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Knowsley Community Respiratory Service - part 1

Introduction to integrated care with Dr Dennis Wat

Monday, December 10, 2018

Dr Dennis Wat - Consultant Chest Physician - gives us some background on integrated care, the Knowsley Community Respiratory Service and the challenges of setting up an integrated service.

Welcome to Respiratory Futures Dr Dennis Wat. You have been working in integrated care for 7 years now, but for many this is still a relatively new area. Can you outline what is meant by the term Integrated Care?

NHS England defines Integrated Care as “patient centred, coordinated care which is tailored to the needs and preferences of the individual, their carers and family”.  An Integrated Care service is one that has moved away from episodic health care to a more holistic approach that puts the feedback of patients at the heart of how services are planned and provided.

In practical terms, what does integrated care mean?

Integration is about the linking up of primary, secondary and tertiary care services. It also encompasses closer working with third sectors including health and social care, physical and mental health, geographical areas and professionals who have a wide variety of expertise and backgrounds.

The purposes of integrated care are to:

  • Prevent people from dying prematurely
  • Enhance quality of life for people with long-term conditions
  • Help people to recover from episodes of ill health, or following injury
  • Ensure that people have a positive experience of care
  • Treat and care for people in a safe environment and protecting them from avoidable harm

Why do you think integrated care is becoming so important?

With the ageing population, many people live with long term respiratory diseases, and therefore joined up care is a crucial part of providing seamless support. Traditionally, services have been commissioned separately and are fragmented, therefore forcing patients to access them with little or no regard for their overall needs. Many of the components of care people need operate in silo with no communication between them, leading to gaps or duplication, and this wastage is not something which the modern NHS can ill-afford. 

What prompted the development of the integrated care service you work in?

We have been the provider of the community COPD service in partnership with Knowsley Clinical Commissioning Group since 2011.

The service was commissioned by Knowsley CCG for 2 key reasons:

  1. as part of a drive to reduce avoidable COPD admissions;
  2. to address marked health inequalities exemplified by a local prevalence of COPD of 3.2% (5053 patients) which is greater than double the national prevalence.

Following the success of the community COPD service, the service was expanded by the CCG to cover additional respiratory conditions to further reduce admissions.

To give people an example, what are the key components of your integrated care service?

Heimlich valve
Diagram of the key services joined together by Knowsley Respiratory Service

 We have joined together the following key services:

  • Diagnostic services
  • Consultant-led MDT clinic
  • Oxygen service
  • Counselling
  • Early supported discharge
  • Rapid response discharge
  • Pulmonary rehabilitation & chest physiotherapy
  • Admin hub

We offer clinics at a range of locations in the community, at a range of times (including a weekend slot). Given we have healthcare professionals working alongside each other, patients are able to access a number of services in a single visit.

You have a very successful service, having won awards for the care delivered by you and your colleagues.

Yes, our community COPD service won a prestigious HSJ Respiratory Integrated Care Award in 2013 for the work it has been doing to provide high quality care to people in their own community. This award acknowledges the team’s dedicated work to provide patients, their families and friends with a better, safer, and a more integrated experience of healthcare. Our reputation for strong performance is important in delivering the best care for our patients. This is underpinned by a culture of research and innovation, facilitated by technology. The excellent care delivered by the service was awarded ‘Outstanding’ rating by the CQC in 2016.

Starting a new way of working will always present challenges along with new opportunities. What experiences would you share with colleagues who may be looking to start an integrated care service, or indeed expand the service they currently offer?  

The biggest challenge is meeting the KPIs set by the commissioners: reduction in annual respiratory admissions and reduction in respiratory re-admissions. These KPIs can be unpredictable and are influenced by the change of patient demographics, social factors, cultures within A&E departments and environmental factors such as influenza epidemics. However, the implementation of many of the aforementioned pathways and the close working relationships with various care providers have helped to achieve the targets set by the commissioners.

The other challenges that we have encountered since the inception of the service include the followings:

  • Meeting patient and family expectation- it is vitally important to maintain a high standard of care and have clear communication strategy with patients and families to ensure they have a fantastic experience with the service. This will ensure they continue to utilise our admission avoidance service to aid with admission reduction.
  • Staff recruitment and retention- the constant change of care provisions and implementation of new pathways can put staff under additional strain. Therefore, clear communication with staff, ensuring staff feel valued by the service and making sure staff are constantly upskilled to meet the demand is key to the success of the service. Attracting and retaining nursing staff with appropriate experience to fulfill the following roles can be challenging:
    • Nurse-led rapid response visit
    • ‘Initiating and interpreting diagnostic tests and would be able to undertake independent extended prescribing to manage acute exacerbation…’ - as stated by the Department of Health
    • Non-medical prescribing
    • Advanced clinical course
    • Provision of education to care homes, community matrons and practice nurses
  • Community respiratory medicine is a specialist area and it is an area in its infancy. Specialist chest physicians require expertise in the community, leadership skills, clinical decision-making and supervision. The role requires respiratory specialty expertise and often acts as an “integrated champion” for all of the health sectors. Other roles required include:
    • Domiciliary, nursing home, residential home visits
    • Chairing Community palliative care MDT, community matron MDT, oxygen MDT
    • Attending GP lead meetings.


Read more about the Knowsley Community Respiratory Service in part 2 of our interview with Dr Dennis Wat here.