Chronic Obstructive Pulmonary Disease (COPD): best practice guide

This document is for healthcare professionals and patients to show how this condition could be best managed from the unscheduled care perspective.

9. Case Studies

What follows are case studies from three different regions that showcase this best practice through taking a whole system, multi-disciplinary approach to best practice.

Case Study 1

Integrated Care in NHS Lothian – Edinburgh Health and Social Care Partnership

Shifting the Balance from Hospital to Home

The team in Edinburgh have set out to change the way the COPD pathway is delivered, shifting the balance away from care in hospital to care at home. The aim is to support patients to self-manage confidently and safely out of the acute setting, to reduce avoidable ED attendances and admissions, and to future proof against unsustainable increases in demand. It secured short-term Invest to Save funding to drive forward an improvement programme.

Programme Manager for Long-Term Conditions, Edinburgh Health and Social Care Partnership, Amanda Fox explained:

"In 2013, hospital was the default destination for too many COPD patients. Our aim was to create a person-centred Community Respiratory Hub that would provide an alternative and support patients with COPD to stay out of hospital and manage their condition effectively at home. We looked at every aspect of COPD – physical, psychological and social - and devised a holistic multidisciplinary team approach to patient care."

The Crucial Role of Prevention and Supported Self-Management

Respiratory Consultant and COPD Clinical Lead for NHS Lothian, Gourab Choudhury explains how his region is leading the way in COPD care by focusing on prevention and supported-self management:

"The situation for us here in Lothian in relation to COPD care is not uncommon. Currently, over 75s are the highest users of NHS services and that figure is set to rise significantly. COPD represents 20% of all respiratory conditions presenting in hospital and is the most common condition presenting in primary care."

Early Intervention

Education and communication are important if we are to make a difference to the lives of COPD patients. The onset of the disease can be insidious and we estimate that there are high numbers of people who are undiagnosed. It's important to catch the disease early as 20-30% of lung function decline happens in the first phase, and stable and moderate patients can quickly become severe and complex.


"There are some things that patients can do – such as giving up smoking and improving their self-management - to slow the decline and improve their quality of life. The Community Respiratory Team ( CRT) play a crucial role in supporting people to better understand and effectively self-manage their condition using LiteTouch telehealth and it acts as a first point of contact for people when their health deteriorates."

Reducing Bed Days

"Between 30-50% of acute COPD exacerbations could be treated effectively at home, which was a driver to developing a community-based respiratory hub that integrated primary and secondary care, out of hours and emergency services whilst delivering consistency of care across the city. Since the creation of the new integrated multi-disciplinary team in early 2014, we have succeeded in reducing respiratory bed days by 3000."

Prompt Intervention

"The improvements are not simply about exacerbation management, rather the focus is to adopt a 'whole system' and 'whole person' approach ensuring people at risk of health deterioration are proactively identified and supported earlier in their pathway, ensuring unnecessary admissions are prevented. To achieve this, a new pathway has been developed for patients who are attended by the Scottish Ambulance Service ( SAS) but who do not need to be conveyed to hospital. As an alternative, SAS refer to the community respiratory team who are committed to responding to the patient within 90 minutes".

Immediate and Early Supported Discharge

"The team recognises that a number of patients will require an admission to support their respiratory deterioration however facilitating early supported discharge is a key role for the community respiratory team who proactively identify inpatients via Boxi reports. The team has established a 'prof-to-prof' telephone support line with the hospital consultant to enable direct and frequent communication for advice and support. There is a percentage of patients who self-present at the ED or are conveyed but an admission is preventable. To support these patients, they have a dedicated team of respiratory nurses who visit ED and the Medical Assessment Unit ( MAU) three or four times a day to assess if they are stable enough for an immediate discharge into the care of the community respiratory team. This has significantly increased the number of immediate discharges since we began the COPD improvement work.

It is in everyone's interests to discharge COPD patients from hospital as quickly as possible. Aside from saving money and freeing up beds, older patients who remain in hospital can decondition quickly, losing muscle mass and confidence. It might take a week in hospital to bring a patient back up to their baseline, which is frustrating for them and an inefficient use of resources.

Acute and Chronic Condition Management

The CRT responds to acute episodes for COPD patients before handing over to the IMPACT team of district nurses who manage chronic cases. Every COPD patient has an anticipatory care plan which is created by their GP and shared via their Key Information Summary ( KIS) and can be accessed by those involved in their care including NHS 24, the Scottish Ambulance Service, Lothian Unscheduled Care Service ( LUCS), and primary and secondary care teams. Additionally, an alert is placed on the patient's record in hospital and community IT system, Trakcare, to highlight that CRT is the first point of contact for care of patients known to their team.


