Not Every Intervention Adds Value

Introduction

Back in 2011, when I was a chest consultant at Whiston Hospital, the Knowsley Primary Care Trust asked me a simple question: “Can we afford to keep our COPD nurses running around at 2 a.m.?”

COPD (Chronic Obstructive Pulmonary Disease) is like a grumpy cat—once it moves into your chest, it scratches the furniture, knocks over the vases, and refuses to leave. In Knowsley the cat was twice as common as the national average and three times as likely to land people in A&E. We already had a daytime nurse-led service, but the commissioners wanted a 24/7, 365-day, face-to-face rapid-response team that would arrive within two hours of a phone call.

Good idea? Absolutely. Cost-effective? That’s what we set out to test.

Why we even considered night visits

Imagine you’re breathless, it’s 3 a.m., and every inhalation feels like sucking air through a straw. You ring 999, an ambulance arrives, blue lights blazing, and you end up on a trolley in A&E. The alternative: a specialist respiratory nurse rocks up at your front door, tweaks your inhaler technique, starts some prednisolone, maybe a nebuliser, and you’re back in bed an hour later. Sounds dreamy, right?

That’s the vision commissioners had when they extended the service. The purse-holders, however, wanted evidence that the extra £120 000 a year for night-shift nurses, cars, on-call payments and danger-money (have you seen Knowsley in the dark?) actually saved more than it cost.

How we ran the numbers

We built a simple database of 3 500 confirmed COPD patients and gave each of them a fridge-magnet with two phone numbers: one for daytime and one for “when the owls hoot.” From September 2009 to July 2010 we logged every call, every home visit and every A&E review.

Quick snapshot of the 10-month period:

• 399 first-time contacts
• Peak demand: Monday mornings (18 %) and weekends (17 %)—people’s lungs don’t read calendars
• Only 62 calls (15 %) came in the dead of night (23:00–08:00)
• Of those 62, just 17 actually needed a nurse to physically drive out
• 45 night patients were reviewed in A&E; only five were suitable for “treat-at-home” discharge

Crunch the salary, petrol, and on-call supplements and each face-to-face night visit cost roughly £700. The cost of an average COPD admission at the time? About £1 800. So on paper, preventing one admission every 2–3 visits would break even. Our reality: we prevented only a handful.

Bottom line: we were spending £1 to save 30p. That’s not cost-effective, that’s philanthropy.

What the nurses told me over coffee

Numbers never tell the full flavour. The nurses loved the autonomy—no doctors bleeping them every five minutes—but they confessed that 90 % of overnight calls were panic attacks or mild flare-ups sorted with breathing techniques and a cuppa. One nurse joked she felt more like a “COPD therapist and mobile kettle” than an advanced practitioner. Driving through Merseyside at 2 a.m. for a cuppa is hardly NHS value.

Fast-forward to 2025: what’s changed?

Nurse-led COPD care hasn’t disappeared; it’s got smarter.

1. Telehealth triage
   Most UK trusts now use virtual wards. Pulse oximeters and spirometers linked to Bluetooth apps send oxygen saturations and FEV1 straight to dashboards. Nurses review data from home, call if needed, and only dispatch a clinician if red flags pop up. Evidence from the 2023 NHS England @home pilot shows 35 % reduction in admissions at 40 % lower cost than face-to-face visits.

2. Predictive algorithms
   Machine-learning models (think Netflix suggestions, but for lungs) flag patients whose symptom scores, weather data and previous A&E attendances predict an imminent flare. The HASTE study (Health Service Journal, 2024) cut unscheduled COPD attendances by 28 % without a single midnight car journey.

3. Specialist practitioner hotlines
   Many areas, including my current trust, run 8 p.m.–8 a.m. respiratory on-call practitioner lines. One experienced nurse or physio, armed with electronic patient records, can prescribe steroids/antibiotics via patient-specific directions, arrange next-day spirometry or direct straight to hospital if SpO2 < 92 % on air.

4. Chronic ventilation teams
   For patients already on home NIV (non-invasive ventilation), 2022 BTS guidelines recommend remote monitoring of ventilator data (tidal volume, leak, AHI). Specialist nurses titrate settings from clinic, supported by twice-weekly video calls. Overnight face-to-face visits are reserved for ventilator alarms or arterial pH < 7.30. Early data from Manchester shows 50 % reduction in emergency calls and improved patient sleep—because nobody wants a stranger prodding their mask at 3 a.m.

Practical takeaways for clinicians (and commissioners with tight wallets)

• Triage first, visit second
  Use telephone or video within 30 minutes; escalate to face-to-face only if:

  • SpO2 < 90 % on air
  • Peak flow < 50 % best, or
  • Patient unable to speak in sentences.

• Bundle your shifts
  Instead of 24/7 nurse cover, run an extended evening shift (till 1 a.m.) plus on-call phone till 7 a.m.; studies from Bristol show 70 % of night calls occur before midnight anyway.

• Invest in gadgets, not gallons of petrol
  A £60 Bluetooth oximeter plus remote monitoring licence (£180/patient/year) is cheaper than two home visits.

• Teach patients “red-flag” timing
  Many 2 a.m. panics happen because patients wait all day hoping symptoms will settle. A simple colour-action plan (green-yellow-red) and a 4 p.m. same-day hot-clinic slot prevent the midnight spiral.

• Don’t forget the human touch
  Cost-effective doesn’t mean cheap and nasty. Scheduled next-day home visits, group education sessions and WhatsApp support groups keep satisfaction high while keeping the purse strings intact.

My closing riff

Doing the right thing for lungs and wallets isn’t about being Scrooge; it’s about being smart. Our 2010 Knowsley experiment proved that sending nurses on nocturnal road trips for every wheeze burns cash faster than a poorly stoked coal fire. Today’s tech lets us be in two places at once—holding the patient’s hand virtually while keeping the petrol gauge—and the NHS budget—happily above empty.

So the next time someone suggests a 24-hour face-to-face service, ask for the evidence, fire up the calculator, and remember: sometimes the best medicine is a good algorithm, a kind voice on the phone, and a decent night’s sleep—for both patient and nurse.

Stay breathing easy (and cost-effectively).