Chronic Obstructive Pulmonary Disease (COPD): best practice guide

Appendix A

National COPD Working Group

Terms of Reference

1. In advance of winter 2015 an analysis was made of the admissions trends for the most frequent conditions presenting to emergency care, which revealed that respiratory illness featured as a key diagnosis in three of the top five emergency presentations. Underpinning a significant proportion of these is chronic lung disease, of which the most frequently encountered is Chronic Obstructive Pulmonary Disease ( COPD).

2. Forecasts for the next twenty years indicate a steady rise in admissions from respiratory disease so that if the current model of care were to remain unchanged we would expect an almost 29% increase in admissions by 2034. Similarly if length of stay remains the same, bed days will increase from 519,898 in 2014 to 669,920 by 2034. Admissions for COPD exacerbations, defined as episodic deterioration in respiratory health, therefore present a significant financial burden to health services, which is set to worsen dramatically in the next twenty years, but are also associated with a stepwise deterioration in an individual's quality of life.

3. The National COPD Working Group has therefore been established to address the healthcare challenges arising from this long-term condition and in particular to reduce unnecessary hospital admissions wherever possible, aligning with the Six Essential Actions of Unscheduled Care – 6EA; keeping patients at home or in a homely setting.

4. The group will look at all aspects of COPD management, from pre-hospital care, including ambulance service management and community respiratory teams, through to discharge from hospital, readmission avoidance and palliative care for patients with end-stage disease. The group will focus on strengthening links between the different services that can support and manage patients with COPD through tests of change across and within these services. The ambition of the group is to improve the management of patients with COPD along every step of the patient journey so that the right patient is managed in the right place at the right time, in line with the following national strategies:

• Realising Realistic Medicine
• National Clinical Strategy
• Pulling Together, transforming urgent and emergency care
• Taking Care to the Patient – the Ambulance Service 2020 Vision, and
• The Six Essential Actions of Unscheduled Care.

5. The full group will be composed of four subgroups that each focus on different aspects of the patient journey:

a. Reducing unnecessary hospital admissions

b. Scottish Ambulance Service initiatives

c. NHS 24, Telehealth and Technology-Enabled Care

d. Palliative Care and Anticipatory Care Planning

6. Each subgroup will have its own terms of reference and subgroup leader. The subgroups will meet independently and their leaders will share any actions and outputs in the full group forum.

7. Key deliverables for the group and subgroups will be to:

a. map out the patient journey from the patient's home through to hospital and subsequent discharge

b. identify areas of good practice nationally

c. interrogate each step of the journey to look for improvement opportunities

d. carry out tests of change at each step

8. The impact of any tests of change will be analysed in terms of the following key performance measures:

• Reduced attendances at A&E
• Reduced TOTAL admissions to hospital
• Proportion of COPD patients being admitted
• Re-admission rates (within 28 days)
• Length of stay in hospital for COPD patients

Supporting Measures

• Saved bed days (to be derived from reduced length of stay)
• Numbers of patients contacting the NHS 24 helpline
• Increased uptake of home health monitoring

9. Outputs from the group and subgroups will be reported through a number of mechanisms including case studies, sharing learning via the Respiratory National Advisory Group ( NAG) and a national event which is set to take place in October 2017.