Improving adult asthma care: emerging learning from the national improvement projects

1. NHS
CANCER
NHS Improvement
Lung
DIAGNOSTICS
HEART
LUNG
STROKE
NHS Improvement - Lung: National Improvement Projects
Improving adult asthma care: Emerging
learning from the national improvement
projects

3. CONTENTS 3
NHS Improvement - Lung National Improvement Projects -
Improving adult asthma care: Emerging learning from the
national improvement projects
Contents
Foreword by Professor Martyn Partridge 4
Professor of Respiratory Medicine, Imperial College London and Senior Vice
Dean, Lee Kong Chian School of Medicine, Singapore (A joint school by
Imperial College London and Nanyang Technological University)
Introduction 5
The case for improvement work and a summary of the emerging
learning from the sites
Case studies 9
Acute Trusts
Guy's and St Thomas' NHS Foundation Trust 10
Reducing re-attenders at Accident and Emergency
Mid Yorkshire Hospitals NHS Foundation Trust 12
Asthma Care Bundles
University Hospital of North Staffordshire NHS Trust 14
An Integrated Care Pathway for Accident and Emergency
Community Respiratory Teams
Sandwell Community Respiratory Team 17
Reducing admissions and increasing community support
Clinical Commissioning Groups and Primary Care
Durham Dales Clinical Commissioning Group 20
Pharmacists and Medicines Use Reviews
ESyDoc Clinical Commissioning Group 22
An integrated approach to asthma care
NHS South West Essex Primary Care Trust 24
Targeted Medicines Use Reviews through a Local Enhanced Service
References 26
Acknowledgements 27

4. 4 FOREWORD
Foreword
Martyn R Partridge
At a time of financial stringency, it if there were one simple answer
is important that we deliver care in we would have implemented it
the most cost effective manner some time ago. However, I have
and this will often involve us found the observation of these
thinking outside the box and projects at this mid-point stage to
assessing new methods of be incredibly stimulating and
delivering care. When doing so it is invigorating, and I congratulate all
important that a full needs who have been involved in this
assessment is undertaken and that work. I look forward to the project
all stakeholders are involved and end in the summer when the full
where ever possible the innovation extent of the learning can be
has to be undertaken with a clear shared.
expectation that the enhancement
will be extrapolable, deliverable,
and sustainable.
In the first round of the NHS
Improvement - Lung asthma Martyn R Partridge
projects, colleagues have shown
remarkable innovation, Martyn R Partridge
perspicacity, and above all Professor of Respiratory Medicine,
determination to improve the care Imperial College London and
which they are delivering to their Senior Vice Dean, Lee Kong Chian
patients with asthma. School of Medicine, Singapore (A
It is inevitable that over the years a joint school by Imperial College
number of asthma projects have London and Nanyang
had varying degrees of success, for Technological University)

5. INTRODUCTION 5
Introduction
Background – the case for waste) to the NHS of these types of The improvement work
improvement medications in the UK is high. In May 2010, NHS Improvement –
Asthma is a respiratory condition Unlike COPD, asthma is not a Lung invited NHS organisations to
which affects between 3 and 5.4 condition in which patients will work in partnership on projects
million people in the UK deteriorate over time, but dedicated to improving the asthma
(Department of Health Outcomes unfortunately it cannot yet be cured. patient pathway and to help address
Strategy for Chronic Obstructive With optimal self-management the the variation in care that patients
Pulmonary Disease and Asthma: goal for nearly all people with receive. Projects plans were
2011) with approximately 80% of asthma should be to lead a normal, submitted from a number of sites
those being over 18 years of age healthy and active life, but this relies including acute Trusts, primary care
(Asthma UK). It is characterised by on a partnership approach between Trusts (PCTs) and community
inflammation of the airways leading the healthcare professional and the organisations to work in four key
to acute episodes known as patient in order to be truly areas of the pathway: improving
‘attacks’. These exacerbations can successful. The Outcomes Strategy asthma diagnosis and medicines
often be managed by the patient for COPD and Asthma (DH: 2011) optimisation, transforming acute
through medication and lifestyle noted that asthma is a condition care, chronic disease management
modification but from time to time which is very poorly controlled. It and integrated care.
can require treatment in Accident also highlighted the high number of
and Emergency or an admission to preventable admissions and lack of The primary aims of the projects in
hospital. In 2008/09 there were 49 adherence in published guidelines the national work stream are to:
054 emergency adult admissions for (the gold standard is the BTS- SIGN
asthma at a cost of £61 million to Asthma Guideline: 2011), despite • Define the patient’s pathway
the NHS, however it is currently the UK being a world leader in this • Identify and reduce variation in the
estimated that three quarters of field. delivery of care
these are preventable (Right Care • Challenge the system and test the
Atlas of Variation: 2011). The aim of the NHS Improvement – components of care that lead to
Lung asthma work stream is to test consistent and effective
Because asthma symptoms have which interventions have the biggest management of the condition
many similarities with other impact on patient outcomes and • Identify the success principles that
respiratory conditions there is often experience. This will help to ensure other organisations and teams
dual or misdiagnosis with other that people with asthma are could learn from and adopt.
illnesses such as COPD. Asthma is managed optimally in both primary
treated through a mixture of inhaled care and secondary care, to improve
‘preventer’ steroids which are taken patient outcomes and reduce the
on a constant basis and ‘reliever’ demands placed on emergency care.
bronchodilators which are inhaled in
the event of worsening symptoms.
Due to the plethora of drugs and
different combinations available for
respiratory patients the cost (and

