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How to...work in partnership with nurses on service redesign

GPs, nurses and managers in Hartlepool are working hand in hand to improve respiratory care, as Dr Carl Parker and Valerie Hall explain

GPs, nurses and managers in Hartlepool are working hand in hand to improve respiratory care, as Dr Carl Parker and Valerie Hall explain

Clinicians and managers in Hartlepool have strong views about how practice-based commissioning should work.

When Hartlepool PBC was established in October 2005 as a town-wide group serving 93,000 people, clinicians and managers believed they should work closely together, with neither side taking control of the other.

The group also wanted to focus on operational commissioning and service redesign and to shift from secondary to primary care delivery.

41181082As a GP and member of the PBC group, I'm keen to work with nurses and other healthcare professionals to share their thoughts and aspirations on new pathways of care and how to improve service provision and deliver better patient care.

Engaging nurses and other frontline staff brings different perspectives to the table, enriches outcomes and reduces the tendency for stereotyped responses to issues. This partnership approach means everyone has the chance to influence new services. With this in mind, the PBC group's member-only meetings focus on clinical issues and discuss new evidence.

We identify areas where information and data quality are lacking and where there are service gaps. And we examine potential changes in practice resulting from service redesign initiatives.

GPs and other members of the PBC group are acutely aware of the need to develop local services that are easily accessible and convenient for patients. This is driven by our dependence on secondary care and because our community-based alternatives are inadequately developed.

Sharon Haggerty, community services manager, was aware of these challenges.

As a former respiratory specialist nurse, Ms Haggerty also knew about the high prevalence of respiratory disease in Hartlepool – which, at just under 2%, was greater than the national average of 1.4%.

Recognising that the care pathway was ripe for change, she produced an outline proposal to develop a community respiratory assessment and management service (CRAMS) and presented it to the PBC group.

Because of the PBC group's inclusive culture, Ms Haggerty's idea was seen as a creative and ambitious initiative that could potentially revolutionise the care that COPD patients receive.

We supported her 100%. The plan also adhered to the principles of PBC: to invest in resources and redesign services that could prevent the need for patients to attend secondary care when treatment could be provided locally in a primary care setting.

Under the proposed scope of the new service, patients' respiratory needs would be met by a community-based team who could provide assessment and initiation of treatment for an acute exacerbation of COPD, and diagnostics such as spirometry and blood gas analysis. Patients would benefit from easier access, quicker response and telephone advice.

Supported by the PBC group, Ms Haggerty developed operational policy and referral guidelines which she presented to the clinical governance subcommittee in March 2007. In line with the PBC group's aspirations, it was agreed the service should be staffed by two respiratory specialist nurses, a staff nurse, and a part-time consultant physician, all of whom are employed by the PCT.

During CRAM's development, the PBC group received regular updates and discussed its progress. Before the service opened the respiratory nurse specialists visited all doctors and nurses in primary, secondary and tertiary healthcare settings in Hartlepool to explain the criteria for referrals and the services available.

A press release in the local newspaper was used to tell people in Hartlepool about CRAMS and GPs also spread the word to patients.

Proactive and reactive

Established in October 2007 and operating 9am-5pm weekdays from a local primary care centre, the service is both proactive and reactive and includes oxygen assessment.

Patients experiencing an exacerbation of their COPD symptoms can be referred directly and without delay, for comprehensive assessment, initiation of treatment and home care provision where appropriate. Referrals are accepted from GPs, consultants, A&E, community nurses, district nurses, rapid response, practice nurses and other healthcare professionals.

Patients known to the service are able to self-refer. TB services are also provided at the primary care clinic.

The service has also just begun the first stage of receiving referrals from paramedics supported by agreed protocols and this pathway will be developed further as resources allow.

CRAMS also provides facilities for doctors, nurses and allied health professionals to receive training in high-level respiratory disease management and there are plans to roll out a programme of education across Hartlepool.

Nurse training

One challenge that the specialist nurses faced was to gain experience in blood gas analysis before the service became operational. They were given training in a practical setting provided by the Association for Respiratory Technology and Physiology.

As badged British Lung Foundation nurses, they have also benefited from access to respiratory conferences, study days, support and networking opportunities. Nurses say that as well as benefiting from access to regular, high-quality education and updates every three months, the networking opportunities have proved invaluable, allowing them to share problems, insights and solutions.

To lead and oversee the service, Ms Haggerty set up a respiratory group that holds regular meetings with those involved, including consultants, pharmaceutical companies and the British Lung Foundation. The meetings help the supporting services to work together to ensure patients are seen at the right time, in the right place, by the right clinician.

As with any new service, the main expenditure has been staffing costs: £59,710 in the first year, increasing to the current figure of £119,421. Equipment and materials cost £15,000 in the first year but this is expected to decrease to £5,000.

Cutting admissions

However, the service has also brought financial benefits. The most recent three months of data (October 2007-January 2008) show 160 patients were seen; 39 diagnostic spirometries were performed with a cost saving of £1,443; about 80 hospital admissions were prevented and 11 patients have discontinued oxygen following assessment and appropriate support, with about 10% of those reviewed so far receiving short-burst oxygen therapy.

Staff say the service gives them great job satisfaction on a daily basis. Patients appreciate and value the service because it makes a difference to their lives. They can remain at home, are treated quickly and the service can help to stop their symptoms deteriorating. A recent patient survey also showed high levels of satisfaction with the CRAMS and support given.

We are about to complete work on a multidisciplinary pathway to ensure the patient's journey is as seamless as possible and that professionals work in partnership from all care settings.

A Breathe Easy support group for the benefit of patients and their carers promoting self care, education and support starts shortly with the backing of the British Lung Foundation.

In the long term we are examining such possibilities as longer opening hours, community pulmonary rehabilitation, cognitive behavioural therapy and access to PACS for X-ray viewing.

Team culture

To make this service work it's crucial to involve the PBC group at an early stage to guarantee that commissioners support the service redesign. This ensures a willingness to change funding streams and traditional referral routes so patients can move to the new service.

The culture of the group is fundamental – everyone around the table needs to be treated as equals. Communication is the key to any change and engaging people early reduces the likelihood of future problems.

It's also important to maintain networks and work together with everyone involved to encourage transparency and openness. This helps partnership working, promotes a seamless pathway of care for the patient and ensures effective communication channels, preventing anxiety for staff and patients affected by different ways of working.

You need to be creative and use the process of developing a service to think about local changes. You should also consider local and national policy direction, which can influence stakeholders and commissioners when it comes to supporting a pathway redesign. There comes a time, however, when you have to stop analysing data and just get on with it.

This nurse-inspired service shows the vital role they have to play in assisting the redesign and commissioning of services. PBC commissioners need to encourage and support nurses to deliver service redesign that will improve patient outcomes and offer greater choice.

The development and successful implementation of CRAMS is a great example of just how much nurses can influence PBC to improve service delivery for a local population.

Dr Carl Parker: backed the case for a new respiratory service Dr Carl Parker 60 second summary

Patients say they appreciate and value the service because it makes a difference to their lives.

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