Things are constantly changing

As we come to the end of another year, I felt it was time to write a blog, at first, I thought I haven’t even done anything, nothing has changed. Then I looked back since the last blog and thought quite a few things have changed! Where do I even start? Well our business is slowly but surely growing Sarah has been amazing! Stepping into the business role she has secured us another grant to grow our business, so we now have our first new employees. We have employed an administrator and we have recently took on a nurse who will work on a research program in Hull for us. We also have our own little office in an office block! We have helped a few more areas around the country set up respiratory networks, with our support it makes it easier for them and we also invest in developing the nurses too. In March someone kindly nominated us for the general practice nurse awards and we were humbled to have been finalists!

My contract has been extended until next June, but my remit has grown to 12 practices. As the NHS is changing with the development of the new local care partnerships in Leeds, I have also found myself in the position of the locality lead nurse for Leeds 8&9. This was not in the plan, but at the moment there is no one else to do it so I agreed to do it. Sarah is also one of the locality lead nurses in her locality too. I think it is quite an exciting opportunity, that we have a blank canvass to try and make some changes. I have enjoyed getting out more into the community and working with the different organisations. Although it has been a bit a of a balancing act as I only work four days a week and could be at meetings all day every day!

I don’t feel like I have had many challenges or stress thrown my way this year except for when I’m travelling. I have had some wonderful karma ripening that has enabled me to travel a lot this year and I feel very thankful for the experiences. However, things have always been made difficult, planes have been cancelled, then I nearly missed a plane, trains have been cancelled, I’ve had flat tyres and taxis haven’t turned up! I managed to get myself to the monastery last month for a needed retreat to recharge ready for the year ahead but not without problems! I arrived at the airport and they wouldn’t let me fly because I had four months on my passport instead of six! I had to pay a lot of money to change it to the Sunday and hope that I could get a new passport. After another adventure straight to Liverpool they kindly made me one in two hours for a nice little charge. The only adventure that went smooth this year was when I took the children to Thailand and I was so thankful nothing went wrong while I had them with me. I don’t think Id have handled it quite the same and may have got a little stressed to say the least! But I used the other experiences to put my teachings into practice by practicing patience and not getting angry or upset etc like I would have done in the past.

I said this year I was focusing on my spiritual development and I think I’m just getting weirder and weirder as time goes by! I completed the first level reiki course and booked on to do the second level in the new year. I’ve been doing the Buddhist course and I also signed myself up for an eight-week spiritual development course. I’ve been working on becoming a Buddhist chaplain in the prisons but hasn’t been too easy so in the new year I will be starting in the hospitals. Hopefully the prison work should follow. As if I didn’t already have enough on, I have managed to get myself involved with a group of people and we are trying to organise a compassion festival in Leeds for 2020.  I think this is quite exciting as we have been organising events to get people to come on board with us.  We are thinking of setting up a social enterprise to do this work, so we shall see how that turns out next year. I told myself I wasn’t going to do any more work-related courses for a while but of course I signed myself up for one, so I also completed the talent management course from the NHS leadership academy this year too.

So when I look back we’ve done quite a bit in a short space of time but it has gone so fast! On Friday this week we will be in London as we have been shortlisted for the general practice awards! We are delighted to have been shortlisted and looking forward to having a night to celebrate our hard work. I have no plans for the new year I’m just going to see how it turns out. The last few years have taught us a lot. We have grown and I think I have almost grown out of imposter syndrome! I said to Sarah that I feel like we’ve gone through a transition period and this is the start of a new life for us! I’m under no illusion and know that we have difficult times ahead with more and more nurses leaving our localities and all the other challenge, but I am really looking forward to 2019!

Living the dream......

So I start 2018 living the dream, how exciting! But what does it feel like living the dream? It doesn’t feel any different to normal! I started my new job in September, working for our social enterprise, so I am now my own boss! People ask me, do you feel pressure having your own business, do you feel stressed with the responsibility?  I feel less stressed now than I have ever felt, I feel at peace and I’m just going with the flow. At first after a week or two I did feel a bit overwhelmed thinking OMG there is so much work to do! But I took 3 deep breaths and let that worry float away. I decided to write some lists of actions I needed to take and told myself I had to do it step by step and I couldn’t do everything at once.  I never really wrote lists before just kept everything in my head. Previously if I would have had all these ideas in my mind I wouldn’t have been able to settle until they were all actioned and completed. But these days I’m realistic with what I can achieve and manage my expectations.  (This is the best piece of advice a Dr gave me a few years ago, manage your expectations Melissa! It was hard, but I think I’m getting there now)

