We spoke with Consultant Respiratory Physicians Dr Emily Fraser, Dr Simon Richards and Dr John Park about their development of The Breathlessness Pathway and how it has impacted patients and clinicians to improve diagnostic care.
The Breathlessness Pathway was started in November 2023. Could you provide us with some insights into the creation of the pathway and its key objectives?
The importance of the early diagnosis of diseases such as COPD and ILD has been established as key to improving health outcomes. We are also aware that some patients with unexplained breathlessness undergo multiple investigations and healthcare encounters, with little emphasis placed on management.
Within our region, Buckinghamshire, Oxfordshire & West Berkshire (BOB) Integrated Care Board (ICB) formed a multidisciplinary taskforce to improve the diagnosis and care of patients with breathlessness. With the Community Diagnostic Centres (CDC) pathway project funding from NHS England in Oxford, we had the opportunity to put into practice a pathway seeking to improve diagnostic efficiency.
Utilising our local CDC, we were able to prioritise patient convenience by implementing a ‘one-stop-shop’ clinic, enabling patients to have diagnostic tests and assessment at the same appointment.
Building on experience from the Long Covid service, we realised that multidisciplinary input was an essential component to improving clinical outcomes. Appointments were therefore combined with a review by a respiratory physiotherapist to provide further assessment, education and management.
Recognising the impact of health inequalities on time to diagnosis, we focused our pilot pathway on GP centres situated in areas of higher social deprivation adjacent to our CDC. Audit of the pathway has been a key objective to better understand our patient population and their clinical outcomes.
How has the pathway impacted day-to-day interactions between healthcare professionals and patients?
This pathway not only focuses on early diagnosis but also on empowering patients, providing them with an explanation for their symptoms and practical management advice. As the cause of breathlessness is often multifactorial, this is not always straightforward.
Close working between the physician and therapist has proved essential to allow us to approach this holistically and help ensure patients leave with a clear understanding and care plan. Following the doctor consultation, patients benefit from an immediate reinforcement by the respiratory physiotherapist, who can assist in explaining some of the more complicated concepts, particularly with regard to breathing pattern disorder.
In addition to further assessment, the therapist provides patient education (e.g. inhaler technique), signposting (e.g smoking cessation, exercise groups, talking therapy, etc) and enrolment onto appropriate rehab programmes. This short-cut therapy is not only more convenient (removing the need for separate appointments with often long gaps in care) but also enhances the patient experience and buy-in to their diagnosis.
What has been the response from healthcare professionals and patients since implementing the pathway?
From a clinician's perspective, it is an immensely satisfying process to be able to see patients with the relevant diagnostic tests, supported by physiotherapy expertise, having the opportunity to get to the root of breathlessness quickly. We feel that this early intervention approach may also help offset negative compounders such as deconditioning and psychological morbidity that can adversely impact on rehabilitation strategies.
GPs report feeling empowered by improved access to information provided following patient assessment. They particularly valued the diagnostic confidence frequently offered at the first appointment.
Feedback collected from patients after the clinic shows high rates of satisfaction. Although patients are often at the CDC for a full morning, the convenience of having tests followed by clinical review offsets the logistic burden of multiple visits. Patients expressed feeling more engaged and having a better understanding of their diagnosis, and overall indicated a clear preference for this model of care.
What would you classify as your biggest successes so far, and what impact do you hope to see the Pathway have in the long term?
We have collected patient data from the pathway and compared outcomes with a group of patients receiving standard care. We found that 90% of patients seen in the breathlessness pilot received a diagnosis on the day, compared with 50% of those seen in general respiratory clinics. This has reduced the need for follow-up appointments by 80%. Through a more accurate diagnosis based on objective tests and clinical assessment, we have also demonstrated a reduction in unnecessary prescriptions, particularly of inhalers.
We believe that earlier diagnosis and prompt intervention for breathlessness are key. Data so far suggests that rolling out this pathway is likely to reduce pressure on primary care, ED and ambulatory assessment and offers the potential for efficiency savings. Most importantly, we hope that this streamlined approach to care will improve clinical trajectory and health-related outcomes for patients with breathlessness.
Our aim is to broaden access to all primary care networks in the vicinity and serve as a model for the expansion of the pathway to different centres across the region. We are exploring ways to bring care closer to home and address health inequalities through satellite clinics and consideration of a mobile diagnostic unit.
Which aspects of the pathway do you think are most important to highlight for our audience?
This pathway addresses several NHS priorities. We feel that the most important aspect is the streamlined approach to care, which places the patient at its centre. The number of appointments for tests and clinics in standard care pathways is often burdensome to patients, time inefficient and results in fragmentation of care. This pilot pathway addresses these issues and helps to improve health inequalities by focusing on areas of higher social deprivation. It also emphasises the importance of collaborative MDT working to deliver not only a diagnosis to the patient but also education, signposting and rehabilitation.