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It is currently fashionable to believe that patients with chronic diseases can be managed safely, effectively and more cheaply, entirely in the community. In the UK, current commissioning and financial models encourage the development of services to provide continuing care as well as to replace acute care traditionally provided by hospitals. For some patients, this may be appropriate, but there is a danger of taking it too far and for patients to be denied appropriate input from specialists.
In the late 1990s, home care services to manage exacerbations of chronic obstructive pulmonary disease (COPD) were introduced in the UK, largely as a way of reducing the strain on the National Health Service’s (NHS) resources caused by the number of patients admitted during the winter months.1 It is now well recognised that some patients with exacerbations of COPD2 3 can be managed safely at home, and in fact this model of care fits into a model of intermediate care for older patients which has been evolving for several decades.4 Intermediate care has been seen as a way of overcoming the loss of independence and disruption of informal and formal patterns of support in the community that can occur on admission to hospital. In some cases, transferring care to the community also has a political dimension and has been seen as a way of reducing the influence of secondary care in determining priorities within local healthcare communities. Although home care or early assisted discharge may minimise the loss of independence that accompanies hospitalisation, patients at home often struggle because they are frail and they may take longer to recover because they miss out on the reablement services available in hospital.
Intermediate care is, however, undoubtedly a suitable way of managing exacerbations for some patients with COPD—but not all. In trials of intermediate care, the proportion of patients who were considered suitable for home care varied between 33% and 80%5 6 and thus it is not a complete replacement for hospital care. Studies have shown that it is safe and as effective as hospital care for those patients considered suitable5–7; however, these evaluations have usually been undertaken by hospital specialists. It is difficult to know whether their findings can be generalised and the same outcomes achieved when services are run by clinicians whose primary interests and experience lie elsewhere.
Relatively little up to date information is available about General Practitioners’ (GPs) attitudes to intermediate care. Hood et al found that inner London GP support for intermediate care varied according to the condition being treated, with highest support (77%) for terminal care, but the majority were in favour of home care for a range of conditions despite the fact that they thought intermediate care increased their workload.8 However, there is mixed evidence about GP use of intermediate care services, suggesting that they may have variable enthusiasm for them.9 GPs are often the victims of initiatives led by enthusiasts who suggest that they are “well placed” to deliver services traditionally offered in secondary care settings. While they may be in a position to deliver each of these individually, the range of services that they are now expected to provide may mean that they are simply not able to cope with all the demands placed upon them. There is evidence that GPs already have difficulty in providing high quality care to patients who are managed in another form of intermediate care. They have difficulty in providing care to nursing home residents and difficulty undertaking regular visits,10 and it seems likely that similar problems will develop in home care schemes, particularly if the number of conditions deemed suitable for community management increases and patients in the schemes are more sick.
Deciding who is suitable for home care is crucial. Most studies have pre-specified inclusion criteria that tend to be conservative and acceptable to ethics committees. The British Thoracic Society Intermediate Care Guidelines recommend that the suitability of the patient for home care is determined by assessment, which should confirm that the patient has COPD, that the current symptoms are due to an exacerbation of COPD and that it is safe to manage the exacerbation at home.2 The latter question may be difficult to answer for although a number of factors have been shown to be associated with worse outcomes, none is sensitive or specific enough to be used alone or in combination, and ultimately the assessment involves clinical judgment based on experience. Excluding other causes for the patient’s symptoms is essential. As has been pointed out recently, pulmonary emboli may cause worsening breathlessness in patients with COPD but they are not a cause of an exacerbation.11 Similarly, appropriate testing shows that up to 20% of patients presenting with acute breathlessness and a history of COPD or asthma actually have acute heart failure.12 Because there are no absolute diagnostic criteria for an exacerbation of COPD, other diagnoses need to be excluded before a patient is diagnosed as having an exacerbation. This requires clinical experience and may depend on access to diagnostic tests. The British Thoracic Society Intermediate Care Guidelines also recommend that acute changes on a chest radiograph are excluded before the patient is considered suitable for home care.2 In practice, this also means that patients will need assessment at a hospital.
Concerns about establishing the correct diagnosis and identifying those needing specialist input are not unique to home care for exacerbations of COPD. The proposal to extend intermediate care to people with pulmonary emboli13 moves this model of care into a condition that has a significant acute mortality. This means that it is particularly important to ensure that those patients entering intermediate care are at low risk of death, and while admission to hospital may not prevent death from pulmonary emboli, coping with a death at home and understanding the decision to use intermediate care may be more difficult for family members than if the death had occurred in hospital. Once again, risk stratification of patients with pulmonary emboli and exclusion of alternative diagnoses depends on assessments that are most efficiently undertaken in a hospital setting.
