Abstract
The aim of this project was to see if and how practice-based commissioning (PBC) can be used to set up a pulmonary rehabilitation (PR) service for my practice and the neighbouring practices within our PBC consortium.
Background and Literature
Pulmonary rehabilitation is ‘… a multidisciplinary programme of care for patients with chronic respiratory impairment that is individually tailored and designed to optimize physical and social performance and autonomy’ (Morgan, 2001). In the management of chronic lung disease and particularly chronic obstructive pulmonary disease (COPD), it has been shown to be one of the most effective interventions (Berry, 1999). It increases exercise tolerance, improves walking performance, raises the quality of life, reduces symptoms and brings patients into a community of support and shared experience. This benefit is seen equally in those suffering with mild, moderate or severe disease (Berry, 1999). The Cochrane database review of pulmonary rehabilitation included 31 randomized controlled trials and found statistically significant improvements for all outcomes and concluded that Pulmonary rehabilitation should be ‘part of the spectrum of management for patients with COPD’.
However, despite the American, European and British thoracic societies putting out statements regarding the benefits of Pulmonary rehabilitation, only one quarter of British hospitals provide it (Davidson, 1998). In our region, every effort has been made by dedicated doctors, nurses and physiotherapists to maintain a service but despite this the provision has been intermittent and largely based in secondary care outpatients where dropout rates are high due to frequent journeys and long distances (Strijbos, 1996). Programmes have been developed on DVD which patients can use in their home such as ‘move on up’ produced by St Georges hospital but patients tend to lack motivation and miss out on the social aspect of a group programme (Tregonning, 2000).
The NICE guidelines on COPD state that pulmonary rehabilitation should be made available ‘to all those who consider themselves functionally disabled by COPD’. It continues ‘For pulmonary rehabilitation programmes to be effective, and to improve concordance, they should be held at times that suit patients, and in buildings that are easy for patients to get to and have good access for people with disabilities'. Janet Ward (2002) looked at providing pulmonary rehabilitation in a community hospital run by GPs in Honiton and found that community programmes could achieve similar results to those in secondary care but with improved access. This led us to believe that pushing forward with our own programme of pulmonary rehabilitation would be beneficial and would be an ideal candidate for funding via PBC.
PBC is an attempt to solve the limitations of the two main systems of commissioning health care: competition and centralized bureaucratic planning. ‘Primary care led commissioning offers a middle way between these two extremes, seeking to enable informed general practitioners to improve health services for their patients by directly influencing the content and location of their care (Smith, 2005).’ GP practices or groups of practices have the opportunity to assess health needs and develop new services or providers to meet those needs. They may then keep the majority of any money saved to pay for additional services. This is meant to encourage competition, efficiency and entrepreneurship.
Thus far, the main effect of PBC has been on primary and intermediate care while its effect on secondary care has been equivocal. For it to become more effective, there is a need for good management but above all engaged clinicians. Primary care can be slow to respond while hospital providers may be defensive, feeling their territory is under threat. However, with cooperation, there is a real opportunity to develop ‘seamless services for people with long-term conditions, and ultimately make a real impact on the wider care system (Smith, 2005)’.
As with any new system for funnelling money efficiently through the NHS, there have been those who resisted the change (Wynn Jones, 2007) and also some who have embraced the opportunity. A group of practices in our area decided to explore this new area at an early stage. They formed a consortium which covered around 67 000 patients. Among those patients, we have identified 631 who are currently on our COPD register. They accounted for a total of 265 bed days at a cost of £56 000.
My question therefore was this: with good management, information and cooperation among medical professionals, could PBC make a genuine difference to our patients and particularly to those with chronic respiratory disease?
Method
This methods section will be structured according to the main points of the British Thoracic Society (BTS) guidelines (Morgan, 2001). The BTS is a registered charity that seeks to improve patient care and staff education in respiratory conditions. It has published a series of guidelines which are essentially systematic reviews incorporating all levels of clinical evidence. This structure was backed up by papers detailing the community application of Pulmonary rehabilitation and by visits to existing services. This combined approach assured us that we were taking an evidence-based approach as well as avoiding previous mistakes and setting realistic goals.