6. 6 INTRODUCTION
During the ‘testing’ phase of the
programme, project teams are
exploring the reality of making this COMPONENTS OF CARE THE WORKSTREAM IS TESTING
happen by taking stock of current
practice and understanding the 1. Supportive self-management
process of implementation to ensure Hypothesis: A written self-management plan with ongoing support
patients receive optimal care in a increases a patient’s ability to better self-manage by providing
challenging environment. Prior to information on what to do when feeling unwell to mitigate symptom
commencing the work, the project escalation. This should lead to better patient outcomes, more patient
sites have been required to establish control when exacerbations occur and reduced need for a GP
their service baseline through appointment or an attendance at a hospital.
analysis of local qualitative and
Testing sites: All
quantitative data and to understand
the variation in services and quantify
2. Medicines Use Reviews (MURs) by appropriately
the aims they are working towards.
trained pharmacist
The project teams were trained in
Hypothesis: The MUR ensures optimal treatment and effective use of
service improvement tools and
medication with the patient. This should reduce medicines waste and
techniques including the ‘model for
spend as well as improving patient outcomes and reducing the need
improvement’ methodology and
for emergency primary or secondary care interventions.
held local events to process map
their current pathways. Testing sites: Durham Dales, NHS South West Essex
At this half-way point the teams 3. Defining and standardising care in the pathway according
have begun to remove duplication to the BTS-SIGN Guideline
and waste from the pathway or Hypothesis: The standardisation of care according to national
specific processes through different guidelines in an acute setting supports patient safety and quicker
ways of working and service patient recovery from illness which reduces the risk of re-attendance
redesign. They are testing small scale or readmission.
innovations using a Plan, Do, Study,
Act (PDSA) approach and are Testing sites: ESyDoc, University Hospital of North Staffordshire
measuring productivity gains on a NHS Trust, Mid Yorkshire Hospitals NHS Foundation Trust, Guy's
monthly basis to identify the impact and St Thomas' NHS Foundation Trust
of the improvements. During the
final six months the sites will 4. Access to assessment and review
continue to evaluate, learn and Hypothesis: Patients who receive education in self-management from
retest to refine models of care. clinically trained staff who have training in asthma are able to self-
manage more effectively and this will reduce the need for additional
primary care appointments and potentially reduce emergency
attendances and admissions.
Testing sites: All

7. INTRODUCTION 7
Summary of emerging learning • There is significant variation in the • There is recognition amongst
The emerging learning from the delivery of care and the both primary and secondary care
project sites to date demonstrates configuration of and access to clinicians that there are many
some of the practical challenges asthma care services around the opportunities for meeting the
around implementing those country. One example of this was productivity and prevention
elements of good asthma care that significant disparity in proactive agenda whilst improving the
we already know to be effective. follow up by GPs following receipt quality of services and outcomes
This highlights not only what works of discharge summary issued from for asthma patients. Data from
and how people are doing it, but the acute Trust (which in itself sites has identified opportunities
also what barriers still exist and varied from within 24 hours to for reductions in use of resource
where we still need to find solutions two weeks), which ranged from across the pathway, for example,
to enable people to adopt best every patient to none. in primary care - through
practice. systematic management of the
Every pathway contains differences asthma patient register and in
• Data is essential for improvement with varying adherence to the best secondary care, through targeted
and there is plenty of data practice national recommendations, intervention on those who
available to understand the current for example some GP practices in frequently re-attend or who are
circumstances and drive change. the projects supply limitless repeat readmitted.
However, it is important to take prescriptions, others only supply • A fundamental part of asthma
time to identify what data are one script to those patients who care is evidence-based supportive
most useful and to understand the are overdue for review and then self-management. Core
best way to present and use the no more until a healthcare components of this consistently
information. Consistently professional has seen the patient. include a primary care annual
recording and collecting relevant review, the delivery of education
data is also needed to allow Defining the current pathway with for patients (including inhaler
monitoring of the impact of any issues or gaps is essential to technique) by clinical staff with
changes in care and to highlight understanding the current state of specialist asthma knowledge in
any areas to target interventions the local services and along with appropriate healthcare settings
where appropriate. data provides the foundation for and the clear explanation and
• Managing a condition such as future improvement work. documentation of a self-
asthma successfully often requires management plan.
patients to draw on both primary • Standardised care – for example,
and secondary care. Testing sites through the use of templates,
are broadly supportive of the proformas, care bundles, CQUINs
emerging principle that integration (Commissioning for Quality and
between services is one way to Innovation payments) and
maximise use of local resources pathways – is strongly advocated
and manage patients more by all the project sites as a
effectively, however there are still potential solution to variation in
barriers around the practical steps the management of asthma and
needed to help organisations work a way of improving patient
more closely together. outcomes and experience of care.

8. 8 INTRODUCTION
Barriers and Issues • Traditional organisational
Clinical teams in each of the sites boundaries are often a barrier to
have been working on different completing the information loop
parts of the asthma pathway. Each to enable optimal patient
site has faced individual challenges management for example, follow-
and barriers however a number of up within 48 hours of discharge.
common themes have begun to Mapping the patient pathway with
emerge. all stakeholders present can often
reconcile differing procedures and
• Although clinicians understand the technologies between healthcare
components of optimal asthma providers to allow information
care and are familiar with the BTS/ exchange to be more timely and
SIGN Guideline there is effective.
widespread variation in adherence
to recommended practice. For Focus for the next six months
Phil Duncan
example, in the administration of This mid-term guide represents the
Director - NHS Improvement Lung
written self-management plans. halfway point in the progress of the
Although recommended, one project sites within the asthma work
project site found that less than stream. For the remainder of the
five per cent of their diagnosed time left the project teams will be
asthma patients had documented focussed on small testing of
and read-code recorded plans. innovation and improvement using
• Variation also exists amongst PDSA cycles in the four different
healthcare professional in the areas of the pathway: improving
management of the patient asthma diagnosis and medicines
journey specifically in secondary optimisation, transforming acute
care and in many cases no current care, chronic disease management
care pathway was available or and integrated care.
known to staff in the emergency
departments. The challenge will be to identify
• There is a difference amongst models of evidence-based best
organisations involved in the practice in each of these areas along
improvement work in the with practical solutions for Hannah Wall
understanding and the utilisation overcoming barriers and issues. The National Improvement Lead
of different healthcare providers final Asthma Improvement Guide
and the role they can take. For with all of the findings will be
example, in the use of pharmacists published in Autumn 2012.
and the sharing of information to
and from primary care around
Medicines Use Reviews.

