COPD care is 'sidelined by PCTs'

COPD kills 25,000 people a year in the UK, with 835,000 diagnosed cases and two million more unaware they have it.

COPD: 835,000 people in the UK are diagnosed with the respiratory disease (Photograph: SPL)
COPD: 835,000 people in the UK are diagnosed with the respiratory disease (Photograph: SPL)

But despite its heavy burden on the country's health, one of the most effective treatments, pulmonary rehabilitation, is sidelined by many primary care organisations.

Disjointed picture
A GP investigation of how services are provided across 91 PCTs in England reveals an uneven and disjointed picture.

Almost 45% more patients attended rehabilitation classes in 2010/11 than the year before, figures show. But 42-fold variation in the number of patients accessing such services exists between areas, as well as 25-fold variation in spending. Evidence suggests variation also exists across other UK nations.

NICE guidance and the DoH's COPD outcomes strategy require commissioners to fund pulmonary rehabilitation. But the investigation found that one in 10 PCTs fails to provide access in part or all of its area.

Somerset GP Dr Steve Holmes, education lead for the Primary Care Respiratory Society (PCRS), is not surprised by this disparity between regions.

Recent research by Dr Holmes and colleagues from NHS South West gave a similar picture. Their findings, presented at the recent PCRS annual conference in Telford, West Midlands, showed high variability in capacity, access, organisation and funding.

They wrote: 'This has the potential for creating inequities in access and outcomes from pulmonary rehabilitation that should be reviewed nationally.'

Dr Holmes says more must be done to encourage both GPs and hospitals to refer patients to the service. He concedes that some GPs are more aware of pulmonary rehabilitation and its benefits than others, but rejects the idea that under-use of the service is down to clinicians failing to refer.

Education of GPs
'There is always the implication that the solution is to educate GPs. I think this is a systemic problem. We don't see many patients who are referred following discharge from hospital.'

There is strong evidence in favour of the treatment. A Cochrane review published last month found that treating just four patients with exacerbations prevents one hospital admission. One life is saved for every six patients completing a course.

By comparison, 167 patients at risk of cardiovascular disease must take statins for more than four years to prevent one death.

Review authors concluded that pulmonary rehabilitation was a 'highly effective and safe intervention' to cut hospital admissions and mortality and to improve quality of life. The good news is that provision in England is increasing and commissioners are continuing to invest.

Budgets on the rise
Budgets for 2011/12 are 9% higher than the previous year, which will boost capacity. For example, NHS Gloucestershire, which had the fewest patients undergoing the treatment in 2010/11 among the PCTs sampled, is expanding its programme from 80 to 240 patients a year.

National prevalence of COPD is 1,629 cases per 100,000 of the population. In some areas, as few as 14 people per 100,000 are attending pulmonary rehabilitation courses. The picture may be improving, but there is a lot of catching up to do.

CASE STUDY

A Manchester pilot scheme in GP practices that aimed to maximise use of local pulmonary rehabilitation services led to a reduction in hospital admissions and saved the PCT thousands of pounds.

NHS Trafford's service had suffered from high patient drop-outs and variable referral rates from GP practices.

Andrew Giles, urgent care project lead for the trust, worked on the early stages of the programme in collaboration with local GPs.

He says patients had been 'fearful' of attending the classes because of their breathlessness.

Rebranding the service
In response, the trust rebranded the service, conducted patient surveys and sent out leaflets to highlight how it had changed patients' lives for the better.

Meanwhile, a team of health professionals visited two pilot practices to explain the benefits of pulmonary rehabilitation and install computer 'pop-ups' on practice systems.

These alerted GPs to patients who might have benefited from using the service. The result was a marked increase in referrals and numbers attending courses, and was well received by practices and patients.

Organisers estimate that across two practices, the scheme avoided hospital admissions costing £26,410. The PCT now hopes to save half a million pounds by rolling the scheme out across all 40 practices in the area.




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