The National Primary Care Collaborative (NPCC) Phase III focused on helping GP practices to achieve improvements for patients with diabetes and chronic obstructive pulmonary disease (COPD). The programme ran in three waves - Wave 1 was run from the Manchester office and Waves 2 and 3 covered the whole country via our area teams.

COPD is an umbrella term covering a range of conditions including chronic bronchitis and emphysema. It is a long-term condition that leads to damaged airways, causing them to become narrow, making it harder for air to get in and out of the lungs. There is no cure for COPD, but it can be managed through drug therapy.

While the prevalence of COPD is estimated to be 1-2% nationally - which is low when compared to some other chronic diseases, such as diabetes or CHD - it is increasing. It is currently the sixth most common cause of death in the UK and it is estimated that by 2020 it will be the third most common cause of death globally.

While COPD cannot be treated, the symptoms can be relieved and quality of life improved. Those COPD patients who are frequently and repeatedly admitted to hospital as a medical emergency with respiratory distress made worse by fear can be helped. The financial cost of these acute admissions has been estimated at £500m per annum and this can be significantly reduced.

The Government is currently developing a National Service Framework for COPD which will be published in 2008 and implemented from 2009.

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Who is involved

All PCTs took part, including 1,931 general practices, which included 5,793 primary care team members and 300 lay/patient representatives covering a population of nearly 13 million people.

Each PCT established an improvement team of up to 15 people. These included, GPs, practice nurses, practice managers, a project manager, PCT senior managers and secondary care colleagues. PCTs were strongly encouraged to ensure that they had patient or carer representation on the team.

What we are doing

Phase III of the NPCC had a clear aim and focus:

• To support patients, frontline clinicians and PCT managers in using quality improvement skills and techniques to deliver significant improvements in the management of chronic diseases
• Specifically, improving diabetes care and the management of patients with COPD

Central to good chronic disease management is having an effective partnership between the patient and the practice. The programme involved patients as key members of the participating teams, and worked closely with the national Expert Patient Programme to assist in promoting the importance of self-care.

Specifically practices were asked to focus efforts around change principles and associated change ideas that the experience of others had shown to deliver maximum effect. These were:

• Adopt a multi-skilled, multi-agency approach to ensure effective co-ordination of the care of people with diabetes and COPD
• Establish a system for creating, validating and updating a register of people with diabetes
• Be systematic and proactive in managing the care of people with diabetes and COPD
• Involve patients in delivering and developing their care (create expert patients)

Key results