Dr Elango Vijaykumar and Dr Joe McGilligan describe how internal integration of existing resources and external support from a pharmaceutical company have provided a structure to improve the care of people with COPD.
ESyDoc LLP is a partnership of 20 GP practices in south east Surrey. We commission health services both in primary and secondary care for a population of 170,000 patients.
At a time of financial challenges and uncertain and changing administrative relationships, the ESyDoc board had become frustrated by an inability to show progress to its members or to deliver better clinical care to their patients.
There was a sense that NHS Surrey had focused away from practice based commissioning and, like many others,
With a backdrop of enormous budgetary pressures and a focus away from practice based commissioning, we were not able to free up or access resources and no pump-priming money was forthcoming. Similarly, the practice-based commissioning mechanisms did not appear sufficiently empowered to drive forward projects.
Our incentives for change, therefore, were improved patient care and better clinical services.
A formal (objective) and informal (subjective) needs analysis led the ESyDoc board to instigate a project to improve the care of people with chronic obstructive pulmonary disease (COPD). Due to the heavy burden of this disease on the individual and the health care system, this condition has risen to the top of many health care organisations’ agendas. A national strategy document, long in preparation and consultation, is about to be published, as is an updated NICE guideline.
There were two over-riding goals: firstly to improve the care of people with COPD and secondly to reduce unnecessary hospital admissions, always a compelling theme and a useful, important and measurable outcome for both patients and the health service.
We identified some internal challenges. At the start of the project, we had no identifiable clinical leadership for COPD in the community and some upskilling of front line nursing staff was required. No local management protocols or prescribing advice existed. There were no agreed referral or discharge pathways at the primary / secondary interface and communication was patchy. Critically, the primary, secondary and outreach teams were all working in a disjointed fashion. There was no clear direction for the service.
In terms of the patients’ perspective, we sought to address this in two ways. Firstly, we were faced with a considerable number of people with COPD (1800, the “prevalence”) who could benefit from a comprehensive clinical review and treatment optimisation.
Secondly, we needed to put in place sustainable procedures to manage newly diagnosed or identified patients (the “incidence”). The logistic requirements of these two groups are quite different.
The project could not be funded from existing resources, driving us to involve the pharmaceutical sector. A competitive tender and interview process was held for companies interested in collaborating. AstraZeneca was selected as our partner.
We were determined to drive bespoke, integrated, long-term solutions which would involve all health care professionals and have an enduring impact and sustainability, underpinned by a long term business case. We did not want the project high jacked for short-term commercial purposes - goals the pharma company were happy to agree to.
AstraZeneca provided management and marketing expertise, consultancy support (by identifying and integrating potential contributions from different disciplines), data collection and interpretation facilities and additional frontline nursing staff to perform patient review and staff training. Internally, our outreach team re-aligned themselves to meet the project’s needs. The ambulance service participated enthusiastically. NHS Surrey primary care medicines management team produced a protocol for the management of stable COPD, to which all clinicians, including those seconded from the pharmaceutical company, are expected to adhere to.
A natural division in workload emerged. On one hand, we have a large group of patients with predominantly stable COPD who will benefit from periodic review. Both the patient review programme and primary care staff up skilling project are working well. Both are now to be accelerated. On the other hand, we have a smaller group of people with more severe disease who may have frequent hospital admissions. These patients are benefitting from the close attention of a reinvigorated, realigned outreach team, supported by secondary care colleagues, at no additional cost.
The contribution of the ambulance service in dealing with out of hours emergency requests in a pragmatic, sensitive and thoughtful way cannot be underestimated. Our collaborating pharmaceutical company was a good partner, based on a relationship of transparency and trust. The involvement of an academic consultant and the medicines management team help ensure due probity.
Principally through personal initiatives from our consultant colleagues, communication between primary and secondary care is at an all time high.
Critical success factors include: the willingness of staff to reorganise their roles; the redeployment of the outreach team and the collaboration of ambulance staff faced with “emergency” requests; an internal, independent clinical management protocol; agreed, shared goals with our industry partner.
A sense of teamwork across disciplines and practices has been fostered which bodes well for future initiatives.
We would like to thank Dr John Haughney for his help throughout the project and with the preparation of this manuscript.
Dr Joe McGilligan is GP member and chairman and Dr Elango Vijaykumar is GP member of ESyDoc LLP