Prior to the integrated service, communication between primary and secondary care was not well established. It was a challenge to deliver the vision of one integrated team across this interface, but this was achieved by running a series of innovation sessions where the wider teams, including external partners, could contribute to a 'share and learn' environment and design the new pathway together. Although the community respiratory team existed before the project they were little known and GPs didn't have the confidence to refer acutely unwell patients at the point of deterioration. Through well planned stakeholder engagement that has completely changed with an increase in GP referrals.

A. Community Respiratory Team - Spreading the Model

"The COPD integrated care model we have developed in Edinburgh has been extremely successful. We far exceeded our bed day reduction target and have been successful in truly integrating teams from primary and secondary care to form one multidisciplinary team with a shared vision of improving patient care: 'wherever and whenever the patient should have the best service'. The person-centred nature of the integrated team ensures a patient's physical, psychological and social needs are met. Currently, the model is being tested within Midlothian where as an ex-mining community, there is a high prevalence of COPD. We believe all parts of Scotland could benefit from a Whole System, Whole Person approach like ours. In each region the particular challenges and circumstances will be different but the key is to have the right team with the right skillset".

What They Did:

1. Community Respiratory Hub: A community based respiratory hub was developed to support people at home during acute exacerbations – preventing unnecessary hospital attendances and to empower patients to self-manage their condition. The aim was to provide the best service to patients wherever and whenever they needed it. The multi-disciplinary hub team includes a dedicated clinical psychologist, integrated care pharmacist and a co-ordinator from the third sector organisation, Grapevine, to provide disability information support to people with COPD that are housebound.

2. COPD Care Bundle Checklist: The team devised a checklist that is used by every team for every COPD patient. Prior to the creation of the checklist, acute staff were assuming certain discussions were taking place with GPs and vice versa. Now, the checklist enables everyone to see what interventions have taken place and when, including advice about quitting smoking, anticipatory care planning and end of life discussions. The checklist remains with the patient's records and is accessible by everyone involved in their care, including out of hours and the ambulance service.

3. Extended Skills and Operating hours: A community respiratory team already existed in Edinburgh prior to the respiratory hub. The new hub brought in additional services and upskilled staff, with training in effective communication for anticipatory care planning and independent prescribing. Operating hours were extended from 8am to 6pm to provide a seamless transition to out of hours services. Uniquely, the community respiratory team have admission rights and are able to admit patients directly to a respiratory ward if necessary, without having to refer them back to their GP. GPs who request a COPD bed are automatically referred to the hub by the Bed Bureau.

4. Psychology Input: Evidence tells us that up to 55% of patients with COPD have anxiety and up to 25% have depression, and they are ten times more likely to experience panic disorder than the general population [7-9] . This can lead to people with COPD calling 999 when they become breathless. These symptoms can be exacerbated by their hyperventilating due to stress rather than being entirely due to the condition. Prior to the project there was no dedicated psychology input to support these individuals so a dedicated COPD clinical psychologist was asked to join the multi-disciplinary hub team to provide support to patients at home, in hospital and in a clinic setting (see below for more info).

5. Pharmacy Support: Many of the patients managed by the Community Respiratory Hub have multimorbidity and are prescribed an average of 15 medications. An integrated care pharmacist reviews the medications for these patients and provides support with administration and compliance.

B. Psychological Services – Support model

Impact of Mental Health

As mentioned on page 18 there is a high prevalence of psychological distress in people with COPD with some evidence that mental health concerns in COPD patients are three times more prevalent than in the rest of the population [10] . In view of this the Lothian team believed that it was essential to address both the physical and mental health of COPD patients if it was to make a lasting impact on admissions and patient experience. Head of Adult Psychology Services for NHS Lothian, Belinda Hacking explained why:

"Anxiety and depression in COPD patients are strong predictors for hospital admission, readmission, increased exacerbations and longer hospital stays. They affect a patient's ability to manage their condition, making them less likely to stick to their treatment plan and more likely to take risks, such as drinking and smoking. This places increased demand on an already over-stretched system. The cost of treating COPD patients who have anxiety and/or depression is twice as much as treating those who don't. In the past there has been too much focus on a patient's physical symptoms and very little consideration of the psychological factors affecting their behaviour. We wanted to address that."

An individual's ability to cope with COPD is due only partly to the severity of their condition. To a large extent, their attitude to the condition and ability to adjust to their change in circumstances is crucial. For these reasons, tackling the psychological challenges of living with COPD was regarded as the missing piece of the jigsaw by the NHS Lothian team.