9. CASE
STUDIES
ACUTE TRUSTS

10. 10 CASE STUDIES - ACUTE TRUSTS
Guy's and St Thomas' NHS Foundation Trust
Reducing adult asthma re-attenders at
Accident and Emergency
Background
Set in the heart of the capital city St Re-attenders - May 2010 to April 2011
Thomas’ A&E is one of the busiest and
largest departments of its kind in 30
England, seeing hundreds of emergency
patients every day. 25
20
Early in 2010 the respiratory nursing
Patients
team at St Thomas’ undertook a
15
snapshot audit of asthma attendances to
A&E, and this revealed a surprisingly high 10
30 day re-attendance rate of just below
30% and this highlighted a problem 5
which they wanted to improve upon.
0
MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR
Karen Newell, Respiratory Nurse 2010 2011
Specialist and project lead, felt that in Month
order to reduce re-attendances they
needed to work more proactively with
their asthma patients on discharge and
help healthcare professionals in A&E
increase their knowledge to feel more Data Ethnically most patients were white and
confident about working with asthma. A significant amount of quantitative and geographically most patients had a
qualitative data has been sourced in London postcode. In terms of method of
This project is supported by a myriad of order to help the project understand the presentation from the data available a
stakeholders including: the respiratory problem it is aiming to solve prior to significant proportion were brought in by
nursing team, Accident and Emergency implementing any potential solutions. ambulance and then went on to be
staff, the London Ambulance Service discharged from the A&E (60%).
(LAS), Lambeth and Southwark GPs and Quantitative data was derived from the
Asthma UK. hospital’s electronic patient systems. This Qualitative data was gathered by use of
revealed that in 2010/11, 94 patients re- semi-structured telephone interviews
Project aims attended at A&E for primary diagnosis of with a random sample from the 75
The primary aim of this project is to asthma. Of these, 19 were deliberately patients cohort. This revealed fascinating
reduce adult asthma re-attendances at excluded form the targeted cohort data around individual approaches to
A&E within 30 days by 20% of 2010/11 because they were always admitted due self-management, sources of information
baseline by May 2012 as an indicator of to the severe nature of their asthma (and and guidance, why patients attended
better control and quality of life. therefore not a suitable cohort for this A&E and what they felt they needed
type of intervention). from healthcare professionals.
The 75 remaining had made 218 Reason for attending A&E was mainly
attendances in the period. Of these, 143 because of an exacerbation (87%).
were re-attendances (16.1% of total However, 14% of the attendances
asthma attendances) and just over half document the patient had run out of
of these were re-attendances within 30 inhaler medication although the timings
days of previous visit (52%). The majority around this require further investigation.
who had two or more attendances Other reasons cited include: inability to
within 30 days were always discharged access GP and lack of knowledge of
from A&E. other out of hours providers.

11. CASE STUDIES - ACUTE TRUSTS 11
Achievements to date Successes and challenges
• 84 (of 94) A&E nursing staff have been • Bureaucratic process and time scales What’s next?
trained in inhaler technique so that e.g. setting-up the internal referral • Further analysis of the data to
they feel confident teaching and pathway involved many conversations understand the reasons behind the re-
assessing inhaler technique and favours from people attendance so that they can be even
• This has also led to the implementation • Unforeseen delays e.g. the asthma more responsive to the patient
of a placebo box and an updated proforma launch in A&E was delayed population
asthma folder, which includes the until the arrival of a set of drawers that • PDSA results from small scale testing
recently updated local asthma housed and paper form, the letter and of proforma, discharge letter and
guideline the leaflet in one place action plan and monitoring of
• An A&E asthma proforma (following a • Highlights have included: re- implementation e.g. audit of usage of
PDSA cycle) has been introduced back introducing the proforma in A&E, co- proformas
into use within the department to branding on the letter and the action • Work with the LAS to further
ensure that patients are cared for as plan, working with enthusiastic people understand ambulance call-outs for
per BTS/ SIGN Guideline, which and the gems revealed in the data. asthma.
includes a discharge checklist with
referral to GP within 48 hours, an Patient and Public Involvement Contact details
Asthma UK co-branded ‘Asthma A patient representative was present at Karen Newell
Patient to GP’ letter and blank self- the process mapping event and three Specialist Respiratory Nurse
management plan for the patient to patient representatives are sent the karen.newell@gstt.nhs.uk
take to a GP follow-up appointment monthly project report. The telephone
and an Asthma UK’s After Your interviews from the 75 re-attenders
Asthma Attack leaflet cohort involved eliciting the views of the
• The internal referral pathways into the patients.
severe/ difficult asthma clinic when
patients have experienced an acute
severe asthma attack or have difficult “I am really looking
asthma have been reviewed
• The external referral pathway has been forward to seeing the
reviewed and updated by way of an outcome of this project, as I
electronic flag on the patient record
that prompts the hospital staff to give think the impact will be
information on discharge including the extremely positive for a lot
GP referral letter
• A bespoke Asthma Action Plan has of people.”
been designed and sent to local GPs
for use - triple branded with Asthma Guy’s and St Thomas’ asthma patient
UK and NHS Improvement - Lung. (2011)