 

So, I’m working with a collaboration of 8 GP practices that all have different dynamics and different ways of working. This has been quite interesting and has brought one or two challenges with it, but so far so good. I guess it is quite exciting when I think about it and the freedom I’ve been given. I have been doing training sessions, joint clinics, mentoring and building relationships. But after a month or two I started to get itchy feet thinking now what? Not that I was not happy, but I had achieved what I wanted so what should I focus on now. Why couldn’t I just be satisfied with that? I could rest now, just BE for a while! But oh no, inside of me I feel like I need to do more. I go through phases like this every so often, a feeling of itchy feet that a change is coming but I just need to be patient and my next path will be shown.   I’m in middle of the teaching course and this is for my career, but it will also link with my spiritual path.  I feel like this year instead of focusing on my career the focus has shifted to my personal development. I’ve signed up learn reiki and signed up to do a deeper course in Buddhism as I’m starting to teach that at a basic level this year. I wouldn’t have dared do anything like this before, but feel I must do it to benefit others.

 

My mum is already quite anxious because my contract expires in September and she keeps telling me I need to save money in case I’m left without a job. Mother relax, it will all be fine! She says booking her next flight to New York! I went to New York as planned at the end of last year but of course it didn’t go to plan. Our flight was cancelled in Dublin and we were offered a refund and basically that was it. So, I used my negotiating and leadership skills I have been learning over the years and manged to get us a flight. We were the only ones to get a flight, I felt so lucky. But our trip was cut short so it’s only right I should make it back up! I won’t mention to her yet that I have my eyes on going back to the monastery in Nepal at the end of the year to do a course. It might tip her over the edge haha.  I’ve had a lot of pressure and stress over the years and it hasn’t been easy bringing up two kids on my own. They are getting older now, so I think I’ll be a bit crazy for a year or two and have some fun. Then I’ll think about being sensible and settling down.

 

But for now, it’s the start of another year and another chapter to write. I don’t know where I’ll end up or what I will be doing this time next year but I’m excited by what this year will bring.  I have a feeling that 2018 is going to be even better than 2017 and that will be hard to beat!

Learning to let go...

Well I can’t believe it’s been 8 months since I wrote my last blog! I’ve blinked and the year has nearly gone. So I started 2017 in the crazy country that is India. WOW is all I can say, I had a very special time but I don’t think I would have coped there without my mind training. I had already decided that 2017 I was going with the flow, I had no plans at all and I was going to trust in the universe and see where it would take me. This is something I would never have been able to do before I always had to have a plan! (Which never went to plan) So I arrived in Delhi 2.5 hours later than expected, then I queued for 1.5 hours in immigration, to get to the front to be told I was in the wrong queue. I just laughed but I was a little worried as my friend from Nepal was meeting me, his phone was not connecting but I knew he would be waiting for me. So I joined another long queue and a hippie looking guy from London started chatting to me. He said he had been to India 9 times but the first time he came it was too much for him and he had to leave. He said the best piece of advice he could give me for India was that I had to let go and that’s where the magic would happen.
My phone finally rung and it was my friend, I met him 4.5 hours later than originally planned. India was a good place to practice patience and learn to let go!

I came back from India on a massive high. I needed that break so I could start 2017 fresh and ready for whatever the year would bring.  The year seemed quite slow to get going, but now I look back it has gone so fast. I feel this has been a year of resting and relaxing preparing me for the future. In March we were invited to London by NHS England to talk about our social enterprise at the GP forward view conference. We couldn’t believe they had asked us, we were a bit nervous but so excited!

At the end of 2016 two nurses from Wakefield got in touch with us to see if we would help them set up a respiratory network. They came under our social enterprise and had their second meeting this year. It has been nice to watch them grow quite quickly into a successful network. In April we had a joint conference with them which was our biggest and best yet.