What They Did

The Psychology Service proposed a three-level approach to managing COPD patients:

1. Providing psychological support to patients with the most complex disorders.

2. Assessing the most frequent hospital attenders to understand in more detail the reasons for their hospital visits. The need for this was highlighted by the case of one individual whose COPD was relatively mild but whose high anxiety levels had prompted one hospital visit after another, seeking reassurance. The review found that only 40% of those patients reviewed had a pressing medical need to go to hospital. The remaining 60% needed varying degrees of psychological support.

3. Reviewing Key Information Summaries and feeding into case conferences and discharge planning meetings. Highlighting the psychological needs and psychosocial context of each individual ensured holistic patient-centred management plans were created to help people to cope better at home.

Programme Manager for Long-Term Conditions, Edinburgh Health and Social Care Partnership, Amanda Fox created a checklist to identify COPD patients who may benefit from referral to the psychology team. This included all frequent attenders.


Of those patients referred to the clinical psychology service in Edinburgh, 63% had clinically significant anxiety and 38% had clinically significant depression. Before psychological intervention, 28% of patients had 'severe' anxiety symptoms and 36% had 'moderate' symptoms. Following psychological intervention 89% of participants' scores fell within the 'normal' range. It was a similar pattern for depression, with 12% of patients initially having 'severe' symptoms and 27% 'moderate'. After working with the psychology service, 82% of scores fell within the 'normal' range. A clinically significant improvement was seen in the overall quality of life in those people with COPD who completed a psychological intervention. Patients reported less shortness of breath, less tiredness, and increased confidence in their ability to cope with their COPD symptoms following psychological input.

One patient with COPD explained that psychological intervention helped her to understand that anxiety and panic played a part in her breathlessness and admissions to hospital. Introducing new coping skills helped her to manage her panic more effectively:

"Before my COPD got worse, when I had an episode, I would get panicked and go to the hospital, but now I can manage that panic better and manage to stay at home most of the time, which is where you want to be."

There are many reasons why COPD patients experience high levels of anxiety and depression as Dr Grainne O'Brien, Clinical Psychologist, explained:

"People with COPD often experience anxiety – being breathless can be very scary and can cause someone to hyperventilate, thereby adding to the sensation of breathlessness. This symptom of breathlessness is experienced alongside other challenges of living with a long-term condition including other physical symptoms such as fatigue, limited mobility and increased dependence upon family and carers, People with COPD can lose touch with their social networks and have to stop certain hobbies which can be very isolating. These changes can result in increased anxiety, a loss of confidence and lowered mood.

"If we really want to make a difference to the lives of people with COPD, why would we not address their mental, as well as their physical health?"

As well as tackling some of the causes behind a patient's anxiety or depression, the psychology team were also able to support people to become more engaged in their treatment. "It is about understanding what matters to them," added Grainne, "so we can help them to understand the relevance of their treatment to achieving their personal goals and best quality of life. This is a very enabling way of working with COPD patients and it proved very effective."

The Psychology Team also plays a key role in helping patients and their families to adjust to their new circumstances, particularly as they approach the palliative stage of their illness. For some patients the prescription of long-term oxygen therapy at home can represent a significant deterioration in their condition. Psychological intervention can help somebody to adjust to the change in their illness as demonstrated by the below quote from a specialist respiratory nurse in relation to a particular case.

"When Mrs X was required to have Long Term Oxygen Therapy, this became a major hurdle for her to come to terms with. With the help of psychology she was able to overcome this and is now well established at home with oxygen. I feel that if she had not had any input from psychology then she would have required more admissions to hospital due to anxiety and an inability to cope rather than actually due to being medically unwell." - (Specialist Respiratory Nurse).


As clinical psychology was a new service within COPD care in Edinburgh, an initial challenge was to link the new service into the various existing COPD services and demonstrate the various roles a psychologist could play within the team. Time was spent embedding psychology within the wider integrated care team and ensuring accessibility and responsive service provision by locating the service across multiple bases (across community and acute settings), attending regular MDT meetings and providing alternative psychological viewpoints into patient careplans.

C. Principles of the overall approach

1. Collaboration and Co-location: Co-locating the Psychologist, Pharmacist and third sector co-ordinator with the Community Respiratory Hub helped to create a sense of shared vision and purpose. Regular conversations took place between acute colleagues and the Psychology Team to encourage different perspectives on the reasons that patients were presenting for treatment. It was about everyone collaborating and playing to their strengths. Belinda said: "Sometimes colleagues would say "I know there is something else going on here but I don't have the skills to deal with it". Clinicians are very time-limited and when they are trying to work outside their speciality it can take too long. They welcomed being able to refer people to us for further assessment".

2. A Holistic View of Patients: Considering both the physical and psychological factors at play enabled the team to gain a really clear understanding of patients and how best to help them. Once they understood the actual issues it was far easier for the team to address them. For example, one patient who regularly called for an ambulance was found to be suffering from depression and loneliness. She was given the number of a 24-hour telephone helpline for older people and the frequency of her admissions has dropped dramatically.

