An inspiring model of care
Creating the first ever primary care respiratory nurse consultant post was a key factor in transforming COPD services in East Lincolnshire, write Dr Noel O’Kelly and Jude Smith
Creating the first ever primary care respiratory nurse consultant post was a key factor in transforming COPD services in East Lincolnshire, write Dr Noel O'Kelly and Jude Smith
The impact of COPD within our society is, at long last, beginning to be recognised. Nearly 30,000 people a year die from this disease in the UK, and COPD exacerbations can create excessive winter pressures, as research carried out by the King's Fund has shown.
Since the late 1990s, an iterative process of redesigning COPD services in East Lincolnshire has been developed. Many of the lessons learned in implementing this programme have wider resonance in the new world of practice-based commissioning.
The case for change
East Lincolnshire contains coastal resorts that are visited by many people from the Midlands and beyond. Consequently, many of these tourists relocate to the area on retirement, resulting in a high population of elderly people – which means a high prevalence of COPD. The local health economy was struggling to provide quality care for these patients, because of the combination of high numbers and a lack of resources in both primary and secondary care.
The approach adopted to develop the programme used care pathway planning methods to identify the key issues for patients with COPD in both primary and secondary care. The scheme took phased approach, designed to build one success upon another. This was made easier by our participation in the national Primary Care Collaborative programme, which provided an effective change management environment by teaching techniques such as the ‘plan, do, study, act' cycle.
How it worked
There were three phases to the programme.
Phase one concentrated on building robust systems to identify and diagnose patients with COPD. Lead GPs and practice nurses were identified within specific practices to champion better care, and clinicians were trained in spirometry and encouraged to follow a pathway to screen patients for COPD. The implementation of this phase predated the new GMS contract by two years.
Phase two was concerned with GPs providing better evidence-based treatment for patients with COPD. This was achieved through the creation of local COPD forums and locally agreed guidelines for respiratory disease.
Successes in the first two phases gave PCT commissioners the confidence to back phase three of the programme – a new community respiratory team, called Inspire, to provide more specialist services within primary care (see box below).
Participation by practices was also phased. Numbers grew from an initial five to 14 by 2004. By 2006, 34 out of 36 were enrolled in the programme, due to the incentivisation of a local enhanced service arrangement.
Creating clinical leaders
A key feature of the programme was the development of clinical leaders and new professional roles within the programme.
We had excellent communication between passionate clinical champions within both primary and secondary care, which was crucial to developing a shared vision. PCT managers then facilitated the process of developing the programme. New roles were established, including a GPSI in respiratory medicine, a respiratory nurse consultant, community based respiratory specialist nurses and a specialist respiratory physiotherapist.
The primary care respiratory nurse consultant was the first post of its kind at the time and was created to give the gravitas we felt was necessary for the programme's leadership. The successful candidate had a background as a nurse practitioner in primary care, a trainer for the National Respiratory Training Centre and a visiting lecturer at Southbank University. In addition, a psychiatrist was appointed on a sessional basis to provide specific mental health services and support to patients with COPD.
The GPSI promoted the Inspire service to GPs, liaised with both the PCT management structure and secondary care clinicians, and provided education and training to the wider health community. Using her excellent skills and knowledge, the nurse consultant took an operational role, developing other health professionals both within the Inspire team and individual practices, and reconfiguring working practices and team structures on the ground within a huge rural community.
Combining these two leaders' strategic and operational skills created a superb synergy and was an important factor in ensuring successful implementation.
The skill mix
The Inspire team comprises a range of health professionals with individual skills. Striking the right balance with these professionals can be tricky, as the required skill mix can sometimes only be determined once the team is up and running. Taking a flexible, phased approach to recruitment seems to be the key to dealing with this challenge.
Continuing professional development has played a crucial role in the genesis of the team. Most of the team were appointed from primary care backgrounds, with all clinicians having some experience in respiratory disease. Despite this, the nurse consultant identified key learning needs within the team and responded by providing 167 individual days of training in the first year. This obviously caused some stress in the service at the time, but was considered necessary to ensure high standards were maintained by the service.
Lincolnshire PCT appointed and funds the Inspire team. At the moment the team operates within the provider services arm of the PCT. About 10% of the patients with COPD in East Lincolnshire remain on the caseload of the Inspire team.
