COPD pathway redesign offers all PCTs the opportunity to make significant savings, improve clinical effectiveness and increase patient satisfaction, write Meghan Robb and Zoe Bedford

The need to make £20bn in productivity savings by 2014 is driving transformation across the NHS.

If all PCTs were to adopt this proactive approach, inpatient activity would decline by 33 per cent by 2014

Amid projections of reduced national tariffs and spending ceilings, finding creative ways to remain competitive on price while delivering superior quality care and service has become paramount.

Sg2’s proactive COPD forecast predicts a 46 per cent reduction in COPD inpatient activity, indicating that a proven model for redesigning care pathways can help primary care trusts meet or exceed disease-level savings related to their QIPP targets.

Long-term conditions account for 70 per cent of the total health and social care spend in England and this figure continues to grow. There are more than 3 million people in England living with COPD. It is the second most common cause of emergency admission to hospital and the fifth largest cause of readmission to hospital.  It is one of the most costly diseases for acute hospital care and readmission rates vary widely across England.

Variations in access to and delivery of COPD services are known. Across the board, however, the NHS is paying for COPD care in higher cost settings, namely overnight stays in secondary care, while proven models of care that provide more integrated, clinically effective interventions, and more convenient and empowering patient access points at a lower cost, continue to be underused.

The business case, short and mid-term

As shown in the data, an organised, proactive, multidisciplinary approach to the management of COPD is projected to yield significant short-term savings of £208m by 2014. The long-term looks promising too: Sg2’s analysis shows by 2020 the total savings to the NHS could exceed £800m in inpatient COPD costs alone.

There are immediate, short-term efficiency gains to be had too.  A conservative forecast predicts an overall decline in inpatient activity by 6 per cent, compared with a population-based projection of 17 per cent growth.  However, there is opportunity to reduce this further by focusing on a more proactive pathway redesign.  If all PCTs were to adopt this proactive approach, inpatient activity would decline by 33 per cent by 2014.  There is, of course, regional variation. Torbay, Rotherham and Telford and Wrekin could see a decline in COPD inpatient spells of over 30 per cent, which would cut their inpatient COPD spend by almost 50 per cent, whereas many London PCTs can cut their inpatient COPD spend by just over 30 per cent by 2014.

These data indicate large gaps in the provision of integrated, community-based care, the net result being high numbers of patients who are being unnecessarily hospitalised. 

Learning from the best

Last month, HSJ reported that “on average PCTs are forecasting to miss their [QIPP] targets by 24% this year”. One of the key factors in this is an apparent inability to reduce spending in acute care.

It is often argued that evidence-based treatment, proactive management and regular review through an integrated care pathway that provides the right care in the right place for the right person can significantly reduce cost.   As evidenced by the accompanying data, PCTs can reduce their current inpatient COPD spend by up to 41 per cent by proactively implementing these pathway redesign initiatives.

These concepts are not new to COPD care, nor to the idea of standardised clinical performance in general. Last month, HSJ editor Alastair McLellan wrote in his column that reducing variability has now become a necessity, and that the wise in the NHS learn from the best. Case examples of integrated COPD care pathways exist both across England and across the globe, a selection of which we sample here.

Use proven models and learn from others’ experience

While clinical efficiencies can be complicated to manage, COPD care pathway redesign is well documented.  It presents both a recognised clinical case for change and a wealth of proven case examples, with readily available change management processes ensuring long-term success. With these tools in hand, pathway redesign work can become part of your near-term redesign work, ensuring both short-term and long-term results.

Success is dependent on the use of appropriate preventive strategies, and on integrated services that are planned and delivered around individual need, whether that be maintaining health and wellbeing, accurate diagnosis, comprehensive and accessible treatment, or end of life care. Government has a role to play in supporting the development of tools, encouraging and spreading good practice and scientific and technical advances, and harnessing expertise but it is up to the local NHS to make sure that change occurs.

Change management and strong leadership

High levels of inpatient activity, avoidable admissions, 30-day readmissions, and extended lengths of stay can be traced back to cultural as well as structural issues:

  • a lack of integration of care across primary and secondary provision
  • a lack of joint engagement, assumption of risk, bearing of responsibility and receipt of incentives for comprehensive care among specialty consultants, GPs, community providers and patients, families and carers
  • a lack of universal patient records and the subsequent incomplete identification of at risk and high risk patients

Executive teams have a key role in overcoming this. They need to provide leadership and support to clinical teams, commissioners, service managers and other key stakeholders as they start to deliver effective clinical practice through process improvement and redesign.

The short-, mid- and long-term strategic fit with an evolving NHS

So we have a compelling clinical and business case.  How does proactive care pathway redesign fit strategically with the current reforms? Adopted appropriately, these approaches to care:

  • provide for a flexible application, allowing for local decision-making regarding the care pathway, ensuring patient centred wellness models and a devolved NHS
  • incorporate GP clinical input, solidifying GPs as trusted advisers to patients and as informed parties in decision-making. In addition, forward thinking GPs who will lead in the early adoption of GP commissioning have expressed concerns of fiscal balance related to unscheduled care use within hospitals - specifically A&E, access to primary care and management through rehabilitation and preventive care for long-term conditions such as COPD. These care pathway modifications get to the heart of these concerns
  • allow foundation trusts to establish roles in which they serve as active coordinators of care across the patient journey, integrating provider arms with community care as a means of avoiding penalties for avoidable spells, unnecessary admissions and prolonged length of stay, as well as securing community referrals and retaining and/or growing their ambulatory service mix through GP collaboration for community provision of care
  • drive NHS and independent providers to remain competitive under “choice among any willing provider” by yielding a competitive, integrated COPD offering
  • ensure better support, information and education for people with COPD and their carers, so that they become truly active partners in their care

About Change Forecast

Change Forecast is an online resource delivering in-depth analysis on future opportunities for improvement and cost savings in the health service.

This quarterly feature, developed with Sg2, provides detailed insight on what the future looks like for each organisation for a specific disease area, along with best practice case studies and guidance on how to capitalise on the opportunity.

Unlike traditional population-based estimates, this forecast examines the cumulative effects and interdependencies of population, economics, emerging care pathways, epidemiology, innovation and technology, and other key factors driving change in the use of healthcare services.

Use the Change Forecast to help you identify the opportunity, plan a strategy and manage the change.

If you would like more information on the data from Sg2, call 020 7399 4455 or email Yashu at

COPD care: how to save millions