3. Innovation: There was a great deal of enthusiasm and willingness to try new approaches amongst the stakeholders including SAS, community and acute-based respiratory teams. The innovation sessions provided a platform for the different disciplines to learn from each other and share their ideas and support a collaborative approach to developing the new pathways.

4. Support to Staff: Not only does the Psychology Team support patients but it also provides psychological advice, training consultation to staff. For example, the team has held training sessions for senior physiotherapists to enable them to have difficult Do Not Resuscitate conversations with patients. The Prof-to-Prof support line is in place to provide direct communication between the Community Respiratory Hub and the hospital consultant for advice which can be decision to admit or general support.

5. Liaising with the Ambulance Service: The team worked collaboratively with the SAS to develop new COPD pathways providing an alternative to hospital admission. The Community Respiratory Hub will respond to SAS referrals within 90 minutes. Out of hours, SAS can request an urgent visit from a Lothian Unscheduled Care Service GP. Overnight information of these referrals are passed to CRT to follow up, ensuring there is consistency of care.

6. Supported Self Management: Patients are supported to self-manage their condition at home using LiteTouch telehealth. An in-depth assessment establishes their normal levels and they regularly monitor for changes. If changes are noted, patients have a proactive plan of self-care, including use of nebulizer or certain medications, anxiety management strategies such as breathing exercises, along with CRT contact details if symptoms worsen. Rather than being the default, calling an ambulance only becomes necessary when other routes have been tried.

7. Medication Reviews: An Integrated Care pharmacist conducts medication reviews, ensuring that patients are taking the right medication in the right dose at the right time and offering them the opportunity to ask questions. Often the pharmacist will visit patients at home jointly with the CRT to ensure the medication regime is understood.

8. Frequent Attender Database: COPD patients who have had two or more hospital admissions within 12 months are added to the frequent attender database. These patients are reviewed at the regular multidisciplinary team meetings. The team can see the patients' admission patterns and check what types of support services are in place. Using a care bundle checklist to consider all options, the multi-disciplinary team agree a plan of care which is shared with the patient's GP. A member of the team visits the patients to discuss the plan and GPs are asked to create a KIS with action points for review at the next meeting,

9. Multidisciplinary Team Meetings: Full multidisciplinary team meetings are held fortnightly at the Royal Infirmary and monthly at the Western General in Edinburgh. They take the form of a virtual clinic and include members of the extended team, including: respiratory consultants, community respiratory physiotherapists, respiratory nurse specialists, IMPACT nurses, psychologist, pharmacist, PACT doctors, GPs, the ambulatory service and pulmonary rehab. The care bundle checklist prompts discussion and case review for frequent attenders and other patients highlighted at being at risk by the team.

10. Branding and marketing: The project manager developed a brand for the Community Respiratory Hub using the strapline "Think COPD, think CRT". Fridge magnets and mousemats are available to drive home its message to patients and healthcare professionals alike. Every GP practice in Edinburgh was sent mousemats and regular newsletters to raise awareness of the newly formed service and the support available. In the run-up to public holidays, the team holds a marketing campaign to remind referrers to use the hub rather than sending COPD patients to the ED. The 'Think COPD, Think CRT' strapline has been added to every frequent attender KIS to prompt referrals at point of deterioration.


  • Primary care, secondary care, social care and the ambulance service were all accustomed to working in silos. There was no joined up approach to COPD and no alternative pathways to acute care. Innovation sessions helped to break down these barriers and support teams to better understand each other's roles and facilitate integrated working.
  • The COPD project only covers the Edinburgh area. There were some challenges for the SAS as their boundaries were different and they could only refer Edinburgh patients to the service. The team responded by producing easy-reference pocket guides for ambulance crews.
  • There was no ring-fenced training time for SAS staff so any training they attended was unpaid. The team created a series of accessible online video clips that staff could watch without having to take time off work.


The project was evaluated by Lothian Analytical Services between April 2013 and September 2015. The target was to reduce respiratory bed days by 206. The team achieved a reduction of 1,418.

Since that time, bed days have continued to fall. The figure now stands at 2,954. There has also been a 7% reduction in length of stay of 48 hours or less.

There have been 252 multidisciplinary team reviews of frequent attenders and 74% had a new KIS as a result.

10% of all COPD requests to the bed bureau have been rerouted to the Community Respiratory Hub. There has been a 23% increase in referrals to the Community Respiratory Team. 37% of patients referred to the team have avoided a hospital admission.

Pharmacy has conducted 239 medication reviews helping to target non-compliance.

