VOL: 98, ISSUE: 26, PAGE NO: 52
Karen Shirley, BSc, RGN, Diploma in Asthma, Advanced Diploma in COPD, is community COPD nurse practitioner;Rebecca Kelly, BSc, RN, Diploma in Advanced COPD, is community COPD nurse practitioner, Wandsworth PCT
Respiratory disease continues to exert significant costs in terms of morbidity and mortality, of GP consultations, hospital admissions and increased length of stay (British Thoracic Society, 2001). This is reflected by the results of a local audit carried out in Merton, Sutton and Wandsworth Primary Care Trust (PCT), London, which revealed that 25% of hospital admissions were respiratory in origin.
Respiratory disease continues to exert significant costs in terms of morbidity and mortality, of GP consultations, hospital admissions and increased length of stay (British Thoracic Society, 2001). This is reflected by the results of a local audit carried out in Merton, Sutton and Wandsworth Primary Care Trust (PCT), London, which revealed that 25% of hospital admissions were respiratory in origin. In response to this audit, a multidisciplinary, multisectoral working group developed a primary care pathway for patients with chronic obstructive pulmonary disease (COPD), in line with the British Thoracic Society Guidelines (British Thoracic Society, 1997). Emulating other centres across the UK (Cotton et al, 2000; Davies, 2000), we hoped to develop a community-based rapid access service. Funds were designated to employ nurse practitioners and respiratory physiotherapists, and to provide access to a pulmonary rehabilitation programme and a spirometry service. During the initial months of the nurse practitioners’ posts, it became apparent that there was a need to improve the ongoing management of patients with COPD in primary care before developing a rapid access service. Current evidence demonstrates that primary care has not been able to achieve the standards recommended by the guidelines for managing patients who would previously have been cared for in hospital. Practice is variable, and often the quality of delivery is far from ideal (Lagerlov et al, 2000; Nicklas, 1997; Price et al, 1999; Price and Wolfe, 2000; Rabe et al, 2000; Booker and Weller, 2001). This raises questions about whose responsibility it should be within the primary care team to manage these patients. The Department of Health (2000) and the British Medical Association (2002) suggest that nurses’ skills could be utilised more effectively in primary care. This would enable services to improve the quality and organisation of health care and widen access for patients, help doctors to specialise in areas where their skills are in short supply and would also enhance nurses’ skills and job satisfaction. However, Jones (2001) highlighted the fact that nurses might become professionally isolated when extending their roles to incorporate diagnostic and treatment changes during patient management. The working group therefore made a commitment to train the whole primary health care team so that all professions would share the responsibility for managing this group of patients.
The audit (Shirley et al, 2002) identified deficiencies in both the structure and function of primary care within the PCT. These deficiencies included inadequate knowledge, poor diagnostic facilities and insufficient time allocation. The working group decided that, if the rapid access service was to be effective, management of COPD first needed to be standardised across the locality. In order to achieve this, four approaches were used:
All practices within the PCT were offered a variety of study opportunities suited to their needs. They were provided with teaching sessions, which were supported by specialists from secondary care. This gave primary care professionals the opportunity to develop better lines of communication and liaison between sectors.
In order to encapsulate the care pathway in a user-friendly format the COPD nurse practitioners designed a resource pack for distribution to all practices, which included colour-coded guidelines on the management of both acute and stable COPD. The pack also included referral forms for use by all professionals in the multidisciplinary team, whether they worked in the primary, intermediate or secondary care sectors. The aim was to promote and facilitate appropriate referrals of patients with COPD. The resource pack also included a reading list, respiratory handbooks, industry-supported literature and copies of patient information and leaflets. It was designed to allow for changes in local and national guidelines, to ensure that it continued to be based on the latest available evidence. For example, the publication of the GOLD guidelines [Global Initiative for Chronic Obstructive Lung Disease] (National Heart, Lung and Blood Institute, 2001) has led the British Thoracic Society and the National Institute of Clinical Excellence to review current guidelines for the UK at a British Thoracic Society meeting in December 2001. To complement the packs, a ‘care pathway wheel’ was designed. This is a circular, hand-held tool that assists and prompts health professionals in making timely and appropriate referrals. Sets of laminated guidelines were also provided as a quick reference tool.
A computerised template was developed for use with the patient management software system used in all the practices in this area. The template was installed to guide patient consultations and develop a register of COPD patients for future audit.
A technician-led ‘walk in spirometry service’ was set up to provide access to spirometry for all practices in the area.
In 10 months, 91 health care professionals have attended COPD study sessions. Eighteen practices have received resource packs and have databases and are now reviewing their COPD patients. In a four-month period, 67 patients have attended the spirometry service; 19 are still to attend.
It was essential to generate interest in managing COPD among health care professionals and to motivate them to develop and improve services before implementing the working group’s strategy. However, negotiation for incentives, either financial or in the form of new services, helps to maintain the momentum for change. Respiratory community nurses can facilitate the liaison between primary and secondary care to optimise the management of patients with respiratory disease. By working with all health care professionals at a local level and within different environments these nurses are best placed to establish educational needs and to provide specialist advice and continuing support during the change process. We are aware that in other areas this is fulfilled by other professions, such as physiotherapists. This reflects the motivation of interested parties to manage change. Indeed, it illustrates how the roles and responsibilities of different professions are merging, which can benefit patients by providing seamless care. Initially the question was whether to go for an ‘all out’ approach and involve all practices within the PCT or to start with a small-scale trial involving a sample group of practices. The requirements of The NHS Plan (Department of Health, 2000) have increased the workload in primary care for all chronic disease management. At ground level, staff raised concerns about our plans for change and the work it would generate. We therefore decided to use the small-scale approach, with a plan to roll out to all practices once it was up and running. This gave us an achievable workload and enabled us to alter and improve the presentation of the pathway as necessary. The resource pack was developed by the nurse practitioners in consultation with consultants, specialist and practice nurses, GPs, community pharmacists and managers. This ensured ownership across all sectors, laying the foundation for effective change management. The staff training, resource packs and spirometry service made the implementation of the care pathway possible. Practices were supported in recalling patients for respiratory review, using a process similar to that recommended by the British Thoracic Society COPD Consortium (2000) and adapted by other centres (Holt, 2001). The computerised system means they will all be able to provide audit data generated from patient consultations, to enable us to evaluate the pathway. The COPD nurse practitioners will encourage primary care staff to maintain the COPD register, to ensure that patients are reviewed at least annually. Plans for extension of the care pathway to include the acute management of COPD patients are now being developed. Collaboration with the intermediate care team and chest services within secondary care has allowed us to pilot an early discharge scheme. We are also in negotiations with the local A&E department, as the provision of a rapid access service would complete the cycle of care required by many patients with COPD.
Effecting change in primary care in the management of COPD patients is possible when the staff who will be involved in implementing the changed practice are motivated and supported by resources which respond to local need. However, strong leadership and the involvement of the whole multidisciplinary team across the spectrum of services are also essential. The shift to primary care for the commissioning of services gives health professionals the opportunity to develop more seamless services for optimal and dynamic management of patients with COPD.