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Delivering integrated care in practice: my experience in the London Respiratory Network

Dr Vincent Mak is a consultant physician in respiratory integrated care at Imperial College Healthcare NHS Trust, and was clinical director of the London Respiratory Network. With statutory integrated care systems (ICSs) set to cover England by April 2022, he shares how clinicians can successfully work together in clinical networks to deliver more integrated care at a system level.

Integrated care is no new thing

Respiratory networks were initially set up across England in 2010, well before Sustainability and Transformation Partnerships (STPs) and ICSs existed. A group of primary and secondary care respiratory clinicians, along with pharmacists, nurses, physiotherapists and carers, came together to form the London Respiratory Team, funded by NHS England. This was successful in reducing variation in aspects of respiratory care across London, and several other similar networks were set up across England.

I was a co-lead on the network, focusing on responsible respiratory prescribing. We produced a number of guidance documents on COPD, inhaled steroid safety, and responsible oxygen prescribing. Unfortunately, funding ran out and the network disbanded in 2016.

Then, in 2019, NHS Long Term Plan was published. This was vital in revitalising the drive for more integrated respiratory care. I was proud to be appointed as clinical director of the NHS London Respiratory Network (LRN), which was tasked with working across London’s five STPs to improve respiratory care and reduce inequalities. Its goal is the proactive maintenance of respiratory health and providing care in the community to prevent deterioration and hospital admissions.

How we developed system working after the Long Term Plan

Multidisciplinary working is crucial to genuine integrated care, so the LRN focused on bringing together respected leaders in their professions – many of whom were involved in the previous network (before 2016).

However, a lot had changed in 3 years, and instead of dealing with 32 individual primary care trusts and CCGs, we had new systems – STPs and ICSs – that brought together all of these organisations. We took advantage of this new structure to ensure that we had knowledge and influence within each of the five London STPs.

Each STP was represented in our leadership group by at least two clinicians (only one a doctor), recognising that different STPs would have unique circumstances that only those working in that area would fully understand. The LRN was then able to tailor how policies and guidance could be disseminated and implemented within all five STPs.

Underpinning this structure were enthusiastic clinicians with the expertise and experience of working at the interface between primary and secondary care, who understood the unique issues faced by both, and how things could be better by working together.

Successes in delivering more integrated respiratory care

In the LRN, we have made good progress in producing guidance on improving the speed and accuracy of diagnosing chronic respiratory disease. The solution we proposed was to have ‘diagnostic hublets’ based around a primary care network population. We have produced a service specification (now modified for the post-COVID era) and these will shortly be piloted within each CCG in some STPs.

Secondly, we focused on appropriate and sustainable prescribing. We are working on how we can ensure that patients are on the correct medication and that they know how to take it correctly. We are also looking at improving patient adherence to their treatment, and trying to manage the change to greener inhalers. These elements are not well-managed both in primary and secondary care and we have developed the concept of virtual review clinics that bring secondary care expertise into GP practices. 

Our third priority was to ensure equal provision of and access to pulmonary rehabilitation (PR) across the city for people with chronic respiratory conditions. We started mapping the provision of PR and set up guidance to help services achieve accreditation and ensure that provision would meet minimum standards.

Improving system working during the pandemic

Far from stopping the work of the LRN, the pandemic highlighted that these networks were ideally placed to develop plans and coordinate action over multiple STPs/ICSs. Because we already had the expertise in our clinical leadership group, and our LRN members were experienced in working collaboratively across community, primary and secondary care, we were able to help develop the primary, secondary and community care response to COVID-19 in London.

Firstly, we highlighted that non-invasive ventilation, such as CPAP, could be used to prevent patients from needing intubation and ventilation. We worked with the Intensive Care Network to produce guidance for London for the use of non-invasive ventilation, which was taken up nationally within a few days.

We went on to rapidly produce the Primary and community care respiratory resource pack for London. Thanks to our access to colleagues from a number of interconnected services and disciplines, we were able to draw up this document in under a week. This covered everything from how to zone a clinic, identify COVID, triage and stream patients into different pathways, treatments, PPE levels and ethics. This document was an organic piece of work, culminating in its 8th iteration in less than 12 months – the last version covering virtual wards and post-COVID syndrome.

Before the peak of the first wave, we rapidly established a weekly community of practice, bringing together respiratory leads in all the acute care trusts across London. We held weekly teleconferences to share ongoing activity, the difficulties faced and novel solutions. Never before had there been a forum where every acute care trust was represented and involved. We also established regular webinars to update primary care colleagues on the latest developments within each STP. 

The future of integrated care and adapting to ICSs

This rapid response to the pandemic could not have been achieved without this integrated approach to care through clinical networks, enabling more seamless care for patients. It is therefore welcome that NHS England is now funding the establishment of respiratory networks across England.

As the government and NHS seeks to drive more integrated care in England by putting ICSs on a statutory footing with new responsibilities and powers, it is imperative that clinicians work together on the ground to make this a reality.

A properly set up, funded and managed clinical network is an effective way of doing this. These must be multidisciplinary to get the right solutions in place and link in with other specialty networks. Innovations can be developed and implemented rapidly, drawing on the experience of clinicians to come up with new ways of working and new models of care, but it is important that those funding clinical networks should encourage rapid innovation by avoiding unnecessary bureaucracy.