12. 12 CASE STUDIES - ACUTE TRUSTS
Mid Yorkshire Hospitals NHS Foundation Trust
Asthma care bundles
Background
Pinderfields General Hospital is one of Baseline re-admissions for Pinderfields 2010/11
three district general hospitals in the
region (along with Pontefract General 8
and Dewsbury General Hospital). The 7
hospital has recently moved into a new
Number of Patients
6
building which has created the
opportunity for respiratory patients to 5
enjoy state-of-the art facilities.
4
The respiratory team recently decided to 3
look at ways in which they could
2
improve care for asthma patients. They
had already established a designated 1
difficult asthma service and wanted to
0
impact upon admissions (Wakefield has APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR
the highest admission rates in the Month
region). Therefore the respiratory Patients
programme manager for NHS Wakefield
and District, Lisa Chandler, and a new
respiratory consultant, Dr James
McCreanor, considered this an ideal time
to implement a new asthma ‘bundle’ Project aims In 2010/11 there were 210 admissions to
(supported by a Commissioning for The high level aims of the project are: Pinderfields. Of these 60 (29%) were
Quality and Innovation payment - • To reduce asthma readmissions within readmitted for acute exacerbation of
CQUIN) to streamline and standardise 28 days of discharge by 20% from asthma within 28 days of previous
care asthma patients received at A&E, on 2010/11 discharge. A more recent audit (June and
the ward and at discharge. • To increase compliance with asthma July 2011) reviewed the performance
discharge through the bundle, in before the introduction of the care
particular: review of inhaler technique, bundle. From the 24 patients coded as
record of completed self-management having been seen for an exacerbation of
plan, record of recommendation for asthma in these two months, only 14
GP and/or specialist follow-up. were completed admissions. One patient
self discharged, one patient died, one
Data was an incorrect diagnosis and seven
A 2009 BTS asthma audit highlighted sets of notes were not available. Of these
that Pinderfields General Hospital re- 14, only one had a record of inhaler
admissions (within one month) were technique review (7%) and none had a
more than double that of the national self-management plan.
average (19%). The same audit also
highlighted a lack of education and
instruction to patients. Only 19% were
asked to see their GP following
admission and only 16% received a
written action plan, compared to the
national figures of 34 and 38%
respectively.

13. CASE STUDIES - ACUTE TRUSTS 13
The Mid Yorkshire project team (l-r) Jacqui Pollington,
Lisa Chandler and Dr James Creanor
Achievements to date Successes and challenges Patient and Public Involvement
• Diagnostic work around data including • The team found it difficult to get the Asthma UK patient representatives were
review of admissions, readmission and protected time needed to develop and part of the process mapping event.
length of stay pilot the care bundle
• A process mapping exercise and • Working with A&E staff to educate What’s next?
discharge case note audit to establish them on asthma and to implement the • An audit of records of patients
the cohort to focus on – 28 bundle has paved the way for future readmitted within 28 days is being
readmissions (more than one joint working undertaken to identify any themes that
admission and less than 10 admissions) • Process mapping afforded the chance appear to contribute to their
• Education for staff in A&E and on the to bring clinicians from different readmission
wards around the discharge checklist backgrounds and patients together to • The impact of the closure of Pontefract
• Agreement on universal patient envisage the whole pathway for A&E resulting in the majority of
information to be used across the Trust asthma sufferers patients being redirected to the
• A care bundle was piloted prior to • The support from the information Pinderfields site will need to be
launch (using a plan, do, study, act team is vital and excellent considered in terms of effect on data
approach) to allow for evaluation and • Using data and root cause analysis to • Monitor compliance with the care
refinement prior to widespread launch diagnose the right ‘problem’ was key. bundle at Pinderfields with regular
in November The data from previous years revealed reviews to identify and resolve risks or
• A patient satisfaction questionnaire is some concerns around length of stay issues.
now in use but more recent data showed this was
• A discharge letter for patients from no longer an issue. Further Contact details
A&E (adopted from St Thomas’ investigation revealed this has been Lisa Chandler
Hospital) is now in use. recently mitigated by a new hospital Respiratory Programme Manager –
wide in-reach team and so the focus Public Health NHS Wakefield
returned to readmissions. lisa.chandler@wdpct.nhs.uk

14. 14 CASE STUDIES - ACUTE TRUSTS
University Hospital of North Staffordshire NHS Trust
An integrated care pathway for A&E
Background
University Hospital of North Staffordshire Reason for A&E attendance
NHS Trust is currently spread across three
sites in Stoke-on-Trent serving a
population of approximately half a
million people in urban and semi-rural 12% 6%
Increased symptoms
areas.
Within North Staffordshire a ‘Fit for the Viral
Future’ transformation project and an
exciting move into a new Private Finance Infection
25% 38%
Initiative hospital have been developed
to improve people’s access to high Out of meds
quality healthcare. As part of the
reorganisation of emergency services an Severe patients
Urgent Care Centre has been embedded
within the A&E department and the
Clinical Decision Unit is expanding with 19%
the move with the potential to change
the usual care for adult asthma patients.
The UHNS emergency department was
one of 147 departments that took part
in the College of Emergency Medicine Project aims Casualty card data between 1 May and
(CEM) Asthma Audit in 2009/10. The The high level aims of the project are: 30 September 2011 revealed there were
results of the audit showed there were • To understand the current adult 48 attendances for asthma at A&E in
areas for improvement and the asthma asthma patient journey through A&E, that period. Thirty patients had not
clinical nurse specialist, Angela Cooper, the Clinical Decision Unit (CDU) and accessed a medical review immediately
and consultant physician, Dr Martin the Urgent Care Centre prior to attending the emergency
Allen, felt that the modernisation of the • To identify delays in patient care, department, 14 had experienced a mild
hospital facilities signalled the including those that can increase exacerbation, 33 experienced a
opportunity to begin looking at ways in length of stay and lead to admission moderate/severe exacerbation and one
which asthma care within acute to the Clinical Decision Unit had a life threatening exacerbation.
medicine, respiratory wards and the • Introduce a new adult asthma care
community as well as A&E could be pathway for use in A&E and across the The majority of attendances were female
improved by using better communication organisation which correlates with national findings.
and knowledge of patient flow. • To identify interventions which will The main reason for attendance was for
produce a 10-20% reduction in length an infective exacerbation or increase in
of stay. asthma symptoms. All patients attending
the emergency department received
Data nebulised bronchodilator as opposed to
The results of the CEM audit from metered dose inhaler and spacer delivery
2009/10 showed that A&E at UHNS was (contrary to BTS-SIGN Asthma
below the national average for several Guideline). Through reviewing casualty
key indicators such as measuring PEF and cards peak flows were recorded in most
respiratory rate on arrival. It was also patients but were not consistently done.
15% above the national average for
admissions.

