This document summarizes projects undertaken by various NHS organizations in England to improve adult asthma care. It provides an overview of common challenges in asthma management and potential solutions tested by different projects. These include standardizing care according to clinical guidelines, validating patient registers, conducting annual patient reviews, supporting self-management, and taking integrated, multidisciplinary approaches. The document highlights emerging principles for successful service improvement, such as understanding the current patient pathway, collecting baseline data, collaborating across disciplines, and involving patients. Case studies from acute trusts, community teams, and clinical commissioning groups provide examples of specific changes tested.

1. NHS
CANCER
NHS Improvement
Lung
DIAGNOSTICS
HEART
LUNG
STROKE
NHS Improvement - Lung
Improving adult asthma
care: Testing the case for
change

2. NHS Improvement - Lung
Improving adult asthma care: Testing the case for change
Contents
Asthma Project Pathway 3
Foreword by Professor Martyn Partridge 4
Professor of Respiratory Medicine Imperial College London, Senior Vice Dean,
Lee Kong Chian School of Medicine Singapore and Chairman DH Asthma Steering Group
Support from Asthma UK 5
Introduction 6
Case studies 12
ACUTE TRUSTS
Guy’s and St Thomas’ NHS FoundationTrust (GSTT) 14
Mid Yorkshire Hospitals NHS Trust (MYHT) 16
University Hospitals of North Staffordshire NHS Trust (UHNS) 18
COMMUNITY RESPIRATORY TEAMS
Sandwell Community Respiratory Team 19
CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE
Durham Dales Clinical Commissioning Group 21
ESyDoc Clinical Commissioning Group 23
References 26
Acknowledgements 27

3. 3
ASTHMA PROJECT PATHWAY
BTS/SIGN ASTHMA GUIDELINE
DEPARTMENT OF HEALTH COPD ASTHMA OUTCOMES STRATEGY
DEPARTMENT OF HEALTH GOOD PRACTICE GUIDE
NICE GUIDELINES
SELF-PRESENT
CHRONIC DISEASE
DIAGNOSIS ACUTE CARE
MANAGEMENT
REFERRED
REGISTERS STANDARDISED CARE
Sandwell
ESyDoc GSTT (attenders), UHNS,
MYHT (CQUIN), ESyDoc
PRO-ACTIVE ANNUAL REVIEW
CASE FINDING DISCHARGE/REFERRAL
ESyDoc
ESyDoc GSTT (attenders), UHNS,
MYHT, ESyDoc
MEDICINES
Durham Dales FOLLOW UP
PATIENT INVOLVEMENT
Sandwell, ESyDoc,
ASTHMA ACTION GSTT (attenders), MYHT
QUESTIONNAIRES
ESyDoc, Sandwell PLANS
GSTT, MYHT, UHNS,
PATIENT PANEL ESyDoc, Sandwell
GSTT
PATIENT REPRESENTATIVES
COMMUNITY
Durham Dales, ESyDoc
SUPPORT
FOCUS GROUPS Durham Dales,
UHNS Sandwell

4. 4 FOREWORD
Foreword
Asthma remains a major health burden in England. The
General Practitioner Quality of Outcomes Framework
Registers suggest that 5.9% of people were receiving asthma
treatment last year and the 2010 Health Survey for England
suggested a higher figure with as many as 9.5% of adults
and children having asthma and being on treatment.
Whilst we have some solid evidence that care has been improving in that death
rates and hospitalisation rates have fallen, there is also some evidence that this
decline is now plateauing. Any improvement that was achieved may reflect the
efficacy of modern treatments and in the UK we have been helped by the
presence of first class evidence based BTS/SIGN Asthma Guideline to direct and
advise us as to optimal care.
However, there is growing evidence We can see from the case studies the
that we often fail to implement tremendous amount of work which is
optimal care and this is perhaps most being done around the country to
obvious in the non-prescription parts ensure best care for all. These projects
of care. Living with a long term cover important aspects of asthma care Martyn R Partridge
condition like asthma necessitates from: more accurate diagnosis to Professor of Respiratory Medicine,
Imperial College London and Senior
good support from a health care optimal prescribing to focusing on the Vice Dean, Lee Kong Chian School
professional who listens, responds to most at risk to help them make the of Medicine, Singapore (A joint
concerns, explains the condition fully most use of health service resources. school by Imperial College London
and who involves the patient in We can all learn from these reports to and Nanyang Technological
University)
decisions regarding management. extend and extrapolate them and
When care of this sort is offered the hopefully evaluate them in other parts
outcomes are noticeably better. of the country.
NHS Improvement has overseen a I offer my sincere congratulations to
superb range of service enhancements all who have been involved in this work.
to really ensure that best possible care
is given to all with asthma and this
report summarises those projects.

