COPD outreach: reducing isolation

There is a high prevalence of smoking tobacco and drugs within these communities which is likely to cause COPD. North Central London (NCL) Integrated Care Board recognised that people with addiction often don’t engage with routine primary and secondary care and end up utilising urgent care services when in crisis. 

The NHS England five-year plan provides funding for pulmonary rehabilitation. The funding supports services to address the impact of Covid-19, to improve quality/work towards accreditation, as well as working to address health inequalities in the offer and uptake of pulmonary rehabilitation. NCL focused on working to address inequalities within inclusion health groups. 

Pulmonary rehabilitation is not routinely offered to all eligible patients with COPD, particularly users of addiction services or people experiencing homelessness. 

Evaluating access

A pilot study evaluated referral pathways and developed a pulmonary rehabilitation programme for people with addiction. A further pilot expanded the programme for those experiencing homelessness. 

Gabrielle Rankin, CSP research adviser, said: ‘This is a great programme of work addressing health inequalities for people with addiction or who are homeless. It provides important learning not just for pulmonary rehabilitation services but for any service wanting to improve access for this population.’ 

Whittington Health NHS Trust physios leading the programme are Jane Simpson and Divya Narasimhan who are joint NCL pulmonary rehabilitation leads. Both are working to address health inequalities by developing innovative referral pathways and pulmonary rehabilitation programmes to reach people in the community who do not have access to, or previous positive engagement, with pulmonary rehabilitation. 

Listening to service users and providers

Key to making this succeed was undertaking interviews and getting informal feedback from people with addiction and healthcare and other professionals who already work with these groups. Their work has led to almost 100 referrals - just 10 per cent of these had been referred to pulmonary rehabilitation before. The majority of referrals had not even made it to the assessment phase before.

The pilot has received positive feedback from those who engaged and significant improvements in standardised pulmonary rehabilitation outcome measures.

Divya said: ‘Our first challenge was to address the referral process, allowing those who knew the patients best, the addiction key workers, to have the pulmonary rehabilitation conversation and then initiate referral. We also streamlined the process. Sending opt in letters, for example, to this cohort often won’t work, and even answering their phones to an unknown caller is unlikely in many cases. That was why involving the trusted key workers was vital to the project’s success.’

Jane added that patients with COPD frequently didn’t engage well with primary or secondary healthcare services so failed to get the help they needed and ‘fell though the net’. As pulmonary rehabilitation treatment generally takes place twice a week, it requires commitment on the part of the patient, which may be difficult due to competing physical, mental and social priorities that can vary on a day-to-day basis. 

Involving the trusted key workers was vital to the project’s success

They may also have to deal with a housing crisis or a deterioration in their mental health - more than 90 per cent of those referred have diagnosed mental health problems. Their attendance may also be affected by other conditions, previous negative experience with healthcare or nervousness about joining a group, so it is essential to build a relationship of trust with them.

To overcome this, more flexibility was needed around appointments and non-attendance, as well as adapted delivery of education sessions (read John’s story below).

Tapping into local community support

Key to overcoming low attendance for assessments was working with patients’ key workers and holding clinics at the addiction centre, usually coordinating pulmonary rehabilitation assessments with when patients pick up their prescriptions. One successful method used to ensure participation was to deliver the pulmonary rehabilitation programme in collaboration with Arsenal Football Club.

Jane explained: ‘The Arsenal Emirates stadium is virtually around the corner from the addiction services. We were lucky that space and staff were available to run the pulmonary rehabilitation group there. It brings a different, positive dimension to the group. They were really receptive and keen to work with us. An Arsenal coach worked alongside the physiotherapist to deliver the pulmonary rehabilitation and we supported his upskilling and training.’

‘The model of collaborating with Premier League clubs is being used in other pulmonary rehabilitation services in a similar way, with Northeast London services working with West Ham Football Club. Premier League clubs have a commitment to providing local community support, so it is good to tap into this.’

Jane continued: ‘Being a part of the pulmonary rehabilitation programme gives the patients a positive sense of routine.’ 

Jane and Divya work closely with tobacco dependency services which deliver support in the programme.

Divya said: ‘It’s been a steep learning curve for us at times, but great when we hear feedback from the patients like “you made me feel valued”, as they generally struggle with low self-esteem and don’t value their own health.

‘The most valuable ideas to engage successfully with patients included allowing time and patience to gain their trust, offering transport to the location to those who needed it, as well as a sandwich and drink offered at every rehab session. The patients’ positive feedback has included comments about this having helped them attend.’

Asked how the physios and other healthcare professionals felt about working with this patient cohort, and any concerns about safety, Jane explained: ‘It’s important to see this from the patients’ perspective as you work with key workers and have conversations with patients. We surveyed staff involved in delivery of pulmonary rehabilitation across NCL. 

‘In response to findings, we set up training which was delivered by addiction staff. Risk assessment is important as well as setting clear, agreed boundaries.’

Gabrielle said: ‘This project demonstrates some key learning about promoting access and engagement. It highlights the importance of understanding the needs of the populations you serve, co-producing referral pathways and rehabilitation programmes and working collaboratively with community partners.’

Following their success, the next step is to look to work with community patients experiencing severe mental health issues. 

Patient feedback

• ‘Reduced isolation’ 
• ‘I am out more – it helps to distract from drugs’
• ‘The fear I had about getting out of breath is gone’ 
• ‘Arsenal brought in a sense of belonging and familiarity’ 
• ‘I would definitely big up the project because I am genuinely feeling so much better’