Chronic Obstructive Pulmonary Disease (COPD): best practice guide

4. The COPD National Working Group

In December 2016, the Scottish Government established the COPD National Working Group. Chaired by Mr Jacques Kerr, National Clinical Adviser to the Scottish Government the group included multidisciplinary representation from regions across Scotland and sought to inform best management for this group of patients and to take account of inter-regional differences in service availability and patient demographics. (See appendix A for Terms of Reference and Group Membership).

Given the data around COPD attendances and admissions, the forecasts for occupied bed days and, moreover, the need to reduce variation and improve our person-centred approach to care, the group's initial focus was to shift the balance of care from hospital to home, and to streamline the patient journey.

To achieve this goal its three principal aims were to:

• reduce unnecessary emergency hospital attendances
• reduce unnecessary hospital admissions (and readmissions within 28 days), and
• reduce length of stay ( LoS) for in-patients.

The group focused on developing an ideal patient pathway that fulfilled the national strategic criteria of being safe, effective and person-centred, and identified the following key themes:

1. Wherever possible patients should be managed at home

2. Care should be bespoke and tailored to an individual's needs and should also take account of their disease progression

3. All aspects of a patient's wellbeing should be taken into account including psychological and social needs

4. Hospital care in an acute bed should be for the minimum duration possible

5. A multidisciplinary approach should be adopted to facilitate linkage between specialties and to ensure the patient receives the best possible care