5. SUPPORT FROM ASTHMA UK 5
Support from Neil Churchill,
Chief Executive, Asthma UK
The successful projects demonstrate clearly how
asthma outcomes can be improved in a short
space of time if there is energy, integration and
innovation.
They have shown the rest of the NHS what can be done.
We will be working with the Department of Health, NHS
Improvement and Regional Respiratory Boards to push for further
change, particularly in areas where emergency admissions are high.
The projects are a model for the NHS to replicate.
Neil Churchill
Chief Executive, Asthma UK

6. 6 INTRODUCTION
Introduction
Case for change – the current of asthma medications are wasted evidence and learning from the work
position of asthma services in through non-adherence and lack of undertaken by the national asthma
England effective inhaler technique. improvement projects over a 12 month
Asthma is a respiratory condition that period in 2011/12 as part of the
affects approximately three million NHS Improvement – Lung worked with asthma workstream within the NHS
people in the UK. Recorded prevalence clinical teams across England Improvement – Lung programme.
is around 5.9% but estimates suggest supporting them in identifying, testing
the true figure could be nearer 10% - and implementing the changes needed Improvement approach
one of the highest in the world. to their asthma service in order to have NHS Improvement – Lung invited NHS
The cost to the NHS is put at around the greatest impact on the patient organisations to work in partnership
£1 billion with the majority of the pathway and improve the care for their on projects dedicated to improving the
spending on respiratory medications patients. asthma patient pathway to help
and about £61 million on emergency address the variation in care that
admissions (DH: 2011). The first year of project work focussed patients receive. Successful sites
on four key areas: diagnosis and included acute Trusts, primary care
Although asthma cannot be cured it medicines management, chronic organisation and community providers
can be effectively treated and disease management, transforming who worked over a 12 month period
managed and the goal for nearly all acute pathways and an integrated with a variety of aims under four main
asthma patients should be to lead a pathway approach. Local goals pathway areas. These were:
symptom free life supported by health combined with the NHS Quality,
care services in their local area. This is Innovation, Productivity and Prevention 1. Diagnosis and medicines
reinforced in Objective Six within the (QIPP) agenda gave additional context optimisation
Outcomes Strategy for COPD and to the work and provided an 2. Chronic disease management
Asthma in England (DH: 2011). opportunity for clinical teams to 3. Transforming acute care
engage commissioners and health care 4. Integrated pathways
Variation in the provision of asthma providers in new and different thinking
services and non-compliance with gold about asthma service delivery. Focus was given to the removal of
standard guidelines increases the duplication and waste from the
potential for poor quality outcomes This publication is aimed at healthcare pathway, improving specific processes
and waste. For example, when looking professionals, commissioners, patients through different ways of working and
at medicines use it has been estimated and other key stakeholders involved in to improving patient experience of
that anywhere between 45 and 70% asthma services. It draws together the asthma services.

7. INTRODUCTION 7
Through improving self-management, teams a period of ‘diagnosis’ then • Cleaning and validating diagnosis in
standardising care, training and followed in order to allow teams to asthma patient registers in primary
education and involving other health understand the patient pathway and care
professionals with asthma services, dispel assumptions about the process, • Greater adherence to the gold
three of the six project teams its challenges and the solutions. standard BTS/SIGN Asthma Guideline
collectively made savings of over Potential improvement ideas were • Educating and training respiratory
£80,000 against agreed targets with tested using a plan, do, study, act cycle staff who come into direct contact
the Programme at the start of the with ongoing measurement to with asthma patients.
work. There were also significant evaluate the impact of the
additional savings achieved by interventions and refine where Whilst each project site has worked on
reaching locally defined targets. appropriate. a different part of the asthma pathway
a number of key themes have
During this ‘testing’ phase of the Common challenges and solutions emerged across the asthma project
national programme, the project teams Clinical teams at all sites have been sites which has enabled the
have explored the reality of making focussed on specific aims which have development of the following top tips
local service improvements by taking included: for improving asthma services:
stock of current practice and
understanding which processes deliver • Improving self-management by
optimal patient care in a challenging increasing the use of self-
environment. The projects adopted a management plans and optimising
systematic approach to quality inhaler technique
improvement to ensure that any • Standardising care in the patient
changes implemented were thoroughly pathway - in primary care annual
tested and measured. review, community team follow-up
and during an acute episode e.g. in
Prior to commencing the work the A&E and during admission
project sites were required to establish • Utilising health care providers to
their service baseline through analysis support self-management – by
of local data and to understand any increasing and standardising the use
variation present. Upon the of Medicines Use Reviews by
establishment of individual project community pharmacists

