A project to provide a close to home service no matter where respiratory patients start their journey.


Leader:Amanda Baugh, Service Improvement Manager

Lead organisation: Walsall Hospitals NHS Trust

SHA: NHS West Midlands

Duration: Ongoing

Project objectives

Walsall, part of the Black Country in the West Midlands, is a highly industrial area which has high levels of deprivation and other significant factors associated with respiratory problems such as smoking. Over recent years Walsall Hospitals NHS Trust has experienced increasing admissions and re-admissions for patients with respiratory conditions. The BREATHE project aims reduce the number of re-admissions and improve the patient experience for those with a respiratory condition by integrating the acute sector and primary care to provide a seamless route through the patient journey.

A GP register of patients with asthma and COPD was developed and validated. The aim of the register was to ensure that all patients had the right diagnosis and received the appropriate treatment. Diagnosis was performed in the community, with patients fully briefed on the subsequent patient pathway and what to expect next.

As a result of the register, patients who attend hospital are seen and treated by an appropriate specialist earlier in the stay. This is because the register results in an alert to the respiratory team regarding the admission. Patients on the register are sought out rather than needing to wait for a referral.

How it works

The vision of the project is to provide a first class service for respiratory patients that is as close to their home as possible no matter where they enter the service.

The project was matched with one of NHS Live's Corporate Partners, AstraZeneca. Their input focussed initially on project managing the process, which meant focussing on the 'easy wins' and breaking the project down into manageable targets. AstraZeneca encouraged the project team to focus on working with what was already in place rather than trying to overhaul everything at once, which would help to overcome some of the issues of resistance and limited resources.

The project is self-funding, which is achieved by addressing and minimising wasteful systems and processes.

Shared learning and challenges

The project team have learnt a lot since embarking on the project. The motivation and commitment of the team has been incredibly important throughout, a motivation that has not waned for the duration of the project. The project has been managed by a small team, which it is felt has also been crucial to its success.

The project team consider the input from AstraZeneca to have been of great significance, particularly the insight to break the project down into achievable milestones within measurable timescales.

The significant challenges presented by the big changes taking place in the NHS have recently impacted on the project. Project staff report that interest and engagement with GPs and primary care in general has started to wane a little over recent months, therefore presenting the project with the challenge of re-engaging and motivating these key stakeholders.

Outcomes and future plans

The principle measures of success are the numbers of patients on the respiratory register.

As a result of the BREATHE project there is a functioning pathway for patients who wish to receive oxygen in their own home.

Spirometers have been purchased for GP practices and assessments are now carried out in the PCT.

A customer survey has been carried out which has achieved a detailed understanding of what Walsall patients want from a respiratory service.

Key contacts

Amanda Baugh,
Head of Service Improvement
Walsall Manor Hospital