The project has achieved several accolades including a Scottish Health award: Care for Long Term Illness and poster awards at the National Respiratory Managed Clinical Network learning event and Institute of Healthcare Management ( IHM) conference. The programme manager, Amanda Fox, was awarded Scotland's Top Healthcare Manager runner up by the Institute of Healthcare Management.


A View from the Frontline

Laura Groom is Team Lead for the Community Respiratory Team in Edinburgh and Advanced Physiotherapy Practitioner. She joined the service in 2008 and has gained a detailed insight into the factors that contribute to its success.

Plugging the Gaps

Laura explained:

"We recognised in Edinburgh that there were significant unmet needs in the care of COPD patients. For example, we realised that:

  • we might not be capturing all of the patients who could be successfully treated at home
  • COPD patients are at high risk of anxiety and depression
  • patients might need support with other aspects of their life besides their physical wellbeing
  • options for acutely ill patients were limited. They tended to call 999

COPD management is typically fairly standardised. This project set out to identify gaps in the service and plug them wherever possible."

GP Engagement

Members of the CRT visited GPs to discuss the type of support they might need for COPD patients, including mental health provision and prescribing. The team held GP events, both to hear from GPs about their experience of caring for COPD patients and to introduce them to the services offered by the Community Respiratory Team. They also talked at GP forums. Laura commented:

"A key piece of learning for us was to create different presentations for different audiences so you can really target your message. The presentation we gave to GPs, for example, was different to the presentation we gave to colleagues in social care."

GPs have been enthusiastic about the new service. Day-to-day care of COPD patients is provided by the Community Respiratory Team with GPs being kept informed.

A Holistic Perspective

COPD is a risk factor for low mood and anxiety. Laura said:

"Breathlessness, infections and regular hospital admissions are characteristics of COPD. Ongoing poor health and a decline in function can bring people down, making them prone to depression. At the same time, the sensation of breathlessness can lead to rising anxiety, which may contribute to the breathlessness. A patient's mental health, along with factors such as poor living conditions and financial difficulties all contribute to their overall health and wellbeing. One of the major success factors for our work in Edinburgh is the fact that we consider the patient in their entirety, not their physical health alone."

Integrated Model of Care

One of the factors that contributed to true multidisciplinary working in Edinburgh was the fact that services are co-located, making it easier to provide an integrated model of care. This gives clinicians a good understanding of each other's roles and challenges. Some of the services, such as psychology and pharmacy, are co-located for one day a week. The full team meets monthly at the Western General Hospital and weekly at the Royal Infirmary. Patients who are unwell are discussed at these multidisciplinary team meetings.

The team also holds regular shadowing sessions so the clinicians can experience their colleagues' day-to-day reality. The benefits of this, in terms of insights and relationship-building, make it a very worthwhile investment of time and resources. The Community Respiratory Team has successfully built a bridge between primary and secondary care.

Data to Inform Services

The team has used data effectively to identify frequent attenders. This enables them to target COPD patients who need their support the most, thereby allowing them to make the biggest difference. At each multidisciplinary team meeting, the team reviews the latest data on patient referrals and admissions, making decisions based on real-time information.

Clinical Leadership

Strong clinical leadership played a key role both in getting the project underway and in unsticking possible challenges. The team found it particularly helpful for one clinician to be able to speak to another about the most appropriate care of a patient.

Innovation Sessions

At the start of the project, the team held Innovation Sessions to give everybody the opportunity to share their thoughts on what good COPD care looks like. This helped to achieve a good cross-fertilisation of ideas and also assisted with engaging stakeholders in the work taking place and the reasons behind it.

An Alternative to Admission for the Ambulance Service

Paramedics have welcomed the new Community Respiratory Team as it provides a viable alternative to hospital admissions for COPD patients experiencing an exacerbation in their symptoms. Now ambulance teams can confidently refer patients to a community-based service rather than automatically admitting them.

Self-Referral by Patients

"I feel very strongly about this," said Laura. "In the past there has been a perception that allowing patients to self-refer would open the floodgates. Clinicians believed that patients were on a downward trajectory and it was pointless to discharge them when it was likely that they would have to come back into hospital. Actually, we have found that giving them the right level of education and confidence in the service and providing telehealth has enabled us to manage self-referrals effectively. There has undoubtedly been an increase in telephone triage but this is the right thing to do for patients. It is good for us to build an ongoing relationship with them rather than having to start from scratch with them when they become unwell."

The Right Model of Care

Laura believes that the model of care for COPD developed in Edinburgh could be scaled across NHSScotland. "This is the right model of care for COPD patients and is very transferable, if not in its entirety then in part. We have invested a huge amount of time in developing this process. It would be great if other Health Boards could benefit from this and improve their services for this group of patients who are often overlooked.

