Reflections on integrated care from those working in and leading integrated respiratory teams^*

* On behalf of the British Thoracic Society Integrated respiratory project steering group.

Figures & data

Table 1. Components of an integrated respiratory service.

Multidisciplinary team meetings	Weekly in patient (n = 2)
	Yes (n = 7)
Community clinics	Yes (n = 4)
	Hospital based (n = 1)
	No (n = 2)
	Not at the moment (n = 2)
Virtual clinics	Email service (n = 1)
	Yes (n = 2)
	MDT meeting (n = 1)
	Virtual ward round (n = 1)
	No (n = 4)
Education for community staff	Yes (n = 9)
Domiciliary visits	Yes (n = 9)
Producing clinical guidance for avoidance/other pathways	Yes (n = 9)
Supporting quality assured spirometry	Trained (n = 1)
	Provide training and education (n = 7)
	Yes within rehab (n = 1)
Respiratory reviews in acute medical unit	Yes (n = 6)
	No (n = 2)
	Covered by colleagues (n = 1)
Oxygen assessment service	Yes (n = 6)
	On caseload only (n = 1)
	Nurse run service (n = 1)
	For COPD patients only (n = 1)
Smoking cessation service	Yes (n = 4)
	Referrals (to hospital service, or smoking cessation service, n = 3)
	Input from charity in clinics (n = 1)
	Linked to local authority services (n = 1)
Advance care planning	Yes (n = 7)
	Part of a clinic (n = 1)
	Yes (joined by community palliative care team for MDT (n = 1)
Other roles	Clinical ethics committee, drugs and therapeutics committee (n = 1)
	Inpatient ward round for inpatients – 3 times a week (n = 1)
	Care planning conference, (plus mental health, psychiatrist, social worker, medical team OT and patient plus family + plus GP) (n = 1)

Table 2. Barriers and enablers to delivering integrated care.

Participants’ background	Enabler	‘Training flexibly means you’re working in slightly different ways to most of your peers, so you have to negotiate your role sometimes you have to be quite thick skinned, you need to be clear of what the value of your role is when it’s slightly different to the traditional model and that’s actually what I’ve had to continue to do as a consultant, so, looking back, that was also quite helpful.’ (I-2)
	Enabler	‘One of the key things about doing flexible training and flexible working is you have to be able to have time to reflect and think and I think that has been a really big thing in terms of being able to innovate.’ (I-8)
Expertise within an integrated team	Enabler	General practitioners – ‘What a GP can bring to an integrated team is … the consulting skills, dealing with uncertainty and I think that the GP who is aware of the politics of their local borough or whatever, is kind of vital.’ (I-10)
	Enabler	Pharmacists – ‘they [pharmacists] were so high value and I think they are absolutely an integral part of the team’ (I-10)
	Enabler	Flexible trainee post – ‘I don’t think you can understand an integrated service unless you know where the GPs are coming from and being able to form personal relationships with those people is really important ‘ (I-4)
	Enabler	Flexible trainee post – ‘It would be a routine part of SPR’s training for all of them…I think for anyone who’re going to be a general respiratory physician, it should be part of their normal training that they come through an integrated service,’ (I-2)
	Enabler	Flexible trainee post – ‘it’s been the best job I’ve done on my rotation’. (I-4)
Training	Barrier	‘And I think we should all join that up so that it might be that there isn’t one in every hospital but there’s one in every region and that we then make sure that registrars are freed up regionally to come through these services and that happens for other things like cancer trials to CF. If you haven’t got that going on in your hospital, each year you have your review of training, you make sure you spend a couple of weeks even or a couple of months even as an observer.’ (I-2)
	Barrier	‘It need support through the professional specialist organisations like BTS… also they need government buying.’ (I-11)
	Barrier	‘Also needs support from within acute trusts and CCGs’ (I-11)
	Barrier	‘I don’t think people see it as a potential speciality’ (I-1)
Team leadership	Enabler	‘… I’d have loved to have a nurse consultant or somebody supporting the community role side of things, so I think a collaborative role with two people is much better than one person trying to straddle lots of different bits of it. I think a physician in crucial to this – there has to be a physician somewhere along the line’ (I-2)
	Barrier	‘I think depending on how many sessions of your clinical time you spend doing this it can deskill you because the more you spend the less time you spend in the hospital and I think a truly integrated clinician is one that will do both’ (I-7)
	Barrier	‘[I] don’t line manage any of them because as a nurse consultant’
	Barrier	‘Both of the managerial teams [acute/community] want a bit of me, and want me to be their lackey rather than the other person’s lackey’( I-9)
Evaluating the value and outcomes of the integrated team	Barrier	‘Community clinics that we ran were loved by the patients so patient satisfaction was really, really high but it was again it was coming down to cost and I don’t think, we couldn’t demonstrate cost effectiveness within the short time that we had.’ (I-12)
	Barrier	‘The idea that you might look at the cost of the given patient’s care across different providers and somehow make sure whatever rewards come from saving an admission is shared across all providers all of that is extremely challenging and hasn’t been thought through and that’s what really needs to be in place for these things to work properly otherwise you’re constantly coming up against barriers to do with how things are organised’ (I-2)
	Barrier	‘The management which has to be aligned along the lines of patient’s quality of care rather than financial incentives.’ (I-9)
	Barrier	‘We need to do is to prove that these roles are valuable first and there isn’t enough valuation yet to warrant although the commissioners, the other way of doing it is to get the commissioners to believe that this is the way forward because at the end of the day if the commissioners want it somebody has to provide it.’ (I-9)