Integrated Care in Scotland: Overcoming geographical and population challenges

Monday, February 10, 2020

We spoke to Ms Phyllis Murphie about the Integrated Community Care service she is running in the Dumfries and Galloway NHS Integration Joint Board (IJB)


Ms Murphie also shared with us the template action plan that her Integrated Respiratory Team follows; click to download it. 

Your Community Respiratory Team is now just over one year old, how did it all start?

Our GP Managed clinical network Lead Dr Fergus Donachie and I worked with the Health and Social Care team (HCST) to develop a proposal for a “spend to save initiative” bid for the Joint Integrated Board (JIB) and this was approved in April 2018.

The demand and needed capacity to provide more care in the community were the driving factors behind the development of our Integrated Respiratory Team (IRT) service. We have a prevalence rate of COPD of over 3%, with increasing hospital admissions and lengths of stay, so our plan was to provide more early-supported and same-day discharges, but also work on admission avoidance and better access to Pulmonary Rehab (PR) for people living with Chronic respiratory conditions.

The PR service was under huge pressure with very long waits and no service provision in the West of the region. Prior to the expansion of the IRT, the service was heavily supported by the community Respiratory Nurses.

We were successful in our bid to the Joint Integrated Board for increased funding to develop our Integrated Respiratory Team and our Pulmonary Rehabilitation service in April 2018. Following this we recruited additional Respiratory Nurse Specialists and Respiratory Health care support workers to work with the existing respiratory team in the community.

We increased our IRT from a staff base of just two in the community to six, covering our remote and rural region of 2,500 square miles, with a population of 150,000. We completed the recruitment of the additional posts by October 2018, while the PR service recruitment was complete by early 2019.

We now have a team of eight Specialist Nurses and two Respiratory Health care support workers in the team (four of the specialist nurses are based in secondary care providing Asthma, COPD, Sleep and Ventilation service, acute NIV, Cystic fibrosis, IPF service, bronchiectasis, ESD and same day discharges, Oxygen assessment and review service). The community IRT also look after complex patients in their own homes.

Within the funding we secured, there was also capacity to increase the pulmonary rehabilitation team to three physiotherapists and three Physiotherapy support workers to allow PR to be provided in six regions across our health board.

What are the main challenges for respiratory care in your region?

Geography is a real challenge; we cover 2,500 square miles in a remote and rural health board. We also have a high prevalence of COPD and asthma and other lung conditions due to many factors including smoking, industry such as mining communities and agricultural work, social deprivation, an ageing population with also lots of elderly people deciding to retire to this region.

We have a new hospital in Dumfries and there is another small District General Hospital in Stranraer which is a 152-mile round trip, and community hospitals in the main towns which provide care for people beyond discharge from the acute sites.

What does your team do and how is it set up?

We work as an integrated team across primary and secondary care supported by a Respiratory Associate Specialist Lead, Dr Jane Gysin and GP Lead Dr Fergus Donachie.

There are 10 in the Respiratory IRT across the region with 4 in the main hub and the rest based in the East and West of the region. Six of the PR team are also based in the East and the West of the region.

We provide same day and early supported discharge from both acute sites. The community IRT will visit next day and follow up the patient for up to 7 days (in person and by phone) and provide support visits where needed. We also provide an admission avoidance service supported by GP referrals and self-referrals where appropriate. The acute Respiratory Nurses Specialists on the team provide an in-reach service to both the Combined Assessment Unit and ED and are supported by our senior medical team on when necessary.

You mentioned the service has evolved over the past year, how so?

In our initial plans, we anticipated that the IRT would only see COPD patients, however the service has evolved to meet the needs of the patients we look after.

For example, the community IRT now supports people with long term oxygen therapy requirement who have other conditions, such as Interstitial Lung Disease, people with ventilatory failure who use oxygen and nocturnal non-invasive ventilation, and complex cases, where people may need high flow humidification/oxygen therapy at home.

The team have gone on to develop more skills including spirometry, arterial blood gas sampling, transcutaneous CO2 monitoring, fitting masks for NIV, delivery of home humidified oxygen therapy and more, in order to enable us to diversify and manage a wide range of respiratory conditions in people’s homes.

What would you see as your main achievements?

The PR service is now providing rapid access for people who are referred post discharge, and the waiting list for to attend PR had been reduced significantly to less than 4 months. We have provided access to a number of other support services in the region for people living with chronic lung conditions and other co-morbidities. We also have a fantastic programme of work in the West of the region, which is transforming care in Wigtownshire, with access to social prescribing and other support services such as technology enabled care, telecare and telehealth and assistance with anticipatory care planning. We have similar services in the East that the IRT links into.

We are very pleased with the results we obtained. Between 2016 and 2019 our COPD admission rates were consistently below the national average. Our 28-day readmission rates are currently the lowest in Scotland at 10.8%. Our mean length of stay has reduced consistently up to 2019, it now stands at 7 days. The investment in the IRT has certainly contributed to this success.

All this data can also be accessed on line at

And now you are planning to use new technology to overcome your area’s geographical constraints

Indeed. We are developing a further plan of work in addition to the current 18 respiratory action plans, which involves using more technology-enabled care solutions in the service as we move into our second year of the IRT service.

At the moment we use a system called MORSE. It’s an app on our tablets that allows the IRT access to a secure clinical portal. All tablets are synchronised using this portal, which lets us be paper free. We have bespoke forms built within the app, which we upload onto the clinical portal once a home review has been undertaken. This reduces need for double data entry and frees up clinical time to reinvest in the service. We have also now updated our MORSE app with the capability to send the outcomes of home review directly to the GP practice by email.

We use the remote calling system NHS Attend Anywhere to hold our weekly IRT Multi Disciplinary Team meetings. The staff over in the West uses it to meet up with us virtually and discuss complex cases and Early Supported Discharge patients, and challenges we may have. This negates the requirement for a weekly 150-mile commute for the West team to meet at the main hospital. It also reduces fuel consumption, carbon emissions, and frees up 11 hours of clinical time. We already use telemonitoring and teleconsultation in the Sleep and Ventilation Service (for 6 years now) and are in the process of moving this over to the Attend Anywhere platform shortly.

Sounds like your service has already developed massively since the start, is there more scope to develop in the future?

Of course. We now need to look at developing a 7-day service and this will require additional staff recruitment. We are looking to test how remote telemonitoring of HR, RR, Spo2, temp and activity can benefit the service (using specially developed smart watches), and if this can reduce the need for home visits and support admission avoidance and ESD services. 

We are looking at 4G enabled tablets, to be able to provide online education for people in their own home, but also so that we can use Attend Anywhere to review patients remotely where they have the technology for it and it is safe to do so, and also as a link to the clinicians at the main hub for advice.

Reducing the length of stay further with the support of technology enabled care solutions is something we are keen to explore this year and we are in the planning phase of this now.

The Scottish National Respiratory Care Improvement plan is currently out for consultation and I think the IRT in our region are very well placed to deliver the recommendations in this action plan due the investment in the service by the Joint Integrated Board.