ARAS Team,
• Pulmonary Rehabilitation,
• Think Pharmacy First scheme- provided by Pharmacists across South Tyneside,
• Integrated community teams / Social Navigators (housebound patients),
• 3rd sector services and advice are available - visit Wellbeing info.

Key clinical and quality issues in providing effective services for people with COPD include:

• Identification and accurate diagnosis of COPD in people presenting with symptoms and signs of COPD, and confirmation by performing post-bronchodilator spirometry
• Optimally supporting people with COPD to stop smoking by providing brief interventions at the point of contact, and making appropriate referrals to specialist services
• Offering pulmonary rehabilitation,including physical training, disease education, and nutritional, psychological and behavioural interventions
• Providing effective pharmacological treatment,including inhaled and oral therapies and oxygen therapy
• Early identification and partnership working to meet the supportive and palliative care needs of people with COPD,including managing disabling breathlessness, identifying patients at risk of oxygen poisoning and providing information about non-invasive ventilation and end-of-life care
• Educating people with COPD, their families and carers about their condition and providing options for supported self-management
• Ensuring that services for people with COPD are integrated with other services to provide a holistic patient-centred approach to care with good communication and multidisciplinary working
• Ensuring that people with COPD are aware of and have access to relevant services,including psychological therapies, secondary prevention, and voluntary and other community service support
• Reducing inequalities and providing the best possible outcomes for individual patients, their carers and local communities
• Providing a quality assured service

Tobacco smoking remains the biggest preventable cause of death and disease in the UK with over 8 million (20% of adults) Britons still smoking. Of the 80,000 deaths per year attributed to smoking, approximately 50% are caused by respiratory disease. 5% of hospital admissions are attributable to smoking, and smoking is estimated to cost society ~£13.4billion/ year. There is clear evidence from NICE and the British Thoracic Society that smoke-free hospitals and helping people to stop smoking prior to their elective surgery are key priorities to health "treat" smoking in patients.

In 2011 'IMPRESS' reported that pulmonary rehabilitation had been shown to reduce the 90 day readmission rate for COPD from 33% to 7%. According to Impress, pulmonary rehabilitation is the only intervention which has been shown to cut the readmission rate for COPD.

There is very strong evidence that multi-component approaches to managing COPD reduce hospital admissions and are cost effective.[1] The key to this is having a multi-component offer which includes inhaler technique, smoking cessation, flu and pneumococcal vaccination, support to be physically active, selfcare support, and personal care plans. Without clarity of the local offer then patients may not access the full range of services available in South Tyneside.

There is high quality systematic review evidence that multi-component approaches to COPD self care improve patient satisfaction, reduce emergency admissions, and are cost effective (Health Information and Quality Authority (2015) Health technology assessment of chronic disease self-management support interventions).

Directory of Ambulatory Emergency Care for Adults, highlights that 10 - 30% of COPD patients admitted to hospital could be treated in ambulatory care. In addition 'Community Acquired Pneumonia 10 - 30% of admissions could be seen in ambulatory care and Lower respiratory tract infections between 30 and 60% of admissions could be treated in ambulatory care as an appropriate alternative.

In order to engage with key stakeholders and patients in relation to the local COPD pathway, the Respiratory Strategy Group used the socio-technical allocation of resources (STAR) approach.[1] STAR is intended to be one method for understanding where to prioritise resources and needs to be used in conjunction with other tools and approaches. It provides a wide stakeholder group with a collective understanding of the issues around resource allocation for a specific service or condition.

A diverse range of stakeholders were involved in the process, from the local council, acute trust, community services, pharmacy services, the local health commissioner, and patients and carers.

The findings are:

• The approach highlighted that a large part of respiratory spend goes toward high-cost low-benefit interventions such as inhalers and emergency admissions - some of which are potentially avoidable.
• In contrast, high-benefit interventions such as smoking cessation and pulmonary rehabilitation receive little funding with low numbers passing through these services.
• Reinforced the message that effective smoking cessation is by far the most effective intervention to prevent worsening of COPD and improve quality of life and life expectancy.
• The benefit from inhalers could be dramatically increased and costs reduced by improving inhaler technique, also reducing the need to step up treatment and prevent exacerbations.
• A very strong case was made for commissioning Cognitive Behaviour Therapy (CBT) in the COPD pathway, which supports previous iterations of Star application to COPD.

• Detailed look at primary care and self-care interventions for people with needs across the MRC scoring,
• Understanding the true need and opportunity for Pulmonary Rehabilitation,
• Understand the need for community ambulatory care pathways to avoid admissions.

References from Sections 1 to 11

[1] NICE: Chronic obstructive pulmonary disease in over 16s: diagnosis and management

[2] QOF Data March 2015

[3] Source: South Tyneside Primary Care Register as at 31/07/2016.

[4] Source: South Tyneside Primary Care Register as at 31/07/2016.

[1]Adair, T. Hoy, D. Dettrick, Z. Lopez, AD. (2012) 100 years of mortality due to COPD in Australia: the role of tobacco consumption, International Journal of Lung Disease. National Library of Medicine: 100 years of mortality due to chronic obstructive pulmonary disease in Australia: the role of tobacco consumption

[1] Wilson, P. Bickerdike, L. (2014) Self-care support for people with COPD, Centre for Reviews and Dissemination and National Institute for Health Research

Last updated: January 2017