Case Study 2

Hospital at Home Keeps COPD Patients out of Hospital

NHS Lanarkshire

The 2020 Vision sets out the government's aspiration for people to live longer, healthier lives, supported to be at home rather than in a hospital setting wherever possible. In this vision, hospital becomes the place of choice only after all other resources have been exhausted. COPD patients in Lanarkshire are treated on a virtual ward rather than being admitted to hospital, helping to reduce the risk of deconditioning and hospital-acquired infections.

National Clinical Lead for Older People and Frailty, Dr Graham Ellis explained:

"Hospital at Home provides a genuine alternative to admission, taking multidisciplinary care into the patient's own home thereby avoiding the disruption and potential harm of an admission. Crucially, there is no difference between the diagnostics provided in hospitals and the diagnostics that we can provide in the patient's own home."

Since the service was launched in 2012, any GP that contacts the bed bureau requesting admission for a COPD patient is automatically referred to Hospital at Home. Patients are seen by a geriatrician or COPD specialist within an hour of referral and consultants create an individual care plan. Only those patients with a genuine clinical need are admitted to hospital.

Virtual Ward Round

Hospital at Home employs a team of 38 WTE (whole time equivalent) therapists, consultants, nurses, physiotherapists, OTs, ambulance staff and support workers. The team holds a daily virtual ward round to assess all patients under its care. Staff visit patients in their own home to carry out all of the tests that would normally be done in hospital, including blood tests and X-rays. They can also carry out clinical reviews and prescribe or amend medication plans.

A Genuine Alternative to Admission

Graham said:

"The service succeeds in keeping 75% of COPD patients in their own homes. We have an average length of stay of four or five days and our readmission and mortality rates are on a par with the acute hospital. We are working with some of the region's most unwell patients, many of whom have multiple pathologies including COPD. It is important to keep them out of hospital wherever possible as they are highly susceptible to hospital-acquired infection, falls and deconditioning."

Pioneering and Cost-Effective

Hospital at Home in Lanarkshire was the first of its kind in Scotland and has inspired the creation of similar services in Lothian and Fife. The service also attracted the praise of The Scottish Government's Director of Health and Social Care, Derek Feeley.

Allied Health Professional Rehabilitation Consultant in Older People and Lanarkshire Hospital at Home Lead, Claire Ritchie commented:

"When the service began we found we were using far fewer resources than we anticipated – just a third of our total budget. We identified a number of reasons for this. Older people are far more resilient when they remain in their own homes. They remain mobile and cognitively more aware. Often they have family or friends to support them. Hospital at Home gives them rapid access to skilled geriatricians who can create a tailored treatment plan and review their medications. On occasions we have been able to reduce significantly the amount of drugs people are taking."

Meeting Demand at Lower Cost

Since 2015, Hospital at Home has managed 1,751 patients in their own home. It has cut ambulance service costs by £464,000 and reduced A&E admissions by 24%. In addition to seeing patients referred by GPs, the service now manages step-down patients from acute wards. Patient satisfaction levels are high. Prescribing costs are also significantly lower than in hospital.

Graham concluded:

"We believe that virtual wards will enable us to meet growing demand for COPD services over the next 10 years. Forecasters predict that, based on the current trajectory, we would need an additional 440 beds to meet rising rates of the condition. This is clearly unsustainable and Hospital at Home is proving to be a genuine alternative to an exponential rise in hospital admissions."


1. Resistance to Change: As with any new service there was a certain amount of resistance to change and uncertainty at first. The Hospital at Home team met up with GPs and acute consultants to answer questions and allay fears. Bringing together different cultures and teams into one also proved challenging.

"We worked with a coalition of the willing at first," explained Claire. "Once we began to collect evidence of the impact we were making it became easier to engage people."

2. Rapid Diagnostics: For the new service to work, it was important for it the team to have rapid access to diagnostics and for lab results to be processed as quickly as they would be for inpatients. The Hospital at Home team worked hard to engage colleagues in diagnostics and explain the new service.

3. Building the Right Skills Mix: Hospital at Home needs a blended mix of skills. It took time to recruit and train staff in the correct skills mix. The team developed a set of competency-based assessments and used the Aston Model to build a cohesive team culture.

Case Study 3

Small Changes Make a Big Difference in NHS Greater Glasgow and Clyde

Small things can make a big difference to the quality of life of patients with COPD, according to Dave Anderson, Clinical Lead for the Community Respiratory Team and Pulmonary Rehab in NHS Greater Glasgow and Clyde. If you live in Glasgow, you are 45% more likely to have COPD than any other part of Scotland where it accounts for 45,000 emergency bed days costing £9.5 million to the health board annually.