15. CASE STUDIES - ACUTE TRUSTS 15
Accessing healthcare professional prior to attending A&E
35
30
30
Number of Patients
25
20
15
13
10
5
4 1
0
Not Same Earlier >One week
accessed day in week
HCP
Achievements to date • Early results from the patient • A&E attendances to be referred to the
• A process map of the patient journey satisfaction questionnaire who have respiratory nurse
through the emergency portals has already had intervention from the • Collate data from the care pathway
been completed asthma service are positive. and data analyst regarding
• A review and analysis of the A&E attendances, admissions and ength of
casualty card attendance data has Patient and Public Involvement stay to assess for changes and
been completed A patient has viewed and commented on improvements in care
• A patient focus group has elicited the process map (patient journey) and • Evaluate the success of the patient
comments, suggestions and themes written a report for NHS Improvement – forum; if beneficial consider
for areas of improvement Lung. Patient satisfaction questionnaires developing as a regular programme.
• The Integrated Care Pathway (ICP) has have been completed and returned by
been designed and a PDSA cycle has 58 of 100 patients who since May 2011 Contact details
refined the final version launched in have had support and intervention from Angela Cooper
January. the asthma team and a patient forum Asthma clinical nurse specialist
meeting was held on the 18 January angela.cooper@uhns.co.uk
Successes and challenges 2012 for those who had attended A&E
• The management of change and within the past 12 months.
moving into a new building has been
challenging What’s next?
• Locating casualty cards for analysis • The creation of an adult asthma
proved difficult patient database from A&E data
• The engagement of emergency care • Staff education and training sessions
staff along with acute respiratory on asthma for A&E staff
physicians and specialist nurses has • Audit of the use of the ICP in A&E
been encouraging • Semi-structured interviews with adult
asthma attenders

16. CASE
STUDIES
COMMUNITY
RESPIRATORY
TEAMS

17. CASE STUDIES - COMMUNITY RESPIRATORY TEAMS 17
Sandwell Community Respiratory Team
Reducing admissions and increasing
community support
“I was eventually referred
Baseline data on referrals 2010/11
to the CRS and since then, I
have received a brilliant, Inhaler check
personalised service by
Education
various members of the
Number of Patients
team. Their skills and SMP issued
professionalism performed Result - COPD
with a seven day per week Result - Asthma
home-visit service, has Sprirometry
enabled me to manage the
Total Referrals
condition and lead a
0 20 40 60 80 100 120
relatively normal life.” Interventions
Sandwell CRS Patient (2011)
Background Although the CRS were well utilised by Data
The Community Respiratory Service (CRS) the NHS for other respiratory conditions Sandwell’s GP registered population is
in Sandwell is a multidisciplinary team they felt that the time was right to do approximately 320,000. The borough
providing assessment, treatment and more to support the management of has a large ethnic minority population
management to those with respiratory asthma patients in the locality. with high levels of deprivation. There are
illnesses. The aims of the service (which 69 practices including three new Darzi
is now part of Sandwell and Birmingham Project aims practices and a walk in centre.
Hospitals NHS Trust) are to: reduce The three high level aims of the
avoidable admissions, minimise hospital project are: Sandwell and West Birmingham
length of stay and provide care closer to • To reduce adult hospital admissions of Hospitals NHS Foundation Trust provide
home for respiratory patients. asthma by 10% from 2010/11 baseline health care services for around 300,000
• To ensure that by May 2012, 80% of people, seven out of 10 who are Black or
Previously the majority of the referrals the patients on the CRS asthma Asian.
were for patients with COPD and low register will:
numbers of referrals for asthma were • have a confirmed asthma diagnosis In 2010/11 there were 106 referrals to
received from GPs and secondary care - using spirometry CRS. Baseline data showed room for
despite Sandwell having high prevalence • have a self management plan in significant improvement as:
(over 7% as measured by the Quality of place • Only 44 had diagnosis confirmed by
Outcomes Framework) and high • receive appropriate education spirometry
admission rates for asthma. • have a review and ensure correct • 19 were given a self-management plan
inhaler technique • 62 had their inhaler technique checked
Initial thoughts were that high asthma • regular reviews to ensure patients and were given education
attendance and admissions at the acute are managing their asthma • 0 had scheduled follow up.
Trust may be due to healthcare • To increase the referral rate of asthma
professionals in the area not referring patients into the service by 50%.
their patients to the team due to lack of
awareness of the service available.

