Well, not quite on their own, but they can get definitely get things in motion, and it starts with building good relationships.
The way in which the NHS has been run until recently, with a focus on competition rather than collaboration, has meant it has always been a struggle to build the trust required to create effective working relationships across organisations.
Even if individuals, especially clinicians, were feeling well disposed towards their colleagues in other Trusts, the existing systems did not support working closely together. I was always keen to try to overcome these barriers as much as possible and spent much time and effort building and maintaining good relations with primary care and with my respiratory colleagues in the other acute Trusts.
I learnt early on, that it was also very important to engage with the local CCG; I was keen to get to know their objectives and see how I could support them. It is also important not to appear to be a self-interested empire builder, which to me came easy. In fact, I am not very keen on empires – far too much work and they always collapse in the end.
I soon realised that this was a long game – you cannot expect to change hearts and minds with one email: these things take years, you need patience.
Knowing what ticks commissioners’ boxes is very important when trying to develop a service, so one of the things I did was to create some simple pan-Dorset guidelines for COPD and asthma management that seemed to be appreciated by both clinicians and by the CCG. I also made the CCG aware of the fact that they could save several million pounds by more efficient inhaler prescribing. The CCG trusted the respiratory consultants in secondary care enough to fund the DAIRS service and were keen to hear our views on how things could be improved when it became clear that the model was not as effective as they had hoped it would be.
I have always felt that having respiratory nurses driving around the countryside, trying to prevent the possible admission of a person with a COPD exacerbation was probably not that cost or time effective: patients always seemed to come through ED at the weekend or overnight anyway. My view was that more proactive thinking was needed – this needed a broader, more long-term population-wide view, not a reactive, single patient one. I was lucky, because that is also what the CCG was thinking and was strongly reflected in their Sustainability and Transformation Plan.
Dorset consists of 13 “localities” which are being transformed into 18 primary care networks (PCN). Certain PCNs have decided to invest some of their integration money into integrated respiratory services whilst others have favoured diabetes or frailty more. The largest PCN in Dorset is Weymouth and Portland (W&P) with a population of 70,000 which has a high level of deprivation and supplies half of the COPD admissions to Dorset County Hospital.
W&P chose to invest the largest amount of £200,000 in integrated respiratory services, to support the recruitment of two respiratory nurses (Band 7 and 6), two health care assistants and an MDT facilitator, and to fund GP and respiratory consultant time to support the service. Now I have 2 programmed activities per week (8 hours) to support clinical, non-clinical activity and service development in W&P. There are also smaller amounts included to support my role in two other PCNs, so 3 of our 5 PCNs have contributed money to support secondary care respiratory consultant involvement.