Introduction
Long-term respiratory conditions in the UK are very common; over 6 million people live with the two most common conditions, asthma and chronic obstructive pulmonary disease (COPD).1 Treating respiratory diseases costs the UK National Health Service (NHS) an estimated £4.7 billion annually.2 Respiratory disease is the third biggest cause of death in the UK with ∼800 000 patients dying annually.2 A high proportion of these costs are generated by a relatively small group of patients with more severe disease or with complex problems that include multimorbidity, at-risk behaviours and socioeconomic disadvantage.3 ,4 These patients often struggle to engage with the structured, proactive care approach to chronic disease management advocated for asthma and COPD, resulting in repeated emergency healthcare use of primary and secondary care.4 An integrated approach to the management of complex patients, incorporating specialist and primary care teams' expertise, may be effective in improving outcomes for such high-risk patients. However, the evidence is mixed5–8 and there is a need for evaluations of models of integrated care in routine, ‘real-world’ clinical settings.
Over the past two decades, there has been a shift in the locus of care for the majority of patients with chronic respiratory diseases in the UK towards the community.9 Respiratory diseases are among the most common causes of primary care consultations, accounting for 24 million consultations annually.10 Increasing numbers of complex respiratory patients are being managed in the primary care setting by generalist teams, with a focus on avoidance of admissions to hospital.9 Specialist secondary care is restricted to those patients admitted to hospital in a crisis or referred because of uncontrolled disease.1 ,10
There is evidence of significant and unwarranted variability in the standards of respiratory management in the primary and secondary care sectors. Marked variations in outcomes for patients with respiratory disease have also been shown, regionally and between individual general practitioner (GP) practices.1 There is evidence linking the quality of care provided in general practice with unplanned admissions to secondary care,11 and decreased admission rates have been reported in a number of long-term conditions (including COPD and asthma) where GPs were financially incentivised to provide high-quality care.12 Moreover, higher levels of professional education, nurse staffing and clinical recording in primary care are all associated with an improvement in the quality of clinical care for patients with COPD.13 However, a ‘skills gap’ may exist in some primary care settings, where GPs and other healthcare professionals lack advanced training in the management of these common conditions, particularly in the case of patients with multimorbidity, uncertain diagnosis or complex problems.14 Patients with more severe or complicated disease may receive suboptimal care, which may in turn lead to poor outcomes.14 Such patients may fail to reach a specialist assessment that could potentially improve outcomes, either because they are not offered referral to a specialist clinic or because they decline going to a hospital clinic for such an assessment. Therefore, a community-based integrated care approach, harnessing specialist skills and the overall holistic perspective of the generalist primary care teams, is a promising and attractive solution which is being explored by newly commissioned services. Potential benefits of joint specialist–generalist clinics in the community include not only improvement in quality of care for each of the individual patients seen, but also on-site education for the primary care teams, leaving a legacy of improved skills and greater confidence in managing complex disease.14 Such clinics may potentially increase patient and staff satisfaction, reduce secondary care use and consequently reduce the financial burden of respiratory disease on the local health economy.15
Local context
The UK region of Wessex is situated on the south coast of England and represents a diverse population of around 2.8 million people, ranging from inner city deprivation to remote rural populations. Local clinical audit data have demonstrated marked variation between local regional administrative groups (eg, a 1.9-fold difference in COPD admission rates and a 2.8-fold difference in asthma admission rates) and between individual GP practices (eg, a 4.7-fold difference in COPD admission rates). Improving respiratory care is an agreed local priority and the basis for newly commissioned integrated respiratory services. West Hampshire Clinical Commissioning Group (CCG), the Wessex Academic Health Sciences Network (WAHSN) and the Wessex Collaboration for Leadership in Applied Health Research and Care (CLAHRC) collaborated to prospectively evaluate a service pilot of an integrated model for managing complex or poorly controlled asthma and COPD across the organisational silos of primary and secondary care with a view to subsequent regional roll-out.