8. 8 INTRODUCTION
ACUTE
Agree a mechanism for standardising and monitoring care
Standardised care which adheres to the BTS/SIGN Asthma Guideline increases equality of treatment, aids staff in patient
management and improves outcomes for patients. It can also help to meet other standards and national audits e.g. the
BTS/SIGN audit and College of Emergency Medicine audit. For further details on examples of standardised care
such as proformas for A&E, bundles and integrated care pathways and how to monitor them see the
ESyDoc, GSTT, MYHT, UHNS and Sandwell case studies.
ACUTE
Make sure every patient has had the key components of care on discharge
Discharge ‘checklists’ are a key tool in reducing re-attendances and readmissions. A good discharge process would
ensure every patient doesn’t leave without being: advised they need a follow up with their GP within two days, shown
correct inhaler technique and had their medication checked, advised about other out of hours providers available and
referred for smoking cessation – if needed. For examples of good practice on discharge see the ESyDoc, GSTT,
MYHT and UHNS case studies.
PRIMARY CARE
PRIMARY CARE
Validate your patient registers
‘Clean’ registers e.g. diagnosed Make sure every asthma patient has an annual review and
patients with correct read coding chase up patients who DNA
are essential in order to be able Annual reviews are an essential part of asthma patient management and
to: run searches to identify should be standardised within practices so every patient receives equal time
cohorts of patients, for example and input. Qualitative data suggests patients find their review more effective
in order to stratify into degrees if conducted by a clinician with specialist knowledge in asthma – rather than
of risk, call the correct patient for a generalist. For more information on review templates for clinical
their annual reviews and to staff and self-management plans see the ESyDoc case study.
analyse data for QOF purposes.
There are tools available to help
you understand your data. These PRIMARY CARE
are available from pharmaceutical
companies or from local data Consider limiting repeat prescriptions to patients who have had an
analysts. Look at the number of annual review in the last 12 months with others continuing to
patients on asthma medication receive prescriptions for regular preventative therapy but being
without an asthma diagnosis or limited to a single SABA reliever inhaler until reviewed by telephone
the number of self-management or face-to-face
plans recorded as issued for Asthma medications cost approx £850million a year and it is estimated that
potential areas to start with. See between 45-70% of this is waste and non-adherence. If your practice issues
the ESyDoc case study for repeat prescription consider how your policy ensures that patients receive
further information. their prescriptions but are also encouraged to have an annual review.

9. INTRODUCTION 9
PRIMARY CARE
Work with other health professionals to maximise asthma self-management
Community nurses and pharmacists have a vital role to play in helping asthma patients self-manage For example, a
Respiratory Nursing Service can support GP practices who do not have dedicated asthma services and the New
Medicines Service and the Medicines Use Reviews Service offered by local pharmacists are prime examples of wider
support. Pharmacists can appear less daunting to patients and often know the local community and cultures very well.
Examples of case studies on this are Sandwell, Durham Dales and SW Essex.
EVERYONE EVERYONE
Involve asthma patients in the redesign of asthma services Set minimum levels of
A fundamental principle of improvement work is to understand your awareness and competencies
problem before you start implementing solutions. For example, if you have for non-respiratory clinicians
high clinic DNA rates, A&E attenders or readmissions, look at individual who have regular contact with
patient records and ask patients why they behave the way they do. This will asthma patients.
help to really create solutions which will help to solve the problem. Asthma patients regularly come
For more information on how to understand your problem, patient into contact, often in an
involvement and how to test solutions on a small scale see the GSTT emergency, with staff who do not
and ESyDoc case studies. routinely work in respiratory care
e.g. A&E clinicians, paramedics.
This can have a significant effect
on patient outcomes. There are
EVERYONE resources available for all levels of
training, from ‘paid for’
Take a multidisciplinary approach to asthma management qualifications to free online
If you want to improve your asthma service its vital to involve other guides. Case study examples
organisations. Problems are rarely ‘stand-alone’ for a service or Trust and you of different levels of training
may meet with limited success if the patient pathway relies on involvement in practice can be found in
from other providers in primary or secondary care. For examples and ESyDoc, Durham Dales, GSTT
integrated working see ESyDoc and GSTT case studies. and MYHT.