18. 18 CASE STUDIES - COMMUNITY RESPIRATORY TEAMS
The number of admissions between 1 Successes and challenges • Electronic care plan to be uploaded to
May 2010 and 30 April 2011 at Sandwell • Creating electronic templates to ease SystmOne (electronic patient record)
General Hospital was 236, with 171 data collection and extracting data for all clinicians to use which will
admissions lasting for two days or less. that is actually a true representation of enable the team to report outcomes
Between 1 May 2010 and 30 April 2011 what has happened was challenging • Begin to audit case notes of the CRS
there were 638 A&E attendances due to and work is still in progress to ensure from May 2011 onwards to ensure
asthma. data is accurate compliance with the 80% BTS/ SIGN
• Manual review of case notes for Asthma Guideline compliance e.g.
Achievements to date baseline data was time consuming inhaler technique, self-management
• A process mapping session has been • Using the media to advertise the plan etc.
held and actions identified project. • Explore possible future models of care
• Baseline data on previous year’s based on a higher demand and begin
referral has been completed and Patient and Public Involvement to PDSA clinic sessions.
analysed Asthma UK and a patient and carer were
• An electronic asthma project data an integral part of the process mapping Contact details
collection tool has been developed event and a patient satisfaction Kelly Redden-Rowley
• Electronic care plans for SystmOne questionnaire ‘before’ and ‘after’ as part Respiratory Physiotherapist/ Clinical Lead
have been developed and are waiting of the project work. kelly.redden-rowley@nhs.net
for final approval
• The team has been trained in the use What’s next?
of the Professor Martyn Partridge self- • Complete the demand and capacity
management plan for all patients exercise and analyse data
• The referral criteria for the service is • Develop GP awareness
finalised poster/algorithm for GP’s consultation
• A meeting has been arranged with room inclusive of referral criteria and
A&E to develop pathways for referring process to encourage greater referrals
to the CRS team from primary care and target the GP
• A demand and capacity exercise has practices with high admission rates,
been instigated high prevalence and high medicines
• Spirometry is now being conducted on spend to raise awareness of the service
all those who meet criteria within • Meet with the A&E department
project scope lead nurse to develop awareness of
• A GP information leaflet has been service and referral pathway and
developed and printed. explore options for referral process

19. CASE
STUDIES
CLINICAL
COMMISSIONING
GROUPS AND
PRIMARY CARE

20. 20 CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE
Durham Dales Clinical Commissioning Group
Pharmacists and Medicines Use Reviews
Background
Durham Dales Clinical Commissioning Process mapping event at the Durham Dales
Group are a consortia of 12 GP surgeries
in the North East serving a population of
over 90 000.
In 2010, a small scale pilot between one
GP practice and one pharmacy was
undertaken over a three month period in
Bishop Auckland where pharmacists
offered a Medicines Use Review (MUR)
to asthma patients who had missed their
annual review and were over using
reliever inhalers. The initial data
suggested that over half of the patients
benefited from the service and this
evidence supported a bid to roll the
project out in other surgeries in the
consortia as an improvement project.
In May 2011, seven practices agreed to
take part and a joint working agreement
was established with pharmaceutical
company GlaxoSmithKline as a result of Project aims Achievements to date
their previous work in the locality on The high level aims of the project are: • This project was greatly aided by the
COPD. The lead pharmacist, Patricia • To up skill health care professionals in introduction of the new national
King, from the original pilot work then the participating practices in their pharmacy contract which came into
approached pharmacists which understanding and management of force on 1 October 2011 which meant
neighboured participating practices and asthma patients consistent with the that respiratory patients became one
as a result 15 pharmacies are now taking BTS/ SIGN Guidelines and to ensure all of four key groups pharmacists are
part. those involved in delivering MURs are now asked to specifically target for
trained and competent to do so MURs.
• For participating pharmacists - to
undertake 500 MURs in total The main achievements of the project to
• For patients to have increased date are:
awareness and understanding of their • Process map completed with
conditions and be able to be stakeholders
responsible for their own disease • Three cohorts identified for
management. pharmacists to target: those who
missed their last annual review, those
Data on more than 1000mg of inhaled
There are currently 56,172 patients corticosteroids and those who have
registered with the seven participating been prescribed more than six blue
GP surgeries with a total of 3,698 reliever inhalers in one year (from
patients on their asthma register (a pharmacist own records)
prevalence of 6.6%).

21. CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE 21
• All participating pharmacists have been Patient and Public Involvement
trained by GSK on delivering asthma An asthma patient representative is part
MURs e.g. inhaler technique, self- of the Project Steering Group which
management plans, use of the Asthma meets monthly and has been at all other
Control Test questions etc. events associated with the improvement
• A patient satisfaction questionnaire is work e.g. process mapping day.
being given to the patient prior to an
MUR and then sent to the patient six What’s next?
months after • Continue to engage with the
• Letters are being sent out to patients pharmacies on a monthly basis to
on the surgery asthma registers who ensure data is being returned to the
are identified as have not attended project team and sufficient numbers of
their last annual review asking them to MURs are being done
see either their GP or pharmacist • Visit each pharmacy to discuss the
• A schematic is available for project and process and offer further
pharmacists in the delivery of an MUR support
and for any follow up • Organise and deliver educational
• A monthly MUR reporting form has session for all pharmacists and
been designed and trialled for dispensing practice lead to distribute
pharmacists to use in order to record lung models and train on how to use
how many MURs they have them
undertaken to send back to the • Work with practices to extract their
relevant GP surgeries and the Durham data, analyse and collate information.
Dales CCG Project Manager
• A monthly newsletter is sent out to all Contact details
participating GPs and pharmacies. Vikki Reed
Project Manager – Durham Dales Clinical
Successes and challenges Commissioning Group
• Confidentiality issues with GP practices victoriareed@nhs.net
sharing patient identifiable information
with pharmacists has resulted in an Kathryn Kemp
opportunistic rather than proactive Integrated Healthcare Manager –
approach to patient lists GlaxoSmithKline
• Another pharmacy contract Kathryn.x.kemp@gsk.com
requirement – the New Medicines
Service – is impacting on pharmacists’
capacity to undertake the MURs with
targeted asthma patients
• The engagement and enthusiasm of
the participating pharmacists has made
joint working easy and the GSK
mentoring of pharmacists has been
very well received.