Final pulmonary rehabilitation budget for submission to the PCT.
Selection
The guidelines state that Pulmonary rehabilitation is appropriate for all patients with dyspnoea from respiratory disease. We visited three local programmes in neighbouring district general hospitals and two aspects of selection stood out. Firstly, younger patients with milder breathing problems were more able to reach the venue, complete the programme and participate without serious deterioration in their breathing requiring excessive attention by the supervisor. Secondly, all participants agreed that they would like to have known about the programme earlier in their condition to have gained the most benefit. Therefore, the programme would be open to optimally medically controlled patients with COPD and dyspnoea but excluding those requiring regular oxygen or having co-morbidity preventing exercise.
Setting
The guidelines simply state that pulmonary rehabilitation can be carried out anywhere. It seems that hospital outpatients is currently the cheapest venue. However, as we have pointed out, hospital programmes have difficulties with access and dropout while individual programmes neglect the social benefits. In line with NICE guidance, we looked for a local venue for the course focusing on finding a community hall. Alternatives were a local sports centre which would have offered a more social environment and a trained fitness adviser but during the time of the programme it was undergoing refurbishment. We also considered the physiotherapy department of the local community hospital.
Content
The BTS and NICE guidelines suggest a combination of physical aerobic training and comprehensive disease education. The BTS stipulates greater than 6 weeks but a Leicester study in 2006 (Sewell, 2006) showed that there was no significant difference between a 4- and a 7-week programme as long as adequate education and advice for ongoing exercise was supplied. Our proposed programme therefore would last 5 weeks, 2 sessions per week. The first and last sessions would consist of assessment and the remainder were 2 hours each—1 hour of physical exercise and 1 hour of education. Each patient was also to be given a copy of the St Georges DVD, move on up, for home education and exercise.
Process and outcome measures
I took the role of the nominated clinician responsible for the programme and for assessment prior to entry. We allocated a coordinator, our practice physiotherapist, who was keen to be part of the programme. We looked to have 10–12 patients at the beginning of the programme. The contents of the education programme were clearly defined, so we were able to use only myself, a nurse with specialist interest in respiratory disease, a dietician and the physio. Areas to be covered included physiotherapy, nutrition, occupational therapy, smoking cessation, end of life planning and physical relationships. Referrals would be taken from within the consortium from a referring doctor or nurse. Their referral had to be accompanied by a completed Breathing Problems Questionnaire (BPQ) (Tregonning, 2000) and the Bristol COPD Knowledge Questionnaire (White, 2006) which assess respectively the patient's physical state and their understanding of the condition. It was proposed that referrals would be passed to myself and an administrator at my practice for screening. Assessment would continue in the programme itself with an initial shuttle walk where the patient is encouraged to walk a designated circuit at increasing speeds followed by a measurement of saturations and a Borg scale of breathlessness.
During the programme, the breathlessness scale and saturations would be repeated at least once a session and at the end the BPQ and shuttle walk would be repeated. We would be looking to see increasing length of exercise tolerance and reducing breathlessness score. Oxygen would need to be available at all times. It was planned for all this information to be kept for comparison with other services and for future audit.
One of the local courses had been very keen to develop a ‘postgraduate’ course where people who have completed the course can continue to come together once a week to exercise and socialize. This has formed quite a close community and fund raising by this group enabled the purchase of much of their equipment. In time, it was felt this would be worthwhile developing in our area.
Funding was sought from two sources. A community intermediate care fund had been set up by the local Primary Care Trust (PCT) for projects similar to this. The bulk of the money, however, and the ongoing commitment was sort from the PBC consortium. The consortium is composed of local GPs and practice nurses and they meet once a month. The consortium has a lead clinician and an administrator and different clinicians are assigned different project responsibilities. The evidence and budget for the programme was drawn up by myself and then discussed with the PBC through the senior partner in my practice.
Results
The PBC consortium was excited by the proposed project. Key to its appeal was its simplicity and cost effectiveness and a strong feeling in the group that this would make a significant difference to the quality of life of the patients involved and also to their admissions to hospital. The senior partner in my practice agreed to take the PBC lead for the pulmonary rehabilitation project and along with myself and the local administrator, we finalized a budget and a proposal for the PCT based on the above evidence and stressing the potential savings in terms of treatment and admission.
