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An unacceptable variation in the organisation and delivery of care for patients with chronic obstructive pulmonary disease (COPD) in England and Wales was the stark conclusion of the latest audit of acute units from the Healthcare Quality Improvement Partnership (HQIP), released on Nov 19, 2014, to coincide with world COPD day. A lack of out of hours' services, particularly specialist, outreach, and intensive care unit services, and poor availability of smoking cessation programmes, were highlighted as core concerns; 37% of units had no smoking cessation programme. Compared with the last audit that the HQIP undertook in 2008, respiratory nurses were flagged as being under-resourced; the numbers had decreased to 2003 levels—with 11% of units having no specialist nurses. Nevertheless, improvements were noted in some areas, such as the availability of palliative care (rising from 50% to 87%) and delivery of non-invasive ventilation (NIV; 81% of wards compared with 74% in 2008). An increase in the number of respiratory consultants also occurred, from a median of 3 to 4 per unit. However, in view of the gaps identified, the report was aptly named “COPD: who cares?”.
COPD has been described as an invisible disease, but around 3 million people in the UK are affected, and it is responsible for 5% of all deaths in England and Wales. With an increasingly ageing population, care of the patient with COPD will become more complex and costly as patients present with more comorbid conditions and case numbers continue to rise. Indeed, the HQIP report noted a 13% increase in medical emergency admissions for COPD since the 2008 audit so, if not addressed, the current shortfalls in delivery of care in the acute setting will potentially be magnified. Of note, the report authors stressed the importance of addressing the gaps in care identified, rather than seeing the audit as a number-crunching exercise, and made a number of recommendations. These recommendations included increasing the availability of 7 days a week specialist, out of hours, and outreach care, enabling spirometric data to be shared and universally accessed by primary and secondary care services, continuing the improvements seen in delivery of palliative care and NIV, and having a fully funded and resourced smoking cessation service. These recommendations mirror some of those made by a report from the All Party Parliamentary Group (APPG) on Respiratory Health earlier this year that aimed to reduce the unacceptably high mortality rate from chronic respiratory diseases and decrease the UK£4·7 billion spent by the NHS every year to treat these patients. The APPG flagged the lack of measurable goals or incentives for stakeholders to meet NICE guidance as a key barrier to making any inroads to improving patient outcome and reducing costs. Such reports are helpful to benchmark progress and promote a sea-change in the way care is approached. The HQIP authors suggest that development plans should now be put in place by individual units to enable quality and multidisciplinary care to be delivered consistently throughout the UK.
Improvement of care delivery should drive down NHS costs, but these efforts should not overshadow the ultimate goal, which is to prevent patients from developing COPD. The disease continues to lurk in the shadows, and in view of the prevalence and mortality associated with COPD, there's a surprising lack of awareness amongst the general population of symptoms and the association with smoking. As a result, many patients are diagnosed late in their disease course and The Lancet Respiratory Medicine highlighted earlier this year that missed opportunities for diagnosis also exist in primary care practices. Furthermore, new drug development is scarce, with small tweaks of already approved drugs being commonplace, rather than any investment into new drug classes and targets. However, the COPD community has collectively raised its voice in recent years to promote more research and awareness of the disease, and reports such as those described above will help move the disease into the spotlight.
Naturally, realism is needed to balance the priorities of any health-care system, which is a difficult task within current budget constraints. However, given the likely long-term cost benefits, the hope would be that at least some of the recommendations of this latest report will have been met in the next audit so that the NHS can clearly be seen to care about delivery of quality COPD services.