IMPRESS was approached by a commissioner working jointly for the local authority and CCG responsible for telecare and telehealth asking for best practice guidance on care pathways and products that will enable people with COPD to become more independent and reduce their anxiety when their breathing becomes difficult. Other results the commissioner wished to achieve were a reduction in GP and A&E visits, especially if they involved the emergency services.
This was my response:

1. There is no evidence that telehealth is cost-effective in COPD care.  See the diagram from the London Respiratory Team that shows the relative value of a number of interventions for COPD, and also the work from IMPRESS done with the LSE on this.

2. This shows that your top priority investments for COPD (and this would apply to the other main category of breathless patients, people with heart failure ) are flu vaccination, stop smoking (have a look at your data on the percentage of people with a long term condition who are current smokers - it's a new primary care indicator, but you ought to be able to get historic data - for COPD it could be as high as 40%; for asthma it could be as high as 30%) and rehabilitation programmes.  The IMPRESS breathlessness work shows you can combine cardiac and pulmonary rehab as most heart failure patients would benefit but don't get access to cardiac rehab.   The IMPRESS breathlessness algorithm has now been adapted for use by Lambeth and Southwark CCGs and we keenly await an impact assessment.  The important thing here is that they are not creating new services, but joining up existing ones better, sharing knowledge better about who can do what, including the voluntary sector, and sharing the benefits of each others' interventions.

3. Rehab teaches people how to breathe better, and sets it in the context of education about their condition.  It works even better if there is a psychologist on the team.  Therefore seek the views and experience of local respiratory physiotherapists and psychologists.

4. Work with your ambulance service, as if someone is breathless in London and calls 999 for example, 90-95% of people will be taken to ER and probably admitted.  The important issue here is that if they have had pulse oximetry - essential- then those at risk of respiratory failure who need admission will be identified. For them, hospital is the right place.     The other thing to push for is that patients known to the system always get taken to the same hospital. That may not be an issue in all areas of the UK, but it is in cities - people get taken to different hospitals so no healthcare professional sees the whole person and history.

5. If one of your aims is to improve the quality of COPD care at a lower cost so that you can release funds for developments such as more rehabilitation programmes, then consider the work of the London Respiratory Clinical Leadership Group on responsible respiratory prescribing.  http://www.networks.nhs.uk/nhs-networks/london-lungs/responsible-respiratory-prescribing-rrp

6. Finally, if you want to introduce telehealth start with telephones (read Nigel Edwards paper Remote Control  for the NHS Confederation).  Make sure your GPs and respiratory physicians have each others' mobile numbers and have a system to call each other to discuss patients who are breathless, because, and this is the final and most important point, breathlessness is frightening, and people's behaviour is entirely understandable given this.

September 2014