The region launched a pilot project to reduce COPD admissions and improve quality of life for patients in Glasgow. A Community Respiratory Team provides home-based care for COPD patients and a hospital-based Pulmonary Rehabilitation Team deliver patient education and support with mobilisation and exercise capacity.

Dave explained:

"There are 120,000 people with COPD in Scotland. The condition is responsible for around 4,500 deaths per year - one of the most common causes of death in Scotland. Nationally there is a lack of recognition of the condition and an almost constant pressure to reduce services.

"Coupled with this is a lack of funding for services, and it can be challenging to get COPD patients to engage with support services. Their expectations tend to be low and it can be hard to get them to recognise the impact that even small changes could have on their life. But, just because it is challenging, that is not a reason to accept the status quo. People with COPD often come from poorer backgrounds. It is a disease associated with smoking and it is easy to overlook these patients because of that. But this is a growing challenge for all of us and I feel strongly that these patients deserve better. This is happening on our doorstep, right now, and we owe it to people with COPD to do what we can to make things better."

Community Respiratory Team Working Towards a Patient's Own Goals

Making things better means keeping patients out of hospital wherever possible and supporting them to make changes in their lives. Dave explained:

"We encourage patients to set their own goals. They might want to be able to go out to the shops or to Bingo, for example. The Community Respiratory Team works with them to help them achieve whatever it is they want to achieve, however small. People's quality of life can improve significantly by achieving even marginal improvements in mobility. There is no wonder drug that can cure COPD but there are things that can be done to ensure that patients are receiving the best treatment for their condition, including support to stop smoking or to walk more."

Community Respiratory Team

The Community Respiratory Team serves Glasgow City Health and Social Care Partnership and is located in Possilpark Glasgow, in one of Scotland's most deprived areas. The team has twenty members and consists of physiotherapists, respiratory nurse specialists, occupational therapists, pharmacists, dieticians and support workers. The service covers the whole of Glasgow City HSCP, a population of 596,550.

The Community Respiratory Team was created following a five-year project in primary care. During this time three separate projects were piloted and evaluated and the team implemented some of the most successful components of each. These include having respiratory nurses located within the community and adding in a specialist dietician into the team.

The focus of the Community Respiratory Team is avoidance of hospital admissions. As Marianne Milligan, Team Leader of the Community Respiratory Team explains:

"If you live in Glasgow, you are more likely to have Chronic Obstructive Pulmonary Disease ( COPD) than any other part of Scotland and the condition accounts for 45,000 emergency bed days costing £9.5 million to the health board annually which is the highest nationally. A specialist multidisciplinary team placed in the community to support people having exacerbations of COPD was previously not in existence; people had to be admitted to hospital to receive this support. Piloted initially in one sector of the city, the service proved that it could provide safe and quality person-centred care that produced significant cost savings. With Scottish Integration Care Fund we could expand to city wide and now have secured permanent funding for this service. Scottish Government drivers are to transfer the balance of care into the community and enabling self-management, this is what our service can deliver. In my experience people want to stay in their own homes if there is a safe and effective alternative and wish to avoid a hospital admission as much as possible".

The team provides a reactive service to people suffering exacerbations. GPs utilise it as an alternative to patients going into hospital by accessing the specialist service and supporting the patient in their own home. 92% of acutely unwell patients at risk of hospital admission are seen the same working day and there has been an 83% reduction in anticipated hospital admissions as a result.

The service also facilitates early discharge from hospital by closely linking with secondary care colleagues and providing responsive follow up and support. The ethos of the service is to provide a personalised approach to care, enabling self-management by the patients which includes: increasing their own knowledge of their condition and especially what to do when they are unwell; improving knowledge of inhaled therapies; knowing how to clear their chest and also increasing their physical activity and independence through the provision of home pulmonary rehabilitation and equipment. In addition, malnutrition, mental health issues of anxiety and depression, and complex polypharmacy/ comorbidities that are commonly seen in end stage COPD are addressed through the coordinated, multidisciplinary approach.

COPD patients are frequently living in areas of deprivation. Glasgow City contains 3 in 10 of the 15% most deprived data zones in Scotland, which is the highest proportion for a local authority. Deprivation in patients with COPD is a significant predictor of the frequency and duration of hospital admissions, resulting in increased rates and longer lengths of stay especially during the winter. It is also linked to reduced secondary care outpatient attendance. More than 60% of patients that are supported by the Community Respiratory Team live in the most deprived areas of Scotland (Scottish Index of Multiple Deprivation), this figure rising to 74% when analysing the North East of the city.

