When I arrived in Dorset County Hospital as a Respiratory Physician in 2001, there was one asthma nurse, a new lung cancer nurse and one other respiratory physician.
It was clear that there was a population of patients in the community with respiratory disease who would never be able to see a specialist and would have to be fully dependent on primary care services. How could we be sure that they were getting the correct treatment and how could we stem the slowly increasing numbers of referrals and acute admissions? Since then, I have been working with variable success to develop more integrated ways of working so that people with respiratory conditions were getting the right diagnosis and the right care. It has been an uphill struggle from day one, but over time, things improved.
There are three acute Trusts in Dorset, with Dorchester in the West (Dorset County Hospital), and Poole and Bournemouth hospitals in the East. The West of Dorset is predominantly rural whilst the East is largely urban. Early on, Poole had managed to secure some charitable funds to create an outreach team aimed at facilitating discharge, run and supported by the Hospital. Services in Bournemouth and Dorchester started later. The Dorchester service was funded through “practice-based commissioning”, with the aims of supporting COPD discharges, preventing admissions and providing a small pulmonary rehab service. During this period, the mean length of stay for COPD admissions dropped from 9 days to 4-5 days, partly through the introduction of earlier specialist reviews for inpatients.
In 2013, these various services were merged as the Dorset Adult Integrated Respiratory Service (DAIRS), with an emphasis on preventing admissions, facilitating discharge and ensuring a pan Dorset approach in the provision of pulmonary rehabilitation and home oxygen assessments. It was funded by the CCG and provided largely by the 3 Acute Trusts. However, after 3 years, COPD admissions had not fallen and the CCG was facing a large financial deficit. Some radical thinking was needed.
Dorset CCG decided to undertake a Clinical Services Review (CSR) in 2014, a major piece of work with much clinical engagement, aimed at stripping out a lot of secondary care costs. It became apparent that the only way to achieve substantial savings was to change one of the East Acute Trusts into a major Acute centre, whilst “demoting” the other site to a major elective centre and closing an Emergency Department in the process. The Royal Bournemouth Hospital was to become the major acute site, whilst Poole would lose its ED. However, it also became clear that this would not be feasible without considering the provision of community services and primary care, and so the CSR extended its remit to consider a major review of these, together with mental health services and social care.
When the NHS 5-year plan was brought out in October 2014, Dorset was already considering these issues and was driving change ahead. It was clear to the three Acute Providers, the community provider and the CCG that only by working collaboratively would they achieve what would be required.
As a result, the Clinical Services Review became a Sustainability and Transformation Plan (STP), putting Dorset ahead of the rest of the country, with organisations that already had a plan and that had built good working relations.
An important element of this was that the providers would have block contracts for several years with no new money, so that new resources could be diverted to supporting the development of more integrated services, with £6 million being earmarked across Dorset for investment into primary care networks.
These changes in the financial processes have been key in supporting the development of enhanced integrated services in respiratory care, diabetes, frailty and other areas. Being on a block contract has meant that providers were no longer competing for activity and were instead encouraged to support the development of services that might reduce activity. They are also willing to think with a longer-term perspective.