10. 10 INTRODUCTION
Project outcomes: Emerging All the asthma services mapped the 3. Clinicians and managers
success principles and project patient pathway in order to reviewing data together - access to
learning understand where and how their and effective use of data through
NHS Improvement - Lung provided improvement work was needed. All collaboration between clinical and
structured support to project teams sites collected 12 months baseline data managerial staff enabled the project
enabling them to solve problems by relevant to the aim of their projects teams to better understand the patient
addressing root causes and by e.g. admissions, A&E attendances. pathway and demonstrate the impact
undertaking a systematic approach to Primary care asthma projects used GP of any change. The routine collection
service improvement. Teams across the asthma patient registers and searches and review of data was important in
different workstreams of the national of medications usage to identify implementing sustainable
programme worked through a number patients to target whereas acute Trusts improvements and understanding
of different challenges in order to and community providers used patient outcomes of any service
achieve their project aims. However administration systems and case note improvements.
some common principles have audits to gain a good understanding
emerged as critical success factors in of the target cohort. All sites had Asthma teams worked with non-
all national lung projects: patient and public involvement. clinical colleagues to understand the
local data relevant to their target e.g.
1. Defining and gaining a good readmissions, number of MURs
understanding of the whole 2. Taking an integrated approach completed, number of annual reviews
pathway of care - having a complete to service development - issues and completed. Data was collected on a
understanding of the care pathway challenges viewed in isolation without monthly basis to determine if
supported by robust data to due consideration to the whole patient improvements were impacting upon
demonstrate the effectiveness of pathway were less likely to lead to outcomes so that project plans and
current processes, quantifying sustainable improvements in care actions could be adjusted accordingly.
performance and variation is essential provision.
when embarking on improvement 4. Identifying the key levers and
work. This allowed organisations to Individual asthma project work needed drivers in the system – by
identify priorities for change and also to be viewed within the context of the integrating local and national priorities
to benchmark themselves with others wider respiratory care pathway in into the work such as Quality,
locally and nationally. order to maximise the opportunities Innovation, Productivity and Prevention
for integrating with services to ensure (QIPP) raised the profile and priority of
patients receive optimal and
coordinated management of their
asthma overall.

11. INTRODUCTION 11
the project work with decision makers Future work adherence to guidelines, optimising
and helped to achieve improved In the forthcoming year of the NHS patient medications and standardising
engagement from senior management Improvement – Lung programme care in both primary and secondary
teams. project work sites will be building on care settings.
the learning from the ‘testing’ phase
The QIPP agenda and the publication of the work on both COPD and
of the Outcomes Strategy for COPD asthma. Emerging principles from
and Asthma (2011) provided an work in both these disease areas will
opportunity for clinical teams to be refined and successful principles
engage other clinical and non-clinical that demonstrated the greatest impact
stakeholders in a new dialogue about on the patient pathway during the
asthma services. past year will now be combined and
prototyped in the following key areas
5. Value for money - there was a of the patient pathway.
need to identify and understand the
gaps, duplication and waste in the • Medicines management and
patient pathway in order to make best optimisation for respiratory
Phil Duncan
use of available resources. It was conditions Director - NHS
essential to work and communicate • Risk stratification and identification Improvement Lung
with colleagues, commissioners and of patients for regular standardised
other stakeholders in service provision review in primary care
in order to maximise these resources • Acute care pathways and
and to ensure a consistent and co- standardising the patient journey
ordinated approach to care from A&E to discharge.
Commissioning and medicines The testing phase work demonstrated
management colleagues worked that there are many potential cost
closely with some of the asthma efficiencies which can be realised in
services to identify prescribing policies. practice. It is anticipated that the
All sites worked on their pathways to prototype phase of work will further
address waste and to reduce variation. demonstrate the importance of Hannah Wall
National Improvement
Lead