As well as intermediate care for patients with exacerbations of COPD, it is now being proposed by some in the UK that virtually all care for patients with COPD should be provided in the community. The UK government’s recent white paper describes their vision for shifting health and social care further into the community and away from hospitals.14 In order to implement this, clinicians and managers are being encouraged to commission new models of care, including one known as Specialist Personal Medical Services. These services are privately owned and run, and their financial viability depends on making savings by reducing hospital outpatient attendances and admissions. The management of COPD is a prime target for Specialist Personal Medical Services. This particular issue is specific to the UK at present but similar issues about appropriate specialist care are likely to arise in other countries as they too struggle with meeting demands for healthcare on limited budgets.
Unlike home care for exacerbations, there is little evidence of the efficacy of community care for patients with stable disease. Safe and appropriate management of patients in the community depends on making the correct diagnosis and on care being provided by appropriately trained and experienced staff. Unfortunately, patients with COPD in the UK managed in the community are now frequently being cared for by staff with little or no respiratory experience, and clear lines of medical responsibility have not been defined. As a result, hospital based specialists are increasingly dealing with telephone calls from non-medical staff for advice about patients who they have never seen. Similar problems are already occurring in other European countries, including Holland and Italy, and may become more widespread.
The drive to develop generic intermediate care schemes that can manage patients with a range of conditions ranging from mental health problems to postoperative recovery makes matters even worse. In a hospital setting there is ample evidence that patients managed by specialists have a better outcome than those managed by generalists or non-specialists.15 Specialists practicing in their own areas of expertise are more likely to use medications known to be associated with better outcomes, as well as to practice in line with clinical guidelines. Most schemes that have evaluated home care for COPD have used dedicated staff in the community, many of whom have had previous experience of managing exacerbations of COPD in a secondary care setting. Even then evidence of benefit to patients has been limited.16 The randomised controlled trial of nurse led intermediate care by Sridhar et al in this issue of Thorax17 provides useful new data on the effects of outreach by specialist nurses (see page 194). Even when provided by experienced respiratory nurses, outreach did not affect the number of exacerbations or hospital admissions. Outreach did, however, improve patients’ self-management, reduce mortality and reduce unscheduled contact with primary care physicians. This study provides a bench mark for intermediate care in COPD in a scheme run by experts. Relevant experience and enthusiasm are diluted when generic intermediate care schemes are used and this is likely to affect outcomes. It may also be one of the factors responsible for the increasing demand for telephone advice from hospital specialists.
Around the world there have been significant changes in the training and experience of staff who deliver clinical care. Roles traditionally undertaken by medically trained staff have been undertaken by nurses, and roles undertaken by nurses taken on by healthcare assistants. In many case this leads to more appropriate use of skills and experience, but there is a danger that it may be taken too far. The NHS Improvement Plan18 introduced a new breed of nurses: community matrons. Their remit was to use case management techniques to help patients with high healthcare needs remain at home longer and specifically to help to prevent unnecessary admissions to hospital and to reduce length of stay of necessary hospital admission.
The Department of Health stated that community matrons would be able to assess, diagnose and prescribe for patients in the community. They were to be responsible for initiating and interpreting diagnostic tests and would be able to undertake “independent extended prescribing to manage acute exacerbation of multiple long term conditions”.19 Community matrons are expected to be able to demonstrate that they have the necessary skills, but in practice most do not have skills that extend across a range of conditions and many do not have any previous experience of managing patients with respiratory disease. There have also been problems recruiting sufficient community matrons to deliver the service and it has been reported that less experienced staff, including social workers and physiotherapists, have been recruited as case managers.20 Moreover, the coordination between primary and secondary care in planning these services that is required for them to operate effectively21 frequently does not occur. COPD is a complex disease and patients often have other illnesses that can produce similar symptoms (eg, heart failure or depression). It takes considerable experience and skill to establish which of these is the main cause of symptoms at any one time and many community workers do not have these skills.
The concept of case management itself has been questioned. In their report on COPD, the Healthcare Commission identified a number of concerns about the case management approach.22 These included the fact that there are difficulties identifying who is most at risk of admission, its cost effectiveness, the lack of evidence of impact and the potential to operate in isolation from other services. Since this report was produced, a controlled study of case management has shown that it added a frequency of contact with patients, regular monitoring and psychosocial support, but it had no significant impact on the rates of emergency admission, bed days or mortality.23 The authors of an Australian study of case management concluded that “The possibility remains that the essential premise that better coordination reduces hospitalisation is misguided...better care coordination [may] reveal unmet needs rather than resolving them”.24
Intermediate care is a useful addition to the services available to patients with respiratory diseases, but we must not be bamboozled by politicians and commissioners into ignoring the role of specialists in diagnosing and managing patients and, most importantly, assessing their suitability for intermediate care. In particular, we must not be led to believe that generic case managers offer quality care for patients with COPD.
Competing interests: None.
- Chronic obstructive pulmonary disease