Over the summer I had the wonderful opportunity to join the primary care respiratory academy for the second year running presenting with them. I can tell how much I have grown in the past year as I actually enjoyed it this year rather than being held back by fear. I have also got back in the saddle and I'm back at uni for a teaching course, then I’m not studying ever again! haha

So last September I gave up my job as a practice nurse for a 12 month contract at the hospital as a Respiratory Nurse Specialist.  With the aim, that in the year we would secure a contract for our social enterprise. A few people were a bit worried especially my mum, I told her not to worry and that it would be fine. By June she was like Mel what are you going to do? Previously I would have been very worried by now and jumped at the first opportunity that came along. The hospital also offered me the opportunity to stay permanently so that was a nice back up plan.

But my patience paid off as we have just secured a contract with a collaboration of GP practices to standardise respiratory care and improve outcomes. We have been given a blank canvass to be as creative and innovative as we like, we are so excited for the future!  I have really enjoyed my time working at the hospital with such a lovely team. I would love to have stayed but I feel like Santiago from the Alchemist and I have to continue on my journey. It has been a hard few years in lots of different ways but it has all been worth it to make me grow stronger. I feel like a caterpillar that has gone through the changes to become a butterfly, as this year has past I have felt lighter every day. Learning to let go is the best thing I could have ever done. Letting go everything; control, plans, fear, expectations and just trying to live in the present moment. Being happy to accept whatever comes my way, but this is turning out to be a great year where all my dreams are coming true. In 2 weeks I will be having a girly break in Ibiza before I start my new job. Then in October for my birthday I will be visiting New York a place where I have always dreamt of going. There’s still four months of this year left and I can’t wait to see what happens next…….
 

2016 a year of growth

2016 a year of growth…..

I started January 2016 the way I left 2015, feeling emotionally and physically drained but I knew I had to give it all I had. Just 3 more months and it would all be over! Looking back I can admit that I took on too much in 2015. After a very busy start to the year, setting up the social enterprise, working, completing the spirometry course, completing the frontline programme from the NHS Leadership academy and numerous other projects. I started the prescribing course in September and by the end of the year I had nothing left, I wanted to give up but then I had a wakeup call. I failed the numeracy exam. Me fail? I couldn’t believe I had failed! I always had a fear of failing. That was my drive, the fear of failing was an energy that spurred me on. I felt like it happened for a reason as I don’t think I would have had the energy or motivation to complete the work in the New Year.

Oooh but my ego took a beating. The first thing I thought was well how many others failed? I didn’t want to be a failure on my own. I could feel embarrassment and disappointment in my heart. I was in shock I couldn’t believe it. But it was OK I wasn’t too worried as I only got one question wrong and I could re-sit it and I always get 100% any other time. Like I said everything happens for a reason and this was to help me deal with my fear of failing and help me focus.

So for those next few months I worked hard. January I had to go to court as a witness, as a patient assaulted a colleague. That was quite a stressful time being cross examined. It makes you realise that documentation really is important and that things that seem insignificant can be really big things.

In February I attended a training event to become a trainer for education for health. I don’t know what they must have thought of me, by this point I was almost ready to give up again. I don’t think I have ever felt so drained in my life.

I don’t know where I found the energy from but by Easter I managed to complete my essays, portfolio and exam for the prescribing course and was thankful that I passed them!

My resit for the numeracy exam was due in the summer, just before this stress had been building at work and then we had 2 very serious incidents. I can’t discuss here but the stress of that and an incident at home led to one of the worst things that could have ever happened to me. I thought I was going to lose my mind!

I attended BLS with my colleague when all of a sudden “boom” I can only try and explain what happened to me that day because I have never experienced anything like that before. I felt like my mind had become detached from my body that I was not in control anymore. My heart started racing and all I felt was fear and I didn’t know why. I was trying to reassure myself that everything was ok but I was panicking and I had to get out of there. I was trying to act “normal” and went to the toilet to try and bring myself round but it was no good. What was I going to do? I’ve never felt so scared in my life, I felt really hot and nauseous.  I finally decided to try and go back in the room, as I got there, they were coming out for a break. Luckily I’m very close to my colleague she asked me what was wrong with me I told her I didn’t know. I said there was something really wrong with me and I was trying to hold it together. I told her I had to leave, that I was really sorry but I couldn’t go back in there and I would call her later. Wow what was I doing?  But there was no way I could go back in there I felt like I was about to go crazy. I set off walking from the university through town I felt so scared my hands were trembling. I felt really nervous and anxious it was really overwhelming. I walked all the way home but didn’t really know what to do with myself. I was pacing up and down trying to work out what was wrong with me. A few hours later after the course finished she called to my house, by this point I had brought myself round. I couldn’t believe what had happened I felt so stupid! I apologised for leaving but thanked her for not thinking I was silly.  I was OK but it had shook me up a bit. Later that night I went to bed and boom!!! There it was again I couldn’t believe it my heart was beating so fast and hard I thought it was going to explode. I was really panicking wondering what I could do. I tried to lie on the bed but I was so restless and fidgety I had to keep getting up, I was so tired but couldn’t sleep. I felt sick, I could hardly breathe I felt like I was going to die, it was the most frightening feeling. I am a regular meditator but I couldn’t focus and I couldn’t relax my mind there was nothing I could do. Why was I feeling like this? What was wrong with me? Would I feel like this forever? I’ve been through some really bad times in my life and suffered with depression before I started meditating a few years ago. I’ve felt stressed and anxious but never experienced anything so scary in my life.