The team supports patients with end stage COPD with a myriad of co-morbidities living with significant levels of complex physical, mental and social issues. The ethos of this multidisciplinary service surrounds the collaborative effort between the patient and the clinician. Delivering person-centred SMART goal setting and working towards a personalised outcome approach increases participation and engagement. The multidisciplinary service is then coordinated to meet the needs of the patient and their goal. Over 80% of patients decide and agree on their own individualised and meaningful goals. Patients score their own progress at the end of the intervention as a measure of their own success.

Example of a goal may be:

  • "To feel more confident with my breathlessness and have fewer panic attacks when out walking to my local shop every day so I can have my independence back".

The team signposts to other agencies e.g. in the third sector and utilises community services such as befriending, hospice or services such as Community Connectors to reduce social isolation in this client group. The most common referrals, in order of frequency are: financial inclusion, social care direct, hospice and pulmonary rehabilitation.

Reduced impact of disease and improved quality of life has been demonstrated through validated outcome measures of patients who are supported by the Community Respiratory Team. Statistically significant increases in both the COPD Assessment Test ( CAT) and EQ5DL Quality of Life measures are shown. Significant average improvements of CAT score pre- and post-input have been delivered. This figure was a substantial 5, with the authors of the assessment noting 2 as being clinically significant. Likewise sizeable average increases of 13% in a patient's quality of life are shown.

Virtual Ward Rounds

Development of interface joint working through a "virtual MDT", led by the consultant respiratory physician, allows clinicians in the Community Respiratory Team to discuss current patients on their caseloads facilitating secondary assessment, opinion and input. For example, this could include: addition and optimisation of medication, organisation of investigations and review of chest X-rays/ CTs, decisions for clinic reviews plus educational sessions. This streamlines the referral process for this patient group for secondary referral. The weekly treatment plan of 10 – 12 complex patients are discussed as a team with the plans and outcomes being communicated on Clinical portal but also directly with the GP.

The service has been warmly welcomed by GPs, who are the largest referral group into the service. The team has had a positive impact on primary care by freeing up GP time. 75% of 70 GPs surveyed reported a reduction in the number of home visits and 63% reported that patients were able to self-manage their condition more effectively with 60% specifically being around optimisation and use of inhaled therapies. 85% of GPs rated the service as good or very good. Ongoing engagement sessions with GP continually increase awareness and use of the service.

The service aims to be easily accessible to people with COPD in Glasgow as Marianne Milligan explains:

"We support patients in their home making sure they have an appropriate level of input and care to safely and effectively help them recover. We then look at how we can help them to optimise their own health, what they can do to help their symptoms, particularly of breathlessness, and ensure they have an understanding of their condition so they know how to control their own health. They often have a lack of confidence in how active they can be as breathlessness leads to feelings of anxiety and results in inactivity. By providing them with a rounded approach with all members of the team working towards the patient's goal we support people to be as active and engaged in their surroundings and community as much as possible and their quality of life is massively enhanced as a result. Once they have achieved their goal, we discharge them, however patients can then self-refer into our service when they are becoming unwell. This can greatly relieve any anxiety as they know our team, they know who to call and we can see them that day if required. There are continual increases in patients self-referring into the service and patients are no longer waiting to become so unwell that they need a hospital admission and instead contacting us earlier in their exacerbation. All these factors are leading to a trend of reductions in hospital admissions being shown in Glasgow".

Over 90% of patients supported by the service are graded on the MRC Breathlessness Score as being 4 or 5 (grade 5 being they are breathless when getting dressed). A significant proportion of COPD patients are entering the final stages of their life and the Community Respiratory Team also works with them to create anticipatory and end of life plans.

Combined Respiratory Services

Establishing patient pathways between the combined Glasgow Respiratory services of the Community Respiratory Team, Pulmonary Rehabilitation classes and Hospital-based Respiratory Nursing Teams have considerably improved service delivery ensuring the patient is seeing the right person at the right time.

Investing in training has led to Advanced Practitioner qualification by the majority of clinicians who work with acutely unwell patients.

£1m Savings

The pilot project delivered net savings of more than £1 million a year and avoids, on average, 45 admissions a month. Patient quality of life has improved and GPs are fully onboard with the service. NHS Greater Glasgow and Clyde has now provided full funding for the COPD service and believes there is potential to scale the project to the NHS Greater Glasgow and Clyde area and to apply similar approaches to other long-term conditions. Additional future plans include: increasing to a seven day service, improving links with Scottish Ambulance Service, and increasing presence of health professionals in the Emergency Department to improve the turnaround of patients at the front door towards community support.

The team's success has been recognised and includes best COPD abstract selection in European Respiratory Society Conference, a Scottish Pharmacy Award, a Scottish Respiratory MCN award and a Health Improvement Scotland Research award


Email: Syed Kerbalai

Phone: 0300 244 4000 – Central Enquiry Unit

The Scottish Government
St Andrew's House
Regent Road

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