22. 22 CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE
ESyDoc
An integrated approach to asthma care
Background
ESyDoc is a Clinical Commissioning
Group of 19 practices in Surrey covering
a population of around 170,000.
Dr Vijay Kumar, a GP at Birchwood
Practice, had already led a successful
project on improving COPD care within
the consortia during 2009. Through
further analysis of the COPD data they
discovered that variation in asthma care
existed across the ESyDoc patient
population and felt the time was right to
address the issues.
Given the success of their earlier joint
work in 2010 they decided to undertake
an improvement project in conjunction
with Sussex and Surrey Hospitals NHS
Trust. The project is also supported
through a formal joint working
agreement with pharmaceutical
company AstraZeneca.
As an extension of these beliefs the Data
Project aims project is focussed on four key work ESyDoc have 18 practices which each
ESyDoc and their partners firmly believe streams with their own aims. These are: hold an asthma register. The registers
that: asthma is controllable, there should have been searched for patients who are
be no unnecessary deaths from asthma 1. Diagnosis – increasing the prevalence aged 18 years or over and potentially fall
and that a secondary care respiratory of asthma from 5.3 to 5.8% through into one or more of the four cohorts (see
clinician should be consulted if there is a proactive case finding and analysis of pyramid above – red, amber or green
decision to admit an asthma patient who practice registers denotes priority to be seen in clinic).
presents at A&E. 2. Chronic Disease Management –
inviting cohorts one, two and three Surrey and Sussex Hospitals NHS Trust is
(see pyramid above) in for a structured the main acute site for the area and
review in line with the BTS/ SIGN services a total population of 400,000
Asthma Guideline, and ensuring that patients. Last year there were 86
at least 75% of all those invited are admissions with a primary diagnosis of
seen in asthma clinics and that 50% asthma.
of those seen leave with an up-to-
date action plan
3. Medicines Optimisation –
optimising medication for patients
4. Transforming acute care –
standardising care pathways and
reducing admissions by 10% in the
acute Trust.

23. CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE 23
• The A&E attendance data is not easily
The ESyDoc project team visible which has made it difficult to
create a baseline
• All constituent practices have signed
up to the project.
Patient and Public Involvement
All patients that have attended the pilot
clinics as part of this project have
received and completed a questionnaire
pre and post appointment and this will
continue when further clinics are run
until the end of May 2012. Patient
representatives were present at the
process mapping events and attend all
the project steering group meetings.
What’s next?
• Focused communication for all
stakeholders
• Newsletter for all practices
• Re-run and analysis of the data from
the registers
Achievements to date • A pre and post clinic patient • Continue with post clinic evaluations
• Three process mapping events have questionnaire has been launched • Acute Integrated Care Pathway
mapped the diagnosis pathway, the • A&E attendance data is being monitoring and evaluation
routine care pathway and the acute identified and compiled into an • Identification of work stream
pathway information format to ascertain the monitoring i.e. what data to capture,
• The identification of patients within baseline position, understand the when and how
defined cohorts and inclusion criteria demand/need and set goals for • Host clinical workshop to highlight
• A clinical lead has been identified in reduction aims, objectives and to raise awareness
each constituent practice • A new asthma care pathway has just • Development of an asthma data
• A small scale pilot of review clinics been launched at the acute Trust. dashboard
(using a PDSA approach) has been • Appropriate and timely education for
undertaken to evaluate a standard Successes and challenges clinicians
template and the use of the Professor • Variability in the use of self- • Review lessons learned and refine
Martyn Partridge or Asthma UK self- management plans with patients has patient pathways.
management plan prompted the project team to ensure
• Specific asthma clinics in every all practices are using either the Contact details
constituent practice throughout Professor Martyn Partridge or the Dr Vijay Kumar
ESyDoc have been created Asthma UK self-management plan GP - Birchwood Practice
• The care planning approach has been • Initial register searches showed Vijay.Kumar@gp-h81037.nhs.uk
agreed with both patients and conflicting data regarding numbers of
clinicians asthma patients on QOF and what the
• Training opportunities have been Quintiles search had extracted (as
advertised to all clinical staff in the requested by AstraZeneca). This was
practices remedied by re-running the data set
with improved filters to enable
increased data integrity

