Introduction
Chronic obstructive pulmonary disease (COPD) describes a collection of diseases that affect the lungs. These include chronic bronchitis and emphysema. Emphysema affects the alveoli (air sacs), and chronic bronchitis affects the bronchi (airways). Some citizens with COPD will have one of these conditions, whilst others will have more than one.
COPD usually develops because of long-term damage to the lungs from breathing in harmful substances, such as cigarette smoke or chemical fumes. The most common cause of COPD is smoking tobacco (British Thoracic Society 1997). For information on smoking, see the separate smoking chapter http://jsna.nottinghamcity.gov.uk/insight/Strategic-Framework/Nottingham-JSNA/Adults/Smoking-and-Tobbaco-Control-(2015).aspx
It is estimated that three million citizens in the UK, and nearly 11,400[1] citizens in Nottingham, have COPD (Public Health England 2015). COPD is more prevalent in men than women although the prevalence in women is increasing (National Collaborating Centre for Chronic Conditions 2004).
COPD is the fifth biggest killer in the UK, causing about 25,000 deaths each year, and is a leading cause of premature mortality. In 2012, premature mortality from COPD in the UK was almost twice as high as the European average (NHS England). There were 645 deaths in Nottingham attributed to COPD between 2010 and 2014[2]. Making COPD the 5th biggest killer in Nottingham in 2014.
COPD has considerable effect on the daily life of those with the disease principally due to difficulties in breathing. Airflow obstruction, or narrowing of the airways, and loss of lung elasticity give rise to such symptoms as:
- Increasing breathlessness, especially during physical activity,
- A persistent cough with phlegm and
- Frequent chest infections.
Individuals with more severe COPD can find everyday activities very difficult. They report being very anxious about becoming breathless, and consequently limiting their activity in order to avoid becoming breathless. As a result, they become less fit, and so become breathless after minimal activity. This is referred to as deconditioning.
Many citizens with COPD report poor quality of life (Dransfield et al 2011) and, for some, there is a direct link between COPD and the development of low mood and depression. International evidence suggests that more than one third of individuals with COPD experience symptoms of anxiety and depression (Panagioti 2014).
Citizens with COPD are often on substantial medication. They are more likely to take sick leave from work than those without COPD, and are also more likely to be admitted to hospital and to retire prematurely because of ill‑health. Thus COPD is costly to individuals and society. More than £800 million is spent each year in the NHS on the treatment of COPD, and it costs the UK economy £2.7 billion a year in lost productivity (Department of Health 2010).
[1] Estimate based on 2011 modelled rates and 2013 registered population 16+
[2] This is the actual number of deaths, rather than an age‑adjusted figure, so any direct comparisons with the UK average should be made with caution.
Unmet needs and gaps
- In 2013/14, there were an estimated 11,373 citizens with COPD in Nottingham, 49% of who were recorded as having COPD on the Quality Outcomes Framework (QOF) register. This data suggests that there are more than 5,800 citizens in Nottingham with COPD who have not been diagnosed. More citizens with COPD need to be identified so they can receive the care they need to manage their condition.
- Admission rates for COPD have not reduced since the introduction of a community respiratory service in 2012 yet reducing admissions is one of the main aims of the service. Some citizens have multiple admissions for COPD each year.
- 71% of citizens with COPD are only admitted to hospital once. It is unclear whether the admissions could have been avoided with more effective management of exacerbations in the community.
- Stopping smoking is the key intervention for minimising severity of COPD yet many citizens with COPD continue to smoke.
- Pulmonary rehabilitation programmes are a crucial part of COPD management. Yet in Nottingham it is unclear who is targeted for participation in the programme, at what stage of COPD, and how effective the programmeis. It is also unclear whether there is sufficient capacity to support all citizens with COPD to attend, and if appropriate, re‑attend following hospitalisation for an acute exacerbation.
- Many citizens with COPD report that their condition is not well managed and limits their daily living, specifically, when they have an exacerbation of COPD. It is unclear whether citizens who feel less able to manage their condition are more likely to be admitted to hospital, particularly, for a short length of stay. Action should be taken to increase the proportion of citizens with COPD who feel their condition is well‑managed.
- Tailored exercise programmes can support those with COPD to stay active and thus reduce the likelihood of deconditioning. In Nottingham, Active for Life, an exercise programme led by Healthy Change, is adapted to meet the needs of citizens with COPD. However, citizens with COPD are less likely to complete the Nottingham Active for Life programme than those without COPD.
- Influenza (flu) and pneumococcal vaccination are particularly important for citizens with COPD as these infections can be more serious in this group. Whilst the uptake of influenza vaccination in Nottingham is good the proportion of citizens with COPD having pneumococcal vaccination is lower than the England average.
- Evidence suggests that many exacerbations of COPD, including those necessitating admission to hospital, are linked to anxiety. Currently, no anxiety management programmes are commissioned specifically aimed at citizens with COPD.
- Mental health problems are more common in citizens with long-term conditions such as COPD and they are more likely to have poorer clinical outcomes and a significantly lower quality of life than people with a physical health problem alone. Citizens who have COPD and a mental health problem may experience barriers in accessing services that meet both their physical and mental health needs.
- In 2013/14, there were an estimated 11,373 citizens with COPD in Nottingham, 49% of who were recorded as having COPD on the Quality Outcomes Framework (QOF) register. This data suggests that there are more than 5,800 citizens in Nottingham with COPD who have not been diagnosed. More citizens with COPD need to be identified so they can receive the care they need to manage their condition.
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Admission rates for COPD have not reduced since the introduction of a community respiratory service in 2012 yet reducing admissions is one of the main aims of the service. Some citizens have multiple admissions for COPD each year.
