Dr Carol Dalzell, Chair and GP lead of the Mid Ulster ICP, outlines the range of improvements to existing services and more joined up working between service providers for COPD patients in the Northern ICP area.
ICPs are helping to develop a new mindset amongst health professionals about how we plan and manage care for patients. Crucially, by having service users and carers sitting around the table alongside a range of health and social care providers, including the community and voluntary sector, we know first-hand about the patient experience and can better plan and deliver services to meet their needs.
As a GP with a special interest in respiratory disease I was keen to lead the work of Northern ICPs to look at the current respiratory care pathway – in other words, the route that a patient takes from their first contact with a member of health and social care staff to the completion of their treatment – and identifying ways of amending and improving that pathway.
COPD, known as Chronic Obstructive Pulmonary Disease (COPD), is a growing chronic condition in Northern Ireland causing long term lung problems and breathing difficulties, particularly amongst smokers. Prevention and early intervention is vital in effectively managing the condition yet it’s estimated that only 50 per cent of patients are actually diagnosed. As the prevalence of this disease increases, health professionals must work better together to proactively identify and target those most in need – working reactively and in isolation is no longer an option.
In the Northern ICP area, we decided to ask all GP practices to review their patient registers for smokers over 35 who have taken two or more antibiotics (for chest problems) or cough bottles in the last six months. We have also asked local pharmacists to identify customers buying cough bottles more regularly. GP practice nurses then assess and filter these lists to create groups of patients who are then asked to the practice to undertake lung function tests. As part of these tests, the nurse can calculate the patient’s ‘lung age’ which is usually the most compelling evidence to make patients realise that they need to take action quickly. These tests also provide an opportunity for the nurse to talk to the patient about support services to help patients quit smoking and provide other lifestyle advice.
Smoking cessation services play a vital role in the management of COPD but ICPs in the Northern area recognised that a lack of information sharing was causing unnecessary duplication. For example, a smoker could go to the GP one day and the pharmacist the next and neither would know that the smoker was attending both, or neither. As a result, the ICPs developed a data-sharing form which both GPs and pharmacists can feed into to share information – a simple, but effective, solution. In addition, the Northern ICPs have been working collaboratively with the Hearty Lives Cookstown programme to promote and deliver local group smoking cessation clinics within GP practices or a community pharmacy setting.
The need to reduce the demand on hospital services and manage more care in a community setting is a key pillar of Transforming Your Care and one way of doing this is to prevent COPD patients from ending up in hospital or from getting into the cycle of going in and out of hospital.
The Northern Local Commissioning Group has provided £650,000 of funding for the expansion of community respiratory services. This will include expansion of the community respiratory team to work longer hours and from four sites. The team regularly see and visit people with severe respiratory disease – some after being in hospital. In the past, limited staff resources and working hours had restricted the optimum effect of the service; for example, people who worked during the day weren’t able to attend rehabilitation classes. Fortunately now, as a result of the increased funding, classes are also in the evening and at weekends. The funding will also cover the costs of the aforementioned proactive identification of at risk patients and support GPs and pharmacists to be involved in joint working with the community respiratory team to help treat more patients outside hospital.
When patients do experience a sudden worsening of their condition, eighty per cent of exacerbations are currently treated effectively in the community and expansion of community services team will allow even more patients to stay out of hospital. At present, a significant number of people have to stay in hospital for five or six days, but a proportion of these people could now be discharged after a few days into the care of the GP and community respiratory team.
Our focus in the Northern ICP area has concentrated both on service improvement through the expansion of current services, but also on improving communication and supporting care providers to work better together. We are confident that COPD patients throughout the Northern ICP area will now benefit from a much-improved and proactive service that places them at the centre of everything we do.