12. 12 CASE STUDIES

13. CASE STUDIES 13
CASE
STUDIES

14. 14 CASE STUDIES - ACUTE TRUSTS
Guy's and St Thomas' NHS Foundation Trust
Reducing adult asthma re-attenders at
Accident and Emergency (A&E)
What was the problem?
Early in 2010, the respiratory nursing 28 day adult asthma re-attenders at GSTT
team at St Thomas’ undertook a
snapshot audit of asthma attendances to
10
A&E, and this revealed a surprisingly high
30 day re-attendance rate of just below 8
30% and this highlighted a problem
which they wanted to improve upon.
Patients
6
What was the aim? 4
The primary aim of the project was to
reduce adult asthma re-attendances at 2
A&E within 28 days by 20% of 2010/11
baseline as an indicator of better control 0
MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR
and quality of life. Additional aims were:
Month
• to improve patient control through self 2010/11 2011/12
management plans;
• to increase healthcare provider
knowledge and confidence; and
• to reduce unscheduled hospital
attendance. the best possible care for this cohort of • an A&E asthma proforma within the
asthma patients. This was achieved by department to ensure that patients are
What has been achieved? in depth diagnostic work to reveal the cared for as per BTS/SIGN Asthma
Re-attenders at A&E have fallen by 45% causes of re-attendance through: Guideline, which includes a discharge
from the previous year. examination of A&E data to establish the checklist with referral to GP within 48
target cohort, an audit of A&E casualty hours, an Asthma UK co-branded
Equally important is the legacy of the cards and a telephone interview with re- ‘Asthma Patient to GP’ letter and blank
project. Asthma now has a high profile attenders to understand behaviours and self-management plan for the patient
across primary care and A&E and systems motivators. Some of the key to take to a GP follow-up appointment
have been put in place that will facilitate interventions which have now been put and an Asthma UK’s After Your
in place include: Asthma Attack leaflet;

15. CASE STUDIES - ACUTE TRUSTS 15
• a placebo box and an updated asthma Key learning points
folder, which includes the recently • Inclusion of all stakeholders and
updated local asthma guideline; regular communication was vital to
• an internal referral pathway into the project success.
severe/difficult asthma clinic when • There was a strong correlation
patients have experienced an acute between use of the proforma and
severe asthma attack or have difficult actions that would lead to a decrease
asthma and have been reviewed; and in re-attendance e.g. inhaler technique
• an external referral pathway has been check, referral back to GP.
reviewed and updated by way of an • Testing of innovation on a small scale
electronic flag on the patient record really helped to refine some of the
that prompts the hospital staff to give interventions and make them more
information on discharge including the successful.
GP referral letter. • Data – both qualitative and
quantitative was key to understanding
The project team consisted of the problem and informing solutions.
representatives from A&E, the respiratory
nursing team in the hospital, primary Contact details
care (a GP and a Practice Nurse), Karen Newell
ambulance staff, junior doctors, an A&E Specialist Respiratory Nurse
Consultant and patients. The team met Email: karen.newell@gstt.nhs.uk
monthly for 12 months to discuss issues
arising.

16. 16 CASE STUDIES - ACUTE TRUSTS
Mid Yorkshire Hospitals NHS Trust
Implementation of an asthma care bundle to assist in
the delivery of a structured inpatient care process and
discharge checklist for adult patients admitted with an
acute exacerbation of asthma
What was the problem? respiratory inreach service. This provided Stickers one and two contain all the
In 2010/11, NHS Wakefield District had an opportunity to implement change of elements within the locally agreed
the highest admission rates for acute the asthma service, including creating a asthma CQUIN (Commissioning for
exacerbation of asthma in Yorkshire and difficult asthma clinic, and introduce an Quality and Innovation) payment.
the Humber. The 2009 BTS adult asthma asthma care bundle to standardise care Sticker three is used for all patients
audit revealed that that Pinderfields asthma patients received in the admitted from ED with an exacerbation
General Hospital (PGH) re-admissions Emergency Department (ED), acute of asthma. This again promotes
(within one month) were twice the medical wards and at discharge. appropriate treatment, education, self
national average. The same audit aslo management and follow up.
highlighted a lack of education and What was the aim?
instruction to patients. Only 19% were The main aim of the project was to ED staff have received training from the
advised to see their GP following reduce 28 day adult asthma readmissions respiratory team in the use of the
admission and only 16% received a by 20%. bundle, with specific teaching of acute
written action plan, compared to asthma severity assessment and inhaler
national figures of 34 and 38% What has been achieved? technique assessment and training.
respectively. An asthma bundle comprised of ‘three
stickers’ has been introduced at PGH. An audit of patients admitted with
Pinderfields General Hospital is one of Sticker one is used for all adult patients asthma has demonstrated that since the
three district general hospital that forms attending the ED with an acute introduction of the asthma care bundle
Mid Yorkshire Hospitals NHS Trust, along exacerbation of asthma. This there has been a marked improvement in
with Pontefract and Dewsbury General component of the bundle focuses on the recording of inhaler technique
Hospitals. Pindefields and Pontefract accurate and timely assessment, review, provision of self management
acute inpatient medical services merged treatment and reassessment of patients. plans and advice to see GP or Practice
and moved into a new hospital in Sticker two is implemented when Nurse (see table). There has also been a
February 2011. This coincided with the patients are being discharged from ED, 60% reduction in readmissions at the
appointment of a respiratory consultant focusing on inhaler technique, education Pinderfields site since March 2011 (see
with a specialist interest in asthma and and self management and GP follow-up. the graph on the following page).
establishment of a seven day a week