-
71% of citizens with COPD are only admitted to hospital once. It is unclear whether the admissions could have been avoided with more effective management of exacerbations in the community.
-
Stopping smoking is the key intervention for minimising severity of COPD yet many citizens with COPD continue to smoke.
-
Pulmonary rehabilitation programmes are a crucial part of COPD management. Yet in Nottingham it is unclear who is targeted for participation in the programme, at what stage of COPD, and how effective the programmeis. It is also unclear whether there is sufficient capacity to support all citizens with COPD to attend, and if appropriate, re‑attend following hospitalisation for an acute exacerbation.
- Many citizens with COPD report that their condition is not well managed and limits their daily living, specifically, when they have an exacerbation of COPD. It is unclear whether citizens who feel less able to manage their condition are more likely to be admitted to hospital, particularly, for a short length of stay. Action should be taken to increase the proportion of citizens with COPD who feel their condition is well‑managed.
-
Tailored exercise programmes can support those with COPD to stay active and thus reduce the likelihood of deconditioning. In Nottingham, Active for Life, an exercise programme led by Healthy Change, is adapted to meet the needs of citizens with COPD. However, citizens with COPD are less likely to complete the Nottingham Active for Life programme than those without COPD.
-
Influenza (flu) and pneumococcal vaccination are particularly important for citizens with COPD as these infections can be more serious in this group. Whilst the uptake of influenza vaccination in Nottingham is good the proportion of citizens with COPD having pneumococcal vaccination is lower than the England average.
-
Evidence suggests that many exacerbations of COPD, including those necessitating admission to hospital, are linked to anxiety. Currently, no anxiety management programmes are commissioned specifically aimed at citizens with COPD.
-
Mental health problems are more common in citizens with long-term conditions such as COPD and they are more likely to have poorer clinical outcomes and a significantly lower quality of life than people with a physical health problem alone. Citizens who have COPD and a mental health problem may experience barriers in accessing services that meet both their physical and mental health needs.
Recommendations for consideration by commissioners
- More citizens with COPD need to be identified in order that they can receive the care they need. This can be achieved by:
- Further workforce development, including with GPs, to ensure that the signs and symptoms of COPD are recognised.
- Smoking cessation advisers participating in COPD case-finding. Specifically, advisers could be trained to conduct spirometry on a defined group of smokers who are most likely to have developed COPD.
- Raising public awareness of COPD, including potential signs and symptoms, so those who feel they may have COPD seek support and advice from their GP.
- Further work should be undertaken to understand why COPD admissions are not reducing and target activity towards those individuals who have frequent, and/or short length of stay, admissions.
- 71% of citizens with COPD were only admitted once. It is unclear whether these admissions could have been avoided with more effective management of COPD exacerbations in the community. Further work should be undertaken to explore the reason for admission and whether these citizens were also users of the Integrated Respiratory Service.
- Evidence suggests that strategies to increase the proportion of citizens with COPD who stop smoking can include:
- Exploring an opt-out referral mechanism to stop smoking support for all citizens who receive a COPD diagnosis. Thus everyone who receives a COPD diagnosis will be referred to a stop smoking service (New Leaf) unless they specifically request not to be referred.
- Tailoring stop smoking sessions to meet the specific needs of individuals with COPD.
- Reviewing the activity of stop smoking advisors on secondary care wards to ensure those with COPD are targeted for stop smoking support.
- Conduct a health equity audit and review of the commissioned pulmonary rehabilitation programme, in the context of the respiratory pathway, to understand:
- Who is targeted for participation,
- At what stage of COPD,
- Whether there is sufficient capacity for all citizens with COPD to attend, and if appropriate, re‑attend following hospitalisation for an acute exacerbation,
- How effective the programme is.
- Increasing the proportion of citizens with COPD who believe that their condition is well‑managed can be achieved by:
- Commissioning, and regularly reviewing, respiratory services including nurse led community respiratory teams and pulmonary rehabilitation programmes.
- GP practices working with local community pharmacies to ensure that citizens with COPD are targeted for Medicines Use Reviews (MURs) as evidence suggests that those attending MURs report improved COPD management.
- Increasing the use of COPD care pathways, such as map of medicine, to support diagnosis and effective treatment of COPD.
- Ensuring inhaler technique, important in controlling the symptoms of COPD, is built into existing COPD pathways.
- Implementing, and reviewing, the use of self-management plans for COPD.
- Responding to ‘patient voice’. Currently citizens are not asked if they feel their COPD is well-managed but adding this question to service feedback questionnaires would inform service performance reviews and could enable individual intervention.
- Programme coordinators should consider surveying citizens with COPD who participate in Active for Life to understand barriers to completion.
- Increasing the proportion of citizens with COPD receiving annual influenza and pneumococcal vaccinations can be achieved by:
- Developing initiatives to encourage citizens with COPD to have PPV vaccination.
- Sharing the learning from GP practices with high uptake rates.
- Working with service providers, such as Nottingham University Hospitals Trust, to raise awareness of the importance of PPV vaccination and, where appropriate, offering vaccination during outpatient visits and in-patient stays.
- Commissioners should consider commissioning anxiety management services through IAPT (Increasing Access to Psychological Therapy) providers. An integrated care model, whereby IAPT interventions are delivered within the long‑term conditions treatment setting, could improve both access and uptake.
- In order to improve outcomes for those with COPD and mental health problems:
- Local work on parity of esteem should continue encouraging services to effectively meet the physical and mental health needs of service users.
- Commissioners should consider reviewing the existing IAPT services to ensure they are aligned to the needs of those with long-term conditions.
- Give consideration to whether stop smoking support should be tailored to meet the specific needs of those with COPD and mental health problems.