24. 24 CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE
NHS South West Essex
Targeted Medicines Use Reviews (MURs)
using a Local Enhanced Service (LES)
Background Project aims • Generated, proofed and prepared
There is currently a high prevalence of The overarching aims are to: improve standard proformas for the directed
asthma and significant asthma related care, reduce morbidity and impact on MUR, generation of a care plan
secondary care activity within the secondary care resource use through (Professor Martyn Partridge version),
primary care Trust borders. Access to service delivery via community recording of data, patient consent,
medical practitioners is variable and pharmacies. collection of data (electronically)
there is significant potential opportunity around current medication and
to improve asthma care. The specific aims with regard to the 400 reporting back to the LPC.
MURs and the LES agreement are to:
This work was initiated at the request of • Improve patients’ adherence to their Successes and challenges
medicines management driven by asthma treatment regimen through a • Since the initial project plan in May
feedback from GP practices and number of extended education and 2011 there have been changes in the
community providers regarding the sorts support interventions community pharmacy national contract
of problems they were having in • Reduce asthma medicines waste, (introduction of the New Medicines
reviewing and following up some hard- including through poor compliance Service and the MUR targets in
to-reach asthma patients. and prescription management October 2011). This development has
• Reduce inappropriate prescribing, delayed the start of the asthma project
It was suggested that pharmacist including unconventional regimen and but there have been some benefits:
engagement - through use of Medicines over-prescribing much of the original training outcomes
Use Reviews - would ease difficulties • Reduce avoidable unscheduled and planned for project sites are met by
practices were having in accessing secondary care activity for primary care the training workshops and
certain patients. Pharmacists have a high asthma patients. accreditation requirements for NMS,
level of contact with residents in the PCT and as asthma is one of the eligible
area and are engaged in a whole range Data clinical conditions for both NMS and
of service delivery. They also speak a In 2009/10 there were 400 056 people targeted MURs participants will have
range of languages which will assist in registered with the 78 GP surgeries in completed relevant continuing
targeting some of the hard to reach South West Essex. The asthma professional development on this topic
groups. prevalence in the PCT was just over 6% • The inclusion of South Essex as a
and there were 309 emergency Healthy Living Pharmacy Pathfinder site
The project itself is a collaborative admissions. has again delayed the implementation
between the Local Pharmaceutical of the project but it does mean that
Committee (LPC), the PCT, Medicines Achievements to date the sites involved in both projects will
Management, GP practices, community • Process mapping of current pathway in have Health Champions among their
services and consultants from the acute June 2011 support staff who may be well placed
hospital. Eight pharmacies in the local • Undertaken a ‘world café’ (a method to approach customers and initiate
area who are already part of the which makes use of an informal cafe conversations about the service, and
Department of Health ‘Healthy Living’ for participants to explore an issue by the pharmacists involved will have
initiative have signed up to a local discussing in small table groups) with completed appropriate leadership
enhanced service (LES) agreement to community pharmacists to canvass the training to consider best use of skill
deliver at least 400 MURs to asthma level of interest and willingness to mix
patients collecting scripts. engage in this work • The prescribing and admissions data
• Identified eight pharmacies who are obtained from the PCT information
part of the ‘Health Living Initiative’ team is not suitable for the size and
with track record of service delivery, scope of this project, and therefore a
particularly extra-contractual, centred greater emphasis will need to be
around cardiovascular health checks, placed on pharmacy Patient
for further training and support Medication Record (PMR) data and
• Delivered a training session and patient follow-up interviews for
resource pack to up-skill pharmacists meaningful reporting and evaluation
and staff to undertake the enhanced of the project.
work

25. CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE 25
Patient and Public Involvement
The service has a built in element for
both patient satisfaction and data
capture of patient reported outcome
measures (e.g. shortness of breath,
difficulty with normal activities, number
of times patient has had to resort to use
of rescue plan) as part of the MUR+
process.
What’s next?
• To deliver training to staff and
pharmacists in time for January
initiation of project
• To continue to monitor performance
monthly and feedback to practices of
practitioner’s progress and learning
derived from project delivery, and to
feed these into the QIPP agenda.
Contact details
Balbir (Bill) Singh Sandhu
Associate Director /Head of Medicines
Management
Balbir-singh.sandhu@swessex.nhs.uk

26. 26 REFERENCES
References
COPD and Asthma Outcomes Strategy for England and Wales (DH: 2011)
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd
Guidance/DH_127974
Asthma UK
www.asthma.org.uk
NHS Atlas and NHS Right Care (Problems of the Respiratory System, Atlas of
Variation: 2011 version)
www.rightcare.nhs.uk/index.php/nhs-atlas/atlas-downloads/
British Guideline on the Management of Asthma (BTS/ SIGN: 2011)
www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspx
Professor Martyn Partridge asthma action planning software
www1.imperial.ac.uk/medicine/people/m.partridge/

27. References
Acknowledgements
NHS Improvement - Lung would like to thank all national improvement project sites
for their hard work and dedication to improve quality and care for people with
asthma, and for their contributions to this document.
In addition, the following people have provided a source of expertise and support
and their help is gratefully acknowledged:
Professor Martyn Partridge
Professor Sue Hill – National Clinical Director for Respiratory Services
Dr Robert Winter - National Clinical Director for Respiratory Services
Members of the Asthma Clinical Project Steering Group: Dr Bernard Higgins,
Jan Gould, Dr Dermot Ryan, Dr Mike Thomas and Simon Selo (Asthma UK)
Kevin Holton, Department of Health Head of Policy for Respiratory Services
Bronwen Thompson, Department of Health Policy Lead for Asthma
Phil Duncan, Director, NHS Improvement - Lung
Catherine Blackaby, National Improvement Lead, NHS Improvement - Lung
Ore Okosi, National Improvement Lead, NHS Improvement - Lung
Catherine Thompson, National Improvement Lead, NHS Improvement - Lung
Zoë Lord, National Improvement Lead, NHS Improvement - Lung
Alex Porter, Senior Analyst, NHS Improvement - Lung
For more information please contact
Hannah Wall, National Improvement Lead for Asthma
Email: hannah.wall@improvement.nhs.uk

28. NHS
CANCER
NHS Improvement
DIAGNOSTICS
HEART
LUNG
STROKE
NHS Improvement
NHS Improvement’s strength and expertise lies in practical service improvement. It has over a
decade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lung and
stroke and demonstrates some of the most leading edge improvement work in England which
supports improved patient experience and outcomes.
Working closely with the Department of Health, trusts, clinical networks, other health sector
partners, professional bodies and charities, over the past year it has tested, implemented, sustained
and spread quantifiable improvements with over 250 sites across the country as well as providing
an improvement tool to over 1,500 GP practices.
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Publication Ref: IMP/comms031 - April 2012
improvement agenda
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