Dr Mukesh Singh

Bringing integrated respiratory care to the Staffordshire and Stoke on Trent STP: a success story

Wednesday, October 14, 2020





Bringing integrated care to the STP is a journey that started back in 2011 but that is still ongoing. We made great progress and we have so many successes to share, but we also have plenty more to do before an integrated approach is adopted across the entirety of Staffordshire and Stoke on Trent.

The beginning

It all started when we had a proper look at the state of the healthcare services in the STP and realised that the way we were running things was not good enough, and that we needed to develop a new model of care. At that time, we found deep inequalities in the availability of services across GP practices and substantial differences in the skills and specialisms they were equipped with. Not all practices had access to diagnostics and specialist knowledge.

There was also poor communication across the healthcare pathway, with primary, secondary and community care services, and between them, Public Health England and CCGs. This led to a situation in which service provision was somewhat fragmented and uncoordinated across the region.

When I embarked in this journey, initially, my aim was to find a way to make sure there was better communication and joint planning between all the players in the healthcare landscape, to make sure things were more uniform and standardised across all CCGs.

This had to start somewhere, so I focused my work on two CCGs, Stafford and Cannock, with a combined population of 280,000, where I turned my attention into finding a solution to tackle the clinical challenges that the lack of coordination in the system had caused to the COPD patient population including large numbers of readmissions, inequality of the care offered, high hospital attendance and multimorbidity.

Each hospital in the locality had a slightly different pathway of care for COPD patients, so outcomes were different depending on site, and patients were discharged to GPs on different medications and regimes even when having the same condition.

The formation of the Integrated Care Group

The solution was bringing up the standards of care through both patient education and upskilling staff, ensuring uniformity of care and access, and looking at each patient journey in its entirety, not admission to admission, and this required a truly multidisciplinary effort.

So, with the help of other like-minded healthcare professionals, I formed the Integrated Care Group, a team which included community Respiratory nurses, local respiratory consultants, occupational therapists, mental health practitioners, pharmacists, palliative care specialists, GPs and physiotherapists. Together, we came up with a realistic action plan to improve COPD care, but that could be applied to other areas of respiratory care in the future. Its pillars were:

• Proactive case finding. As the area had unrealistically low numbers of diagnosed patients.
• Proactive case reviews, to make sure patients were on the right pathway.
• Harmonise local guidelines and protocols.
• Harmonise IT systems and record sharing.
• Medicine optimisation, to simplify formularies.
• Patient education and self-management.
• Upskilling primary care practitioners and other community care practitioners.

The Team came up with a plan by the end of 2011 and in 2012 we began to implement it across Stafford and Cannock.

The work on the ground

We introduced community based one stop multidisciplinary clinics led by Respiratory consultant to avoid multiple referrals and visits, in which each patient would be assessed and discussed by a number of specialists to produce a comprehensive treatment plan.  

Our STP covers part of the ex-coalmine belt, so we were naturally expecting a higher prevalence of COPD. Focussed case finding led to the diagnosis of up to 10% more cases in the first year and 23% in Cannock and 27% in Stafford within five years. Members of the Team organised regular educational sessions for primary care practitioners, offering training in diagnostics, inhaler technique, and generally equipping staff with a better understanding of COPD and respiratory disease. We worked particularly with nurses in primary care on developing self-management plans for patients, and to deliver better reviews.

As a result of both case finding and upskilling across 25 practices of Cannock Chase CCG in 2011-12, we saw a significant improvement in NICE standard patient reviews in over 2500 COPD patients over a 12-month period. For the 67% of patients who underwent clinical review during that period, the exacerbation frequency recording increased from 19% to 72%, CAT score recording from 7% to 69% and MRC recording increased from 71% to 93%. Self-management plan recording increased from 2% to 43%, record of inhaler technique demonstration increased from 57% to 74% and record of FEV1 increased from 51% to 72%. Recording of pulmonary rehabilitation data increased from 2% to 21%.

Working with CCGs and healthcare providers, we agreed new pathways of care delivery, uniform across both Stafford and Cannock. This, together with all the other interventions, led to a big reduction of hospital admissions for COPD- 23% in Cannock and 37% in Stafford CCG within two years.

Over the years, the Integrated Care Team expanded further, to welcome practitioners from other areas within the region and commissioners, and in 2015 it turned into the Staffordshire Respiratory Leaders Network, which continue to meet regularly to facilitate the implementation of integrated respiratory care across the STP. We have managed to unify individual Asthma and COPD pathways and formularies into a single Pan Staffordshire pathway. Since the start of the COVID-19 pandemic, the Network has been meeting once a month to help with the local response to the restoration and recovery plans.

We still continue to work on improving COPD care, we are seeing the number of COPD diagnoses constantly increasing, but the number of admissions has remained stable for the past few years, a sign that we are being successful in reducing exacerbations and caring for people at home and in the community. For example, we have managed to keep the number of hospital admissions the same in spite of an average 25% increase in COPD patients over 5 years across Cannock and Stafford CCGs. Our aim now is to expand this proven model for COPD care to all other four CCGs and, in the future, adapt it to other respiratory conditions.