The GPSI spends nine sessions a month providing clinical leadership and, along with the nurse consultant, currently triages all respiratory referrals from GPs.
The success of each phase of the programme built credibility within the local health economy. COPD acute admissions to the local district hospital reduced by 22.5% during the first two phases (2000-2003), which gave the PCT confidence to commission the Inspire team.
Analysis of the impact Inspire has made on reducing admissions has been made difficult by data produced under the Payment by Results system. In one exercise last year, the team discovered only about a quarter of cases coded by the local district general hospital as acute exacerbations matched actual clinical diagnosis shown in notes.
However, empirical data from the Inspire team has shown that, in the past year, up to 450 acute exacerbations have been managed at home. It is difficult to categorically prove that these patients would have ended up in hospital. However, as each of these acute exacerbations required at least daily visits for three days, it was felt that many of these patients would have ended in hospital. In addition there has been a reducing trend in hospital admissions in the local DGH despite the known coding difficulties.
Last year 17 community pulmonary rehabilitation courses were provided to patients of East Lincolnshire in easily accessible sites. Recent analysis of the health outcomes from the patients has shown similar benefits to evidence based hospital programmes.
These specific outcomes do not tell the whole picture. Before the launch of the programme, patients with COPD were unrecognised, poorly managed and had few specialist services dedicated to their needs. Now within East Lincolnshire, COPD has been identified as a major health need and a clear patient-focused pathway of care has been built up over the past seven years. GPs proactively screen, diagnose and manage COPD, the Inspire team provides more specialised support and patients have a choice of hospital or home management of their acute exacerbation.
Recent additions to the Inspire service over the last year include an oxygen assessment service and palliative care service.
The redesign of the COPD care pathway illustrates many fundamental key factors required to commission new services, including:
• clinical leadership
• shared vision across primary and secondary care
• phased approach building success on success
• services built along a care pathway, ensuring interdependency and integration
• providing clear communication and building relationships with all stakeholders
• using national agendas and priorities to drive forward services reflective of local need.
Each stage required specific individual skills and knowledge drawn from the project development group. The partnership between clinicians with vision and NHS managers who helped develop the project within the complicated environment of the NHS was essential.
In addition the appointment of the nurse consultant aided the effectiveness and planning of the delivery of services.
The provision of care for long-term conditions provides an opportunity for PBC clusters to enhance and streamline services to patients. Unless services are constructed along the care pathway and implementation is based on a phased approach, there is a risk of fragmentation of all services that could cast doubt on their sustainability.
Dr Noel O'Kelly is a GP with special interest in respiratory medicine
Jude Smith is a respiratory nurse consultant for Lincolnshire PCT
They can be contacted by email on firstname.lastname@example.org and email@example.com
For more information:
Department of Health (search for Chief Nursing Officer pages)
Services delivered by Inspire
These services include:
• Case management
• Acute respiratory assessment
• Early assisted discharge
• Supported discharge
• Community pulmonary rehabilitation
• Respiratory physiotherapy
• Co-ordinated health improvement programme to support practices in developing better care for COPD and asthma patients
Other ways to involve nurses in commissioning and provision
Community nurses and health visitors have a great deal of experience in working with and listening to views of patients, carers and service users.
Community nurses are experienced at working with other agencies and co-ordinating complex services.
Community matrons can actively target and manage patients with long-term conditions to prevent emergency admissions.
Chronic disease clinics
Specially trained nurses can run these in conjunction with GP to improve disease management and reduce outpatient appointments.
have shown that practice nurses, health care assistants and even receptionists can be trained to carry out diabetes screening.
Nurses can be taken on as practice or SPMS partners to give them more influence over services.
Nurses are often well-placed to come up with fresh ways of working. Examples from the RCN include:
• Elderly patients, many with blocked catheters, were being admitted to A&E, particularly during the evenings and overnight. In response, district nurses developed a 24-hour service, agreeing to work more flexible shifts on an on-call basis to care for these patients at home.
• Young people in an area with a high rate of unplanned teenage pregnancies were not visiting local GP sexual health clinics. School nurses listened to the views of teenagers and developed a drop-in service at school.
The role of primary care respiratory nurse consultant was the first of its kind