The London Respiratory Clinical Networks and its role in the COVID-19 response.

Wednesday, June 17, 2020

A conversation with Dr Vince Mak, Consultant Physician in Integrated Respiratory Care and Clinical Director of the London Respiratory Network.

London, which had an established respiratory clinical network, has been able to respond quicker than other part of the UK to the COVID-19 pandemic, particularly in the early days and weeks. The existing structure provided by the network, their multidisciplinary nature, and the connected working across primary and secondary care they are built upon have been the key to their success, says Dr Mak.

We are witnessing a renewed awareness from NHS England, in its Long term Plan and beyond, of the role clinical networks can play in developing and delivering integrated care services, but these networks are nothing new. When was the London Respiratory Network formed?

Respiratory networks were initially set up across England in response to the Department for Health’s Consultation on a Strategy for Services for Chronic Obstructive Pulmonary Disease (COPD) in 2010. This was when the ancestor of the London Respiratory Network was set up, and it was extremely successful in making respiratory care consistent across London; this was before the introduction of STPs.

In the time it was in operation, it produced a number of guidance documents on COPD, steroid safety, and responsible oxygen prescribing, among many. Several other of these networks were set up across the whole of England, based on a similar structure, which included primary and secondary care respiratory professionals, but also pharmacists, nurses, physiotherapists. Funding for its operation came from NHS England.

I was a co-lead on the network focusing on Responsible Respiratory Prescribing. I use the past tense, because a couple of years after it was set-up, funding was dramatically reduced to only cover the lead, so we had to re-invent ourselves. Enthusiasm and a sense of doing “the right thing” kept it alive as the “London Respiratory Network” but even this was short lived, as within two years all funding ceased, and the network was disbanded. I am afraid this was the fate of several other nascent respiratory networks. It is worth reminding here, that stroke, cardiovascular, cancer and other clinical networks were maintained, only respiratory fell off the agenda.  However, a few did survive to this day.

That was the case until the NHS Long Term Plan was announced, with respiratory prominent again within it. In London, NHS Rightcare begun looking for a way to implement the respiratory parts of the plan across the city’s five STPs, and to reduce the inequality of care across them. Rightcare working with NHS London, advertised for a Clinical Director post, to come up with ways of delivering the LTP, which came with additional programme funds.

This was the chance to resurrect the Respiratory Network, so I applied. I was selected and appointed, and proceeded to recreate the clinical leadership structure of the old team. That was 2018 and this is where we are today, although we are again faced with the prospect of uncertainty in a matter of months, of continued funding.

How is the new London Respiratory Network structured?

The old structure was very effective, with lots of different disciplines bringing their contribution, so we didn’t diverge much from it. In fact, even about two thirds of the clinical leadership team are the same that formed the very first network.

There are few but significant differences though. London is now covered by five STPs, so we made sure that each of them was represented in the group, and we have more integrated care clinicians on the team. This was one of the most productive changes, as they have the expertise and experience to work at the interface between primary and secondary care, and understand the unique issues faced by both. Inspired by the LTP, our focus was on maintaining health and providing care in the community and to prevent hospital admissions. Integrated care practitioners have been instrumental to be able to do that.

The clinical leadership meet regularly and discusses how to best fulfil the Long Term Plan’s recommendations.

The other change was to set-up delivery groups within each STP. These would be tasked to explore how the guidance developed by the clinical leadership could be implemented, and included commissioners and CCGs. Again, it was important to have one in each STP, to account for the different make up and unique circumstances of each of them.

The first respiratory network was very successful, has the new London Respiratory Network been able to live up to its legacy?

I believe so. Within less than two years since it was funded, the network made good progress in producing guidance on how we may improve the speed and accuracy of the diagnosis of chronic respiratory diseases such as asthma and COPD in London. This is key, as without the correct diagnosis we run the risk of prescribing an ineffective treatment. The solution we proposed and implemented was to have diagnostic hubs in each Primary Care Network and we have been working in the service specification for these hubs. Some CCGs are now commissioning these hubs.

Secondly, we focussed on prescribing. We are working on how we can make sure that patients are on the correct medication, but also that they know how to take it correctly and on improving adherence to their treatment. At the time we started our work, these three elements were not well managed both in primary and secondary care, so the way we set off to solve this was by developing the concept of virtual review clinics for the whole of London, and standardise the review process.

Our third priority was to ensure equal provision and access to pulmonary rehabilitation across the city, for people with chronic respiratory conditions. We started mapping the provision of PR to see what can be done there, and standardise it, this work is still ongoing.

We have also been asked to look at flu and pneumonia vaccination as well as the impact of the environment on health, across the whole of London, as there were stark inequalities there too. We have also taken the London Clinical Oxygen Network under our wing that oversees the prescribing of oxygen in the community and the role of HOSARs.

And then COVID came along and everything fell by the wayside.

Understandably. So how has the Network’s work been affected by the pandemic?

Far from stopping our work, the pandemic highlighted that networks such as ours were ideally placed to develop plans and coordinate action over large areas and multiple STP/ICSs.

Because we had the expertise in the clinical leadership group already in place, and were experienced in working collaboratively across community, primary and secondary care, we were ideally placed to help develop the Primary, Secondary and Community Care response to COVID for London, which we did since the middle of March.

The first thing we did was to bring to notice that non invasive ventilation such as CPAP could be used to prevent patients from needing intubation and ventilation, and we worked with the Intensive Care Network to produce the first combined document for London for the use of NIV and CPAP in COVID patients, which was taken up nationally within a few days of us producing it.

We went on to rapidly produce the Standard Operating Procedure (SOP) for primary and community care for London in relation to COVID-19. Thanks to our access to colleagues from a number of interconnected services and disciplines we were able to draw up this document in under one week. This was a comprehensive document, covering from how to zone a clinic, identify COVID, how to diagnose it, triage, streaming patients into different pathways, treatments, PPE levels, and ethics. This document is an organic piece of work and has developed as we have learnt more about COVID -19 and is now in its 6th iteration in just over 2 months. 

In no way could we have done that without an established network in place, a leadership team able to access the expertise required, and everyone pulling together and doing their bit, supported by programme managers and administrative support already used to similar tasks.

There have been attempts to set up similar networks quickly in response to the pandemic, but this has had varying levels of success. These things take time and need to be properly supported and funded in the long term.

Our network had an uncertain future with regard funding just as COVID hit, and up till recently, there was no funding planned for respiratory networks across the country until next year. I am pleased to hear though that NHS England has now brought forward the funding for Respiratory Networks across England so things are moving fast. 

Despite the uncertainty around, we continued our work and thanks to the efforts of everyone, we were able to update and refresh our guidance once a week for the first four weeks of the pandemic, with more details based on the emerging evidence, into a 50 plus pages document by version 6. It has now been used by a lot of Local Medical Committees across the country.

If you were to make the case for establishing and funding respiratory networks across the country, what would be your main selling point.

The COVID pandemic has demonstrated the utility and practical response that a network can put in place in a consistent form across a large area. If you are seen for COVID related symptoms in the East of London today, you will be assessed and receive the same treatment as in the West of London, for example.

If I was to pick one, I would say that a properly set up clinical network can develop and introduce innovations very quickly, drawing on the experience of all members to come up with new ways of working, new models of care, but importantly, and this is where their strength lies, they can also immediately sense-check their own proposals, thanks to the multidisciplinary nature of the team. It has been invaluable for us during the pandemic, for example, as this made sure that every initiative, every intervention was not only reasonable, but also doable and realistically implementable.