I went to work the next day exhausted, with everything that had been going on at work I didn’t dare tell anyone at work that I had walked out of BLS. I was trying my best to act normal even though I felt like I was going to die. I am so glad I had my colleague to confide in, who didn’t judge me and supported me. I saw a Dr and got some medication to help my symptoms, but even with diazepam I didn’t get any sleep the next night. Even though I had this dread and fear and full of negative energy. I was trying to stay positive, telling myself that nothing is permanent and it won’t last forever. That it is happening for some reason and I will be ok once I get through it. I don’t think I truly understood prior to this, how patients actually felt when they have told me they suffer with anxiety and panic attacks. I didn’t appreciate how it actually made them feel. I really  don’t  know how I got through those next 2 weeks and I don’t think I’d have made it without the beta blockers and diazepam. I’ve never needed medication like that before and I still had insomnia for a week. I had to send my children to my mums for a short time I was just about functioning myself. I couldn’t look after them. I felt so ashamed and guilty and a bit of a failure. Sometime in this crazy state I went and retook the numeracy exam because I daren’t not go to that after walking out of BLS. 

Just after that episode when I was coming back to “normal” Sarah saw a job advertised at the hospital for Respiratory Nurse Specialist. She told me to apply for it, that it was meant to be because she never looks on NHS jobs and something had told her to. So I applied for the job even though it was only a 12 month contract covering maternity leave.

The good news was I got the job! The bad news was I failed the numeracy again by one question so that meant I had failed the course! So here it was my biggest fear staring me right in the face. But it was ok I was alive! I still had my job, I still had my mind! I was lucky and only felt like that for a short time. To think that some of my patients have to live with it for a long time and often have long term conditions as well. I can see why some people find things too much and sadly take their own lives. Your mind can either be your best friend or your worst enemy and you are stuck with those thoughts 24/7. After all that work I had done I thought I should try so I put in for extenuating circumstances to see if I could have one more try being of sane mind. It was refused even though I had a Drs letter as it did not provide evidence that I would have been unable to engage with the University’s extenuating circumstances procedure at the time of the assessment.

They advised me that if I was not happy I could contact the Office of the Independent Adjudicator for Higher Education. I decided I should do that as I feel I give 110% to my job I’m never off the sick. The amount of money the NHS spent on the course and the time of the Dr to support me. The one time I needed some support and understanding and I didn’t feel I was getting it. So I took it to OIA and asked my GP to write me another supporting letter. I was caught up in emotion I felt they didn’t understand! Like I didn’t understand before this happened to me so I asked her to write my symptoms and how I had felt at the time. To try and express what I was going through at that time. Around this time I started my new job. Even though it can be scary starting a new job I was so excited and felt like a huge weight had been lifted. As these last three months have passed I can feel myself coming back to normal my energy has returned and I’m feeling better than ever.

Last week I received an email to say even though it is disappointing the university followed their guidelines and procedures and my new letter still didn’t specifically say that I was unable to engage with the University’s extenuating circumstances procedure at the time of the assessment. So unfortunately there is nothing more I can do. So there it is I failed. But that was just the way it was meant to be, I have faced my fears now and let it go. There is no point stressing over things you can’t change. I have no more fears now, I have been on a journey for the past few years pushing myself and overcoming my fears.  I have had so many ups and downs but now I feel ready for 2017. I feel like everything I have been through has been preparing me for what is going to be the best year of my life! I don’t know what will happen yet my contract will end and I have no plans but I feel more confident and I am so excited for the future! So 29^th December I will be saying goodbye England, goodbye 2016. I started the year on a low and ending it on high. I will be celebrating the new year in India receiving special teachings from HH Dalai Lama having some R&R before the fun of 2017 begins ;)

#self development #growth #journey

Laying the foundations and building relationships

Friday night was Leeds Respiratory Network (LRN) 3^rd educational committee meeting.

