King’s Health Partners/Lambeth and Southwark Integrated Respiratory Team (IRT)

The King’s Health Partners/Lambeth and Southwark Integrated Respiratory Team (IRT) is a seven day “team without walls” working across King’s College Hospital and Guy’s and St Thomas’ NHS Foundation Trusts. Their aim is to bring specialist care closer to the patient. The service ensures that people living with respiratory disease in Lambeth and Southwark, and their carers, experience care which is high value, consistent, coordinated and supported, and that healthcare professionals looking after them have confidence and a clear pathway to deliver care.

The joint working team, led by Dr Irem Patel (pictured below, centre, with her team), Consultant Integrated Respiratory Physician at King’s College Hospital and King’s College London, have been nominated for a Royal College of Physicians Excellence in Patient Care Award and will be presenting an evaluation of the service at the Royal College of Physicians Conference in March 2016.

The teamRespiratory team with Dr Irem Patel

The multi-disciplinary team is led by two local GP respiratory leads and an integrated respiratory physician, and works across primary, secondary and community care within Lambeth and Southwark. The local population, consisting of around 700,000 people, has some of the highest mortality rates and poorest outcomes for respiratory disease in London, particularly smoking related conditions like chronic obstructive pulmonary disease (COPD).

Aims and results

The aims of the IRT are to bring specialist care closer to the patient and to ensure that patients get the right care in the right place by the right person. Since the beginning of the IRT, acute COPD admissions to King's College Hospital (within relevant Healthcare Resource Group codes) have reduced by 34% from 2012 to 2015. Total COPD admissions have decreased by 8% and length of stay for COPD admissions has reduced by 17% from 4.45 to 3.7 days. The team has also achieved the highest organisational score in London for King’s College Hospital in the National COPD audit 2014. Through a programme of innovative respiratory virtual clinics, the team have worked with local primary care and medicines management teams to promote high value respiratory care and accurate diagnosis in the community.

Factors contributing to improvements seen:

  • Supportive long term commissioning process informed by local expertise, focusing on value based healthcare and outcomes which matter to patients
  • A multidisciplinary team of like-minded respiratory experts from primary and secondary care, with strong leadership and shared values, supported to work beyond traditional organisational boundaries of care
  • A focus on both individual patient are and the respiratory health of local population
  • Seven day inpatient specialist team
  • Financial incentives for primary care to allow clinical time to make improvements

The IRT supports patients with complex breathlessness both in hospital and at home, with a focus on long-term conditions management and collaborative care planning. Through focusing on outcomes that matter to the patient, joining up key components of care and bringing specialist care closer to home, the IRT strives to ensure that individual COPD patients receive excellent care.

Outcomes

This type of integrated working through teams without walls offers huge opportunities to improve patient care both at an individual and population level. Patients with long term conditions need the specialists and generalists who care for them to come together to deliver joined up care 7 days a week. Through clinical leadership, a focus on well-defined components of care and guided by value, the King’s Health Partners Integrated Respiratory Team has been instrumental in delivering excellent care for individual patients and in making significant improvements in the care of their local population.

Dr Irem Patel, lead of the joint working team, says:

We are delighted to have been nominated. This is a testament to the incredible hard work and dedication of our multidisciplinary team, who take the care to the patient, wherever that is needed. Patients with long-term conditions need the generalists and specialists who care for them to come together and focus on their needs, as people, to get the care right. We are fortunate to work with both excellent GP respiratory leads and engaged local commissioners who have shaped the service.

Professor John Moxham, Director of Clinical Strategy for King's Health Partners, says:

This project and nomination shows how partnership working can provide better outcomes for the local population we serve. By joining up our care in this way we can achieve sustainable health improvements and value for our patients and community. The nomination is thoroughly deserved by Dr Patel and her team, it shows true excellence in patient care and I wish them all the best at the Royal College of Physicians Awards.

Professor Jules Wendon, Executive Medical Director of King's College Hospital, says: 

COPD in full is a particular problem in south east London, and by literally bringing care closer to home, the team has made a huge difference to the quality of life of our patients with chronic respiratory conditions.  Dr Patel has very much been the driving force, working across all spheres of healthcare, supporting and developing a team that is a fantastic example of primary, secondary and community care coming together to provide solutions for patients.