In recent years, there has been a growing awareness of the importance of illness prevention in healthcare (Baggot and Jones, 2011, p. 531-532) and the benefits of an upstream approach to improve patient care and reduce costs to the NHS. The NHS’ Five Year Forward View (FYFV) (England, N.H.S., 2014) they have recognised that people are now living longer with illnesses that people would previously die from which takes up a large amount of the NHS’ budget. It draws to attention the importance of an upstream approach to the prevention where they anticipate serious illness to avoid wasting tax-payers money downstream treating preventable illnesses. This essay will focus on the application of physiotherapy in the prevention of serious illness and its impact on public health. Specifically, this essay will critically discuss whether utilising physiotherapy is an integral intervention in the prevention of hospitalisation and use of antibiotic prescriptions as a result of infective exacerbations in patients with chronic lung conditions such as non-cystic fibrosis (CF) bronchiectasis and chronic obstructive pulmonary disease (COPD). Current UK guidelines will be used to discuss whether they are effective and are being met. Current literature, policy and case studies relating to pulmonary rehabilitation (PR) and airway clearance techniques will be drawn upon with specific reference to the author’s clinical placement experience in a non-CF bronchiectasis outpatient clinic whilst a student physiotherapist. UK based literature has been critiqued together with literature from New Zealand due to the similar healthcare system to here in the UK. (240 words) (citations: 9 words)
Patients with non-CF bronchiectasis and COPD suffer with excess secretions in their airways making them vulnerable to chest infections (Holland and Alison 2016). Bronchiectasis results in airway dilation leading to pockets of mucus forming. In COPD, hypertrophy of the mucus glands leads to increased production of mucus which due to depletion of cilia in the airways is difficult to expectorate. In both conditions there is a build-up of secretions in the airways, being an ideal breeding ground for infectious microbes to colonise making those diagnosed are at risk for recurrent infections (Holland and Alison, 2016). In the UK, each year 700,000 hospital admissions and more than 6.1 million hospital bed stays are due to lung disease (British Lung Foundation, 2016, p.4). The UK currently has the fourth worst mortality rate for lung disease, costing the UK £11 billion a year (Trueman, Woodcock and Hancock, 2017, p.5). In 2012 there were around 210,000 people living in the UK with a diagnosis of bronchiectasis, an increase by 20% since 2008, annually exacerbations due to the condition result in around 8,500 hospital admissions (British Lung Foundation, 2016, p.35). In 2012, the estimate of people living with COPD was 1.2 million, 2% of the population, and in the last decade the prevalence has increased by 27% (British Lung Foundation, 2016, p.38). Annually, 140,00 hospital stays are as a result of this condition (British Lung Foundation, 2016, p.38). (199 words) (citations: 34 words)
The British Thoracic Society (BTS) recognised that there is a huge importance in self-management of these conditions in order to prevent such high hospital admission rate and released guidelines to tackle. The BTS recognised the importance of physiotherapy in the management of COPD in 2009 and in 2010 for non-CF bronchiectasis (Pasteur, Bilton and Hill, 2010, p. i4-i5) (Bott et al, 2009). Their aim is for physiotherapy to educate and teach airway clearance techniques that will reduce the risk of infective exacerbations due to excess secretions in the lungs. Reducing the risk of infective exacerbations will lead to a decrease in acute healthcare requirements. The guidelines also emphasised the importance of exercise and pulmonary rehab for those whose breathlessness affects their day to day life (Pasteur, Bilton and Hill, 2010, p. i4-i5) (Bott et al, 2009). Furthermore, NICE guidelines suggest it is key to ask about smoking status and ascertain patient BMI, to enable the physiotherapists to provide support and refer patients to appropriate services preventing additional health complications (NICE, 2016). This provides a more holistic approach towards public health as physiotherapists look further than merely treating the symptoms at hand. (145 words) (citations: 22 words)
The community respiratory team in NHS Greater Glasgow and Clyde go to the homes of patients during infective exacerbations to provide support and pulmonary rehab (PR) to prevent hospital admission. Treatment includes numerous approaches depending on the individual including education, chest clearance techniques and increasing physical activity levels. It is predicted that this service will reduce annual costs by £463,780 to £1,087,564, whilst improving the health-related quality of life for those with COPD (CSP, 2017). Moore et al (2016) and Revitt et al (2013) discovered through their research that providing PR had a significant reduction in hospital admission rates (Moore et al, 2016) (Revitt et al, 2013). It was found that the difference in hospital admissions in the 12 months following PR compared to the 12 months prior to PR was of significance (Revitt et al, 2013). This follows current guidelines from the BTS and is showing the outcomes of carrying out healthcare according to the guidelines. It expected that the system in Greater Glasgow and Clyde will lead to a reduction in costs for the NHS. Meshe et al (2017) concluded from their study that following PR there is a relationship between increased activity levels and respiratory function (Meshe et al, 2017) which would improve their health-related quality of life. This is further supported by research from Egan et al (2012) which demonstrated that exercise capacity significantly increased after completing PR which would enable them to live a more active lifestyle (Egan et al, 2012). However, it was found that the even though their exercise capacity was greater, the participants did not take advantage of this and after completing PR they did not continue to have an active lifestyle. There are methods of tackling this such as the Chartered Society of Physiotherapy’s (CSP) ‘Love activity, hate exercise’ campaign which aims to create a discussion in order to find a way for those already under physiotherapy care to live an active lifestyle and enjoy it (Hazzard, 2018). This falls in line with the FYFV as it is ‘incentivising and supporting healthier behaviour’ (N.H.S, 2014). However, this is a new campaign, so the long-term outcomes are unknown. (334 words) (citations: 22 words)
