Implementing chronic cough pathways across 12 NHS trusts

Summary

People living with chronic cough can experience repeated consultations, fragmented care and delays in accessing appropriate assessment and treatment. Although national clinical guidance is available, putting structured chronic cough pathways into practice remains inconsistent across the NHS. 

A national programme has supported 12 NHS trusts to move from guidance to implementation, developing and testing practical approaches to improve chronic cough pathways. 

Rather than creating a single pathway for every organisation, the programme focused on helping NHS teams apply common principles while adapting their approach to local services, workforce and patient needs.  

The work identified common barriers across the 12 trusts and developed practical resources to help NHS organisations improve referrals, strengthen multidisciplinary working and establish more consistent and sustainable chronic cough pathways. 

Early changes include redesigning referral processes, greater collaboration between primary and secondary care, increased engagement with Speech and Language Therapy and adoption of a practical implementation toolkit. 

Why chronic cough pathways need to improve

Chronic cough affects a significant number of people and can result in repeated healthcare appointments, fragmented care and delays in accessing appropriate management. 

The British Thoracic Society has published a Clinical Statement setting out recommendations for managing chronic cough in adults. However, translating guidance into consistent practice can be challenging. Chronic cough pathways differ between NHS organisations, as do the services, workforce and expertise available to deliver them.  

The programme therefore set out to go beyond providing guidance. It worked directly with 12 NHS trusts to understand the practical barriers to implementation and support them to develop chronic cough pathways that work within their local services. 

The work forms part of the chronic cough workstream of the national Elective Care Respiratory Pathways programme.  

How we supported pathway implementation

Evidence from interviews, trust implementation reports and shared programme learning was brought together to understand the challenges organisations were experiencing and identify what could help them implement chronic cough pathways successfully. 

Six common areas emerged:

• Primary care interface: Understanding of referral requirements varied, and the investigations completed before referral were inconsistent. This created an opportunity to improve both referral quality and triage.
• Referral optimisation: Referral quality varied considerably, with inconsistent completion of baseline investigations. Clearer and more standardised referral criteria were needed.
• Speech and Language Therapy: Access to cough suppression therapy was the most frequently identified implementation gap, with significant variation between organisations.
• Workforce and clinical expertise: Expertise was often concentrated among a small number of clinicians, making services less resilient and highlighting the need to develop broader multidisciplinary capability.
• Data and coding: Chronic cough was not consistently coded, making it difficult for organisations to monitor pathways and demonstrate their impact.
• Local implementation: There was no single pathway that would work for every trust. Local adaptation was essential, but the programme found that common implementation principles could be shared between organisations.  

Developing practical resources for NHS teams

An important part of the programme was turning this learning into practical tools that NHS teams could use. 

Resources developed through the programme include:

• primary care and secondary care chronic cough pathways
• GP referral guidance
• a five-step implementation toolkit
• a minimum dataset to support more standardised data collection
• an Action Learning Set programme for collaborative learning and problem solving
• patient self-management resources
• trust implementation reports sharing learning, challenges and outcomes
• implementation planning resources to support local service redesign.  

These resources are intended to help organisations start with a common evidence-based foundation rather than developing their approach from scratch, while retaining the flexibility to adapt services locally. 

Early achievements

The programme has already led to changes in how participating trusts approach chronic cough services. 

Trusts have used learning from other participating sites to adapt their own service models, helping to reduce duplication and accelerate implementation. 

Referral processes have been redesigned to improve consistency and introduce clearer referral criteria. There has also been greater engagement with Speech and Language Therapy to improve access to cough suppression therapy and support a more multidisciplinary approach to chronic cough care.  

The programme has strengthened collaboration between primary and secondary care and identified improvements to coding that could make it easier to evaluate chronic cough pathways in future. 

The implementation toolkit has also been adopted nationally, and an artificial intelligence pilot is exploring whether extraction of chronic cough referral data can be automated.  

What we learned

The experience of the 12 trusts shows that successful implementation is not simply about providing NHS teams with a clinical pathway. 

Services need clear referral standards, multidisciplinary working and access to Speech and Language Therapy. They also need local ownership, the flexibility to adapt the pathway to existing services and practical support to turn guidance into day-to-day practice.  

Starting small can also help. Rather than trying to redesign an entire pathway at once, organisations can focus initially on one part of the pathway and build from there. 

Crucially, the programme demonstrated the value of NHS organisations learning from one another. Although local services differ, many of the barriers to implementation are shared. Bringing trusts together to solve common problems can reduce duplication and help organisations move more quickly from national guidance to practical service change.  

Resources developed through the programme are available through the chronic cough workstream of the Elective Care Respiratory Pathways programme.