The PCT community fund agreed to give £540 for accommodation, stationary and audio equipment. This needed to be spent within the financial year but hopefully will be a yearly allowance if the project continues.
The practice physiotherapist attended the majority of the pulmonary rehabilitation courses at two local hospitals including the initial assessment in order to familiarize herself with the course and improve her respiratory physiotherapy knowledge and skills.
Our practice healthcare assistant was keen to participate and agreed to assist during the first exercise-based hour of the session. This would be paid for by the practice and reimbursed by the PCT.
We eventually decided that a de-medicalized environment would be better for concordance and reproducibility. We hired a local village hall with good access, parking and a large room for exercise and education and a kitchen. A request was put to the local community for equipment and two exercise bikes were donated by staff and patients. The above budget was submitted by the PBC group to the local PCT and we are awaiting confirmation that the funding is available before starting the initial pilot course in May this year.
Discussion
The original question posed by the project related to whether PBC could be used to facilitate the establishment of an evidence-based programme—namely pulmonary rehabilitation. We have found the local PBC consortium to be quick to receive new ideas. It also has a refreshingly straightforward procedure. As the person making the proposal, I was given the freedom and support to explore the possibilities, contact potential staff and submit the final proposal. This was dramatically different to the experience of all the local hospital programmes where dedicated staff had been forced to use their own time and facilities to maintain a service.
The presence of the service within the community had a great impact. Local goodwill and a sense of ownership of the service resulted in the securing of an excellent hall at minimum price and the donation of expensive exercise equipment. Again this contrasted dramatically with the local hospital where the service alternated on different days between two cramped rooms in a busy town centre district general hospital with no parking. Although the referral process has only just begun, it is already noticeable that there is a lot of interest among the local clinicians. It seems to make a real difference that doctors are not referring to a generic clinic some distance away and there is a real quality in the communication between the local practices and the clinic. Visiting the local programmes served to strengthen further the importance of this service. Many patients had been waiting more than a year for a place and greatly regretted not having had the opportunity sooner to improve their exercise tolerance and gain greater insight into their condition.
The main weakness of the project was not having the time to take the proposal through to its conclusion or have the opportunity to assess the effect of the programme on the local patients. This will be done however over the next couple of months. The local nature of the programme makes it possible that the specialty training of the team involved may not be to the same standard but evidence up to this point suggests that this is not as important as the accessibility of the service (Strijbos, 1996).
My experience suggests that our practice has been right to embrace the early stages of PBC. In addition to this project, the group has put a lot of effort into supporting frequent hospital attenders and preventing admissions by improved coordination between primary and secondary care and social services. These simple solutions are only possible when responsibility and resources are devolved to the teams providing that care. I would suggest that the practice and primary care in general continues to take advantage of PBC while the opportunity remains. In addition, forming these groups helps GPs to compete with new and large independent service providers.
Admittedly, this project is a limited window into PBC. In a recent essay in the British Journal of General Practice, Russel Wynn Jones explained some of the difficulties in their practice. Despite a very professional structure and good evidence of benefit, they found primary care-led heart failure and ultrasound service proposals overturned by unequal budgeting rules and a suspicion, despite evidence otherwise, that primary care cannot deliver high-quality solutions. These attitudes threaten collaborative working between the primary—secondary care interface and burden secondary care with the consequences of an ageing population.
Conclusion
Pulmonary rehabilitation for chronic lung disease is a cost-effective and evidence-based treatment. There are real benefits to hosting it in the community both in terms of making it more accessible and in terms of making it more cost efficient and reproducible on a larger, more devolved scale.
Establishing this programme under the previous financial restrictions would have been difficult but the financial system of PBC has brought a new freedom for primary care to set up services tailored to the local community.
Further work needs to be done in this particular case to see the proposal through to the end and assess in full how the service outcomes compare to other programmes nationally including particularly whether the improved access reduces dropout. In general, the group needs to consider further where else PBC can be applied and how to make the process more dynamic in terms of competing locally in the healthcare market.