First of all let’s rewind and remind ourselves how we got to this point.  Two nurses initially set up LRN to try and reduce variation in respiratory care through education. This was achieved by organising evening meetings and developing a mailing list of interested people. This mailing list was used to send out respiratory updates and guidance but also a way to communicate progress of the network and articulate the vision as it developed. The mailing list keeps growing and hundreds of people have come along on our journey with us as we have progressed. (leedsrespiratory.network@nhs.net)

In April 2015 our social enterprise Respiratory Care Solutions was born! Since then, as well as being full time mothers, running our homes, keeping down the day job, studying at university and meditating with monks in Asia we have been laying the foundations for our social enterprise. We decided that LRN would be the educational arm of our business and we needed help. We decided the best way forward would be to set up an education committee to help us plan our education meetings etc.

So we were starting to get an idea of interested people and we sent an email asking people who would like to come on board to get in contact. We also contacted secondary care and community to see if they would like to get involved. So in October 2015 we had our first educational committee meeting explaining our intentions and asked if they would like to join us on our mission. There was an air of excitement but also apprehension and nervousness. We were open and honest that we didn’t have a clue how it would turn out and that we could just try it. So where are we now?

 

Nine months down the line we have organised two evening meetings and our upcoming conference on Friday 30^th September. (http://www.eventbrite.co.uk/e/leeds-respiratory-network-conference-tickets-25601327259) . The social enterprise paid for a few of our committee members to attend the PCRS leadership course in June and we are also taking 7 committee members to the PCRS annual conference in October. (https://www.pcrs-uk.org/clinical-leadership-programme) The buzz in that room on Friday night was amazing! We nearly lost one amazing nurse after the first meeting due to fear but we maintained contact with her and encouraged her to go on the leadership course. We agreed that after she attended the course if she didn’t want to be apart of the committee we would leave her alone and never bother her again.  Thankfully after that she attended the meeting on Friday and has decided to come to the next leaders event in November.  They were all very courageous to get in a car with strangers and travel across the country together to go and do something that would take them out of their comfort zones!

 We have all bonded now and we feel safe and comfortable to be open and honest. In these hard and difficult times the NHS is facing there was so much hope and positive energy in that room planning for a brighter future. I felt honoured to be in a room full of passionate, enthusiastic, inspiring professionals that give their own time to do this. I don’t know if they have realised it yet, but their job now is to find other leaders and develop them.  

It hasn’t taken up too much of our time to organise and develop these meetings. The only down side to having meetings on a Friday night is that your feet hurt from dancing into the early hours of Saturday morning ;)

Journal of General Practice Nursing, Volume 1, Number 4, November/December 2015 pg 66

What is a typical day  for you?

A typical day for us is just like any other general practice nurse (GPN). We have a variety of clinics that consist of treatment room duties such as baby immunisations, ear irrigation, smears, dressings and also chronic disease management. Sarah also holds minor illness clinics. We also have admin time where we organise visits and complete tasks sent regarding  patient queries.
Do you have one practice experience that has taught you something valuable?

Not one experience in particular, but I would suggest to question everything! Primary care funding is being reduced and this will have an impact on staffing levels so we need to do things differently. When I first started in general practice there were systems in place where the patient would come back several times, now we try to have more time allocated to each patient so that the patient doesn’t have to keep returning. Think about the procedures and systems that are taking place in a GP practice — is that just the way it has always been? Could work be delegated to admin or HCAs to free up nurse time?

Where did your passion  for respiratory care  come from?

I started as a nursing cadet when I was 18 and my first placement was an assessment unit. I couldn’t believe that too much oxygen could kill someone. I became fascinated with chronic obstructive pulmonary disease (COPD) and my love of respiratory grew from there. Sarah had a placement as a student nurse on a respiratory ward and this is where she developed her passion. Then, we later completed respiratory diplomas when we moved into primary care nursing.

What were the main drivers for setting up the Leeds respiratory network?