In a study at Hillingdon Hospital and another study completed by Moore et al (2017) it was discovered that less than 10% of eligible patients complete PR, indicating that in the UK the referral and uptake rates are very poor (Jones et al, 2014) (Moore et al, 2017). This means that the benefits of PR in the UK are not being taken advantage of, impacting patient care and the cost to the NHS (Jones et al, 2014). The cohort study completed by Moore et al, (2017) also identified that there was no significant difference between the number of GP visits and hospitalisations prior to and post pulmonary rehab or compared to the patients who did not complete PR. There have been efforts to explore why referral and uptake in PR is so low in order to combat it. Two clinicians in the Imperial College Healthcare NHS Trust looked into finding reasons for why do not attend PR and from this they suggested how rebranding and marketing can remove the stigma and promote the benefits of adherence to PR (Smith and Partridge, 2009). They found that many people who did not adhere to PR had a lower socioeconomic status or were elderly and suggested that physiotherapists should think better of the language they use and avoid jargon that they may not understand (Smith and Partridge, 2009). Harris, Hayter and Allender (2008) found that fear is also something that has an impact on adherence in PR and through their qualitative research found that motivating patients through acknowledging the fear and explaining that PR is how they will gain control (Harris, Hayter and Allender, 2008). Physiotherapist can now use this information in order to maintain adherence and increase uptake in PR by focussing on people who fall within the categories which are more likely to dropout or decline PR. This will ultimately improve patient care as it will lead to a reduction in the likelihood of a health and wellbeing gap mentioned in the five year forward view (N.H.S., 2014). (310 words) (citations: 27 words)
The respiratory and surgical physiotherapy team at Barnet Hospital operates an outpatient clinic for patients who have been diagnosed with bronchiectasis by a specialist doctor. During the hour-long appointment, education is provided on their condition and the cause of their recurrent chest infections or the risk of them. Management strategies taught including the active cycle of breathing technique (ACBT) with or without gravity assisted positioning (GAP) and an oscillating positive expiratory pressure device. The physiotherapist may refer them to PR to improve their health-related quality of life if they are affected by secondary symptoms such as breathlessness. If ACBT is ineffective for the patient the physiotherapist may opt to choose autogenic drainage which is thought to result in higher expiratory flow rate at lower lung volumes than the forced expiration techniques in ACBT (Agostini and Knowles, 2007). This service aims to promote independent self-management of airway clearance, preventing future chest infections. After 3 weeks the physiotherapist will phone patients to follow up on how they are managing the condition at home and if needed a clinical appointment will be scheduled to provide further support. A similar outpatient clinic for bronchiectasis is run at the Freeman Hospital which carried out research by asking patients to complete a questionnaire which had a response rate of 79%. This questionnaire revealed that the majority of the patients were very appreciative of this service and felt that they had learnt something new leading to an improved confidence in independent self-management (Hester, McAlinden and De Soyza, 2011). From this it can be assumed that this service is something that the public want as they feel more in control when they know more about what they are dealing with. Quantitative research on whether this has an effect on bronchiectasis is very limited (Hester, McDonnell, and De Soyza, 2016). Garrod and Lasserson (2007) emphasised that research has demonstrated the short-term significance of physiotherapy like this in assisting airway clearance and as with increased sputum expectoration there would be reduced infective exacerbations (Garrod and Lasserson, 2007). Although further research into the long-term effects is needed. (326 words) (citations: 20 words)
Murray, Pentland, and Hill (2009) followed the guidelines set by the BTS for bronchiectasis to investigate whether or not increased expectoration had a significant effect on 24-hour sputum volume and sputum microbiology, amongst other things. The authors found that whilst sputum expectoration and exercise tolerance significantly increased, this did not significantly affect the number of bacteria in the sputum samples nor the exacerbation frequency (Murray, Pentland and Hill, 2009). This is of significance as it could mean that investing money in teaching chest physiotherapy has no impact on hospital admissions for infective exacerbations. This is unclear and further research needs to be carried out to confirm any impact on hospital admissions. Despite the failure to prevent exacerbations, it was emphasised that exercise tolerance significantly increased (Murray, Pentland and Hill, 2009). This means that those who were previously inactive, due to the symptoms caused by their condition, could work towards reaching the guideline from the World Health Organisation of 150 minutes of moderate exercise per week (World Health Organization, 2010, p.8) to reduce mortality and the risk of acquiring further non-communicable chronic diseases (Taylor, 2014). Furthermore, it has been found that adherence to airway clearance techniques are below 50% and, in that study, they recognised that there needs to be a greater focus on monitoring patient adherence to their airway clearance techniques (McCullough et al, 2014). As already mentioned, this is something similar to what is done in Barnet Hospital where the physiotherapist will call up the patient a few weeks after the appointment to see how they are getting on. However, maybe based on this research the physiotherapist should have a longer monitoring period. (274 words) (citations: 21 words)
This essay has presented a critique on whether physiotherapy has been used to improve patient care, focussing on prevention of infective exacerbations for those with chronic lung conditions and the role of physiotherapy in this. Related literature sources have been considered to support a balanced analysis highlighting the positive aspects and drawbacks. The literature shows that PR can be very effective in reducing the costs to the NHS and raising patients’ health related quality of life. There are barriers in the referral and uptake of PR for relevant patients displaying a deficiency in patient care even though it can be as the community physiotherapists in NHS Greater Glasgow and Clyde have shown. The literature for bronchiectasis has shown that whilst there is an effort towards preventing infective exacerbations there is insufficient evidence to show that outpatient appointments are effective in reducing hospital admissions. However, they are improving the health-related quality of life for those living with chronic lung conditions. Therefore, the position taken within this essay is that physiotherapy is an integral part in prevention, with aspects that need to be improved upon and more research to be carried out. (190 words)