Hi Nawaid, welcome to Respiratory Futures and thank you for speaking to us about your work in integrated care.
You have developed a consultant-led service for respiratory medicine at your trust, could you explain the catalyst behind this work – what were the problems with the previous non-integrated care system?
The area of Telford and Wrekin has a population of 173,600, with more than a quarter living in the 20% most deprived areas, nationally. 20.7% of adults above the age of 16 are current smokers and the prevalence of COPD - as per the most recent data - is about 2.6%. We estimated that 40% of our general emergency admissions were related to respiratory illnesses, with a large proportion attributed to COPD. Local CCG data also showed that 30 patients accounted for 108 admissions between February 2013-February 2014.
The Shrewsbury and Telford community respiratory team
The following ‘opportunities for improvement’ were identified:
- There was no clear pathway for following up with COPD patients after hospital discharge
- The community team worked within their own limitations with very little communication with hospital consultants
- There was no forum to discuss complex patient needs which were using up healthcare resources in the community and, as a result, often ended up being admitted to hospital with severe problems
- Social services, hospital services, mental health and the voluntary sector were not communicating with each other despite having patients who needed input from all of them
- There was a need to empower and educate primary care colleagues to manage these patients well in the community
What processes did you put into place, and what teams did you establish, to begin integrating care?
We provided the following solutions to counteract the above challenges:
- Consultant Support: A Consultant Respiratory Physician working within the trust at the Princess Royal Hospital in Telford would provide clinical leadership for the community respiratory team. This would be an example of integration between the community and the hospital sector.
- A community MDT for respiratory patients: An electronic MDT pro forma was developed. Community respiratory nurses, GPs, practice nurses and matrons looking after respiratory patients would fill in the pro forma and discuss their patients at the MDT to gain further input in managing their condition. Community nurses, physiotherapists, volunteer sector representatives, palliative care consultants and the psychology team would attend the MDT.
A service evaluation between 2014-15 showed that in 91% of cases hospital admissions were avoided or reduced.
- A community clinic: We established a community clinic in a socially deprived area with smoking and COPD prevalence in the last quartile. We know that COPD patients are prone to social isolation and lack motivation to come to hospitals, therefore a clinic closer to home would be appreciated and will lead to better attendance. This was a ‘one-stop’ clinic for review, advice and guidance with regards to their management. If patients needed further investigations or a change of diagnosis then they would be moved to a secondary care clinic.
- Educational events for primary care staff: We established twice-yearly educational sessions for primary care nurses, community physiotherapists and matrons with regards to COPD, asthma and inhaler guidance. The CCG organised protecting learning events with a respiratory theme for GPs, practice nurses and matrons. My nursing colleagues and I have presented at these events to further enhance their understanding of COPD and asthma.
- A focus group: In the last 12 months we have established a focus group consisting of a CCG representative, a team leader for nurses, a head of medicines management and myself. It is an informal group but we meet every month and discuss strategies to improve areas highlighted in the Right Care pack for the region.
How soon did you begin to see positive outcomes?
We started noticing positive outcomes within the first 12 months.
A service evaluation carried out in 2014 showed that between November 2013-July 2014, 40% of people discussed at our MDT meetings (32 out of a cohort of 80) did not require admission to our hospitals.
At least three frequent service users have not had any further hospital admissions over a 12-month period.
When directly comparing hospital admissions between February–October 2013 and February–October 2014, on average there was 20 fewer admissions and we saved an average of 50 bed days over a 6-month period.
Another service evaluation between 2014-15 showed that out of a cohort of 65 patients discussed at MDT, 31% had treatment optimised, 15% received an alternative respiratory diagnosis and a further 8% were referred onto specialist centres for surgical interventions and management. More importantly, in 91% of cases, hospital admissions were avoided or reduced.
What are the barriers to integration and how can they be overcome?
One of the major barriers we still encounter is the integration of technology. Although we have managed to obtain access to the hospital IT system for our community respiratory nurses, getting the same access to GP EMIS has not been achieved yet. It would be ideal if the system would allow us to integrate the MDT discussions within the EMIS summary which would save time and administrative work. Having one system within the region would save a lot of costs as well as be favorable to patient care.
Shrewsbury and Telford Hospital
Another barrier is the workforce situation in acute hospitals. It is difficult for consultants working across systems to reduce hospital commitments and take up sessions in the community, as the acute work suffers. This situation can only be improved by recruitment and retention of the existing hospital workforce, which will then allow consultants like myself to give more time and commitment to the integrated service.
Of course funding is another issue, but we were lucky that the community nursing services were already in existence through the community trust and all that was required was funding for consultant sessions, for which the CCG agreed.
How can your model be used concretely by others interested in replicating these results in their own trusts? What are the steps people need to take?
The first step in setting up this service is to understand if there is a growing need for the service in the region. If community services exist there - which are being run by a community provider - then it is better to speak to them before setting up something new as it will only give rise to competitive market forces which could be unhelpful for the region. A standard level agreement then needs to be reached between the acute trust and community trust to allow consultant sessions, which would be funded through the CCG.
If there are others interested in this model, they can email me and even come and visit us at Telford to see how everything works.
Given your fantastic work in integrated care, how are you able to use this experience to contribute to the Sustainability and Transformation Partnership in your area?
The local STP suggests development of neighborhood teams in the local areas. These will work towards admission avoidance and early, supported discharge from the hospital, and specialists providing more care in the community. As such, I look forward to our integrated care work fitting well within the realms of the STP.
Thanks for joining us, Nawaid.
Read a case study of this service as part of the RCP's Future Hospitals Programme here.