North East Lincolnshire Care Trust Plus’s HOPE specialist service has developed one of the most successful pulmonary rehabilitation (PR) programmes nationally. One element of this service is the use of buddies (expert patients with COPD), who assist with the design and delivery of the programme, alongside the specialist multidisciplinary team. This service has some of the best patient outcomes seen nationally; it won two awards in December 2007. This article outlines how the service was established and its outcomes.
Hancock, P., Cox, K. (2008) Setting up a buddy scheme for pulmonary rehabilitation. Nursing Times; 104: 39, 31–33.
Pamela Hancock, MCSP, BSc physiotherapy, BSc applied biology, is COPD clinical coordinator; Karen Cox, BSc, RGN, is COPD nurse specialist; both at Hope Street specialist service, North East Lincolnshire Care Trust Plus, Hope Street Medical Centre, Grimsby.
The 2004 indices of multiple deprivation show North East Lincolnshire in the worst quartile of local authorities. There are strong links between COPD and deprivation.
Of the local population, 31% are smokers. As one in four smokers is at risk of developing COPD, (Let al, 2006), this condition will continue to present an issue in the future.
The care trust has a current diagnosed prevalence rate of 1.9%, which is higher than the national average. The high deprivation and smoking rates would indicate that a significant number of patients remain undiagnosed.
The HOPE specialist service provides a one-stop shop for people who either have COPD or who are at risk of falls.
Its ultimate aim is to provide health, optimisation, prevention and education (HOPE) for patients, carers and health professionals throughout the locality.
The service is based on a medical model within a social context, offering individually tailored holistic assessment, treatment and education. It is proactive, paying as much attention to the causes of ill health as to ill health itself. It was developed in line with NICE (2004) guidelines on COPD.
From its inception, the service has been designed and developed through a joint approach between a multidisciplinary specialist team and its users.
Developing the service
In 2005 local services for people with COPD were limited and disjointed. Following a review of health needs, a COPD clinical coordinator (Pamela Hancock, clinical specialist physiotherapist) was employed to assess existing provision and implement a service that was based primarily on NICE (2004) guidance.
Initially, prospective service users were given the clinical guidance and encouraged to map their needs. This was a shift from traditional methods of consultation where patients are presented with options.
The pulmonary rehabilitation (PR) programme was launched in October 2005. From its conception, patients were at the heart of the scheme and involved in decision-making. A local respiratory support group was consulted on its design and delivery.
Initial consultation revealed patients wanted one-to-one tuition, ideally with the physiotherapist. As this was not financially or practically viable, the COPD clinical coordinator worked closely with patients to find a way to meet this need and the buddy scheme was born.
The buddy scheme
PR buddies are expert patients and carers, whose role is to motivate and encourage patients, provide peer/emotional support, help in the programme’s daily running and be an extra pair of eyes.
Buddies help create a relaxed environment where patients are free to express their ideas on how the service can be improved. Patients have said they can talk to the buddies about issues that they would not feel comfortable talking to health professionals about.
From a clinician’s viewpoint, this way of working improves concordance and encourages early engagement. In this patient group, fear of exercise and breathlessness is a major contributing factor to their functional decline. As far as we know, this degree of patient/public involvement in a PR service is unprecedented.
The buddies are involved in all areas of the scheme, enhancing continuity of care. They are empowered to take a lead in developing the service to meet patients’ needs.
Buddies are offered training that closely mirrors the mandatory training programme for employed staff. They are checked by the Criminal Records Bureau and sign confidentiality agreements.
A strong, approachable and flexible management style is vital for this volunteer workforce and good communication is essential. To this end, we identified a staff member as a buddy coordinator.
We now have a team of 24 buddies who help with programmes at both Hope Street and our satellite base at Immingham.
The buddy system contributes to four of the most important objectives required for a successful programme:
Concordance: buddies give patients belief and this helps them overcome their fears of breathlessness;
Emotional support: in terms of living with COPD, the buddies are experts and provide support based on first-hand knowledge;
Personal motivators: they act as role models, inspiring participants by showing they are in control of their symptoms;
Safety: buddies act as an extra set of eyes and can help in the early identification of any problems.
The service not only seeks to improve patients’ physical health but also attempts to address the consequences of long-term conditions. We provide activities such as t’ai chi, chair-based exercise and a fishing group for people with disabilities.
Since 45% of patients with moderate to severe COPD experience depressive symptoms (Nici et al, 2006), it is important to be alert for depression and anxiety (NICE, 2004). Patients with COPD with positive social support have less depression and anxiety than those without (Nici et al, 2006). Peers make good self-management educators and can improve people’s perceptions and self-efficacy, leading to improved health outcomes (Singh, 2005).
The service is responsive and flexible enough to meet both patients’ and commissioners’ needs. It continues to develop innovative strategies for engagement.
Early diagnosis of COPD is favourable, so our team go into the community to raise awareness of the condition and promote services. These health promotion activities take place in a variety of settings, such as supermarkets and cinemas. As a result, we are seeing more enquiries from the public requesting self-referral and advice.
Through further consultation, a significant gap in service provision was identified – a lack of education and support for newly diagnosed patients with mild COPD. Therefore we developed the PROMOTE programme, designed to fulfil these requirements for patients and carers.
Accurate information is vital for self-management. Nearly 1,000 copies of our self-management guide, an easy-to-understand 36-page booklet, have been issued to patients. However, as this level of information may be too comprehensive for some, we also provide a short version.
We offer various forms of rehabilitation to COPD patients. Those with a functional disability of MRC grade 3–5 are offered one of the 320 places on the group-based PR programme if medically suitable.
The HOPE service’s PR programme continues to show life-changing outcomes for patients in both physical capabilities and quality of life. It is also extremely cost-effective, saving one hospital admission per patient on average and reducing A&E attendances through the eight-week course. This results in an average saving of over 2,600 per patient (based on 108 patients).
The incremental shuttle walk test outcomes show increases from 185m pre PR to 239m post PR, while results from the endurance shuttle walk test show an improvement from 234m pre PR to 666m post PR on average. This represents more than eight times the clinical significance suggested by Lacasse et al (2002). The chronic respiratory disease questionnaire results also show a dramatic improvement, with almost three times the clinically significant increase in all four domains, as shown in Table 1.
Table 1. Outcomes pre and post pulmonary rehabilitation
>0.5 = clinically significant increase
We are sure that our joint method of working will continue to produce a high-quality, patient-centred and innovative service. This methodology is easily adaptable to other localities and other conditions.
Implications for practice
Lacasse, Y. et al (2002) Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2002; Issue 3: Art. no: CD003793.
L A. et al (2006) Developing COPD: A 25-year follow-up study of the general population. Thorax; 61: 935–939.
NICE (2004) Chronic Obstructive Pulmonary Disease: Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care. www.nice.org.uk
Nici, L. et al (2006) American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. American Journal of Respiratory and Critical Care Medicine; 173: 12, 1390–1413.
Singh, D. (2005) Making the Shift: Key Success Factors. West Midlands: NHS Institute for Innovation and Improvement University of Birmingham. www.networks.nhs.uk