• Hilary Pinnock, Guro Huby, Alison Tierney, Sonya Hamilton, Alison Powell, Tara Kielmann, and Aziz Sheikh.
• Allergy & Respiratory Research Group, Centre for Population Health Sciences: GP Section, University of Edinburgh, 20 West Richmond St, Edinburgh EH8 9DX, UK. hilary.pinnock@ed.ac.uk
• J R Soc Med. 2009 Sep 1;102(9):378-90.

ObjectivesUsing frameworks, such as the long-term conditions pyramid of healthcare, primary care organizations (PCOs) in England and Wales are exploring ways of developing services for people with long-term respiratory disease. We aimed to explore the current and planned respiratory services and the roles of people responsible for change.SettingA purposive sample of 30 PCOs in England and Wales.DesignSemi-structured telephone interviews with the person responsible for driving the reconfiguration of respiratory services. Recorded interviews were transcribed and coded, and themes identified. The association of the composition of the team driving change with the breadth of services provided was explored using a matrix.ResultsAll but two of the PCOs described clinical services developed to address the needs of people with respiratory conditions, usually with a focus on preventing admissions for chronic obstructive pulmonary disease (COPD). Although the majority identified the need to develop a strategic approach to service development and to meet educational needs of primary care professionals, relatively few described clearly developed plans for addressing these issues. Involvement of clinicians from both primary and secondary care was associated with a broad multifaceted approach to service development. Teamwork was often challenging, but could prove rewarding for participants and could result in a fruitful alignment of objectives. The imminent merger of PCOs and overriding financial constraints resulted in a 'fluid' context which challenged successful implementation of plans.ConclusionsWhile the majority of PCOs are developing clinical services for people with complex needs (principally in order to reduce admissions), relatively few are addressing the broader strategic issues and providing for local educational needs. The presence of multidisciplinary teams, which integrated primary and secondary care clinicians with PCO management, was associated with more comprehensive service provision addressing the needs of all respiratory patients. Future research needs to provide insight into the structures, processes and inter-professional relationships that facilitate development of clinical, educational and policy initiatives which aim to enhance local delivery of respiratory care.

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