We decided to set up the Leeds Respiratory Network for two reasons. First, working as a GPN can be quite isolating and lonely. I work in a small practice and there is no one to discuss patients or share ideas with. Second, we found from looking at data that Leeds was one of the worst places in the country for respiratory outcomes. From discussions, we realised that there was a great deal of variation in general practice, for example, training given, time allowed for reviews, etc. So, we wanted to try and reduce some of this variation through education. We organise evening educational meetings and also a full respiratory event with inspirational national speakers. We use social media to disseminate information, with twitter, facebook and blog accounts. We also send out emails to people, as new guidance and resources become available. We have tried to create a sense of community with our mailing list, and people email questions that we send out to the rest of the network.

What are your plans for  the future?

Setting up the network has led to us forming a social enterprise called ‘Respiratory Care Solutions’. From discussion we were having at grass roots to commissioning level, we realised that there was a gap in the market. There is already a shortage of nurses and this will become worse over the next few years as more GPNs retire. We would like to become a kind of nursing agency that only provides respiratory care, for example, if a practice needs extra help with reviewing their respiratory patients. In addition, we can provide support to GPNs by shadowing their clinics. We hope that in the future, clinical commissioning groups (CCGs) will commission our service.

What advice would you give a GPN Who Was considering setting up a network?

Just do it! It hasn’t taken up too much of our time, but it has really helped us to establish links at both local and national level. We are fortunate that we are affiliated with the Primary Care Respiratory Society UK (PCRSUK), which has put us in touch with appropriate people from its groups throughout the country. PCRS-UK also has an excellent leadership programme that members of the society can attend for free twice a year. We have developed personally and grown in confidence from attending these events. At the leaders event we have also learnt non-clinical skills that we have used to set up the social enterprise, such as project management, business knowledge and how to obtain data to make the case for change. If someone wanted to set up a diabetes network, for instance, find a colleague to work with so you can share the workload and bounce ideas off each other.

How do you see primary care developing in the next five years?

I think primary care will look totally different in five years with co-commissioning and the new federations. The Five Year Forward View will also change the look of primary care with the integration of services. These are exciting times for nurses to be innovative and use their knowledge to fill the gaps in service. Setting up the social enterprise has not been too difficult, and we have received grants and business support from UnLtd (a provider of support to social entrepreneurs in the UK) and Leeds Community Foundation, so it  has not been financially taxing on us  as individuals.

Improving End of Life Care by using PCRS EQUIP Worksheets

THIS WAS A POSTER SUBMITTED TO PCRS ANNUAL CONFERENCE 2015

Aims:
The Practice Lincoln Green is situated in inner city Leeds and we have high levels of deprivation. Our practice prevalence for COPD is 3.9% with the national prevalence at 1.7%.

14.2% of patients on our practice COPD register have severe to very severe COPD. COPD life expectancy is very difficult to predict due to the disease trajectory and often doctors over-estimate survival.  There is reluctance to discuss respiratory patients at gold standards meeting. Our aim was to improve the end of life care for our patients by using the EQUIP worksheets.

 

Methods:
We used the PCRS EQUIP worksheets to help us identify patients approaching terminal stages of disease. The worksheets ensured we provided holistic reviews focusing on symptom management, medicines optimisation and referring to external agencies such as social services and palliative setting. 

 

Results:
Every quarter the practice receives an MOT report from the CCG, highlighting smoking cessation rates and hospital admissions. Currently we have the highest levels of smoking cessation within the CCG and also have the lowest levels of hospital admissions.  The number of people with respiratory disease discussed at gold standards meeting has increased, as has the number of patients with advance care plans and on the EPACCS template. We have also increased referrals to social services and third sector organisations. A small number of patients have also used the local hospice and one patient has moved to a nursing home, both of which have prevented admissions.

 

 

 

Conclusions:
The EQUIP worksheets are very quick and easy to use ensuring that patients receive the highest standards of care. Historically, resistance to discuss respiratory patients at GSF meetings has resulted in patients suffering with symptoms and struggling for longer. It is hard trying to change practice, but the worksheets have been invaluable at persuading clinicians without a special interest in respiratory care, that this is how patients should be managed.  There is still some reluctance to prescribe opioids for breathlessness and in Leeds we do not have a dedicated palliative care team for respiratory. The worksheets have also made us realise there is a cohort of patients that would benefit from a breathlessness service such as the Cambridge Breathlessness Service, so we have contacted the commissioners to try and make the case for change.