17. CASE STUDIES - ACUTE TRUSTS 17
Key learning points
Yes (%) No (%) N/a (%)
• As part of the project a number of
Sticker ‘3’ used 84.4 13.3 2.3 audits and notes reviews were
undertaken. The audits repeatedly
Inhaler technique checked 75.6 22.2 2.3 highlighted coding errors with over
25% of patients being incorrectly
Asthma review (SMP/Education) 88.9 12.1 2.3 coded. This has led to work within the
respiratory team to improve the
Prednisolone on discharge 97.8 0.0 2.3
accuracy of coding.
ICS and B2 agonist on discharge 97.8 0.0 2.3 • The time it would take to fully
implement the care bundle was
Advised to see GP/nurse within two days 80.0 13.3 2.3 underestimated. It has taken
considerably longer than anticipated to
Four week follow up arranged 93.3 4.5 2.3 engage with staff and train them
where necessary.
A&E commenced bundle 43.2 40.0 17.8
Contact details
Lisa Chandler
Respiratory Programme Manager – Public
28 day re-admissions at Pinderfields General Hospital Health NHS Wakefield
Email: lisa.chandler@wdpct.nhs.uk
8
7
6
5
Patients
4
3
2
1
0
Apr11 May11 Jun11 Jul11 Aug11 Sep11 Oct11 Nov11 Dec11 Jan12 Feb12 Mar12
Month
2010/11 2011/12

18. 18 CASE STUDIES - ACUTE TRUSTS
University Hospitals North Staffordshire NHS Foundation Trust
The development and implementation of an integrated
asthma care pathway alongside the provision of an
asthma education package to emergency care staff
What was the problem?
UHNS (%) National (%) Target (%)
A College of Emergency Medicine (CEM)
2009/10 asthma audit highlighted areas PEF on arrival 48 53 98
for improvement in both patient Respiratory rate 70 100 98
assessment and treatment.
SABA nebuliser 85 88 100
What was the aim? Steroids 65 66 90
The aim of this project was to improve
Admitted 67 52
and standardise care delivered to asthma
patients presenting to the emergency
department with an asthma The new pathway was officially of paramedics as 73% of A&E asthma
exacerbation. launched in A&E in April 2012 and attenders arrive by ambulance.
usage is monitored through a monthly
What has been achieved? audit. Key learning points
With involvement from respiratory 2.Development of an asthma database • Initial data always requires further
specialists and emergency care personnel of all patients presenting to the A&E interrogation/root cause analysis.
the project was divided into three main on a monthly basis with an aim to run • Improvement project work requires a
workstreams: quarterly reports to monitor for any team big enough to undertake specific
improvements in care delivery. roles.
1.Development of an asthma care 3.An asthma education package within • Regular meetings are essential to
pathway - Initial research looked at A&E /Acute Medical Unit - ensure progress happening.
casualty card records for asthma A resource file which included the • Plans and progress should be
patients, Trust data around attenders, ‘step wise management of asthma’ documented.
re-attenders and admissions and the (BTS/SIGN Asthma Guideline 2011), • Face-to-face engagement is best.
outputs from an asthma patient focus pictures of inhalers with their names
group. The current pathway was and the correct method of delivery is Contact details
process mapped and a project team now available for A&E staff. In addition Angela Cooper
who met twice a month refined the 12 training sessions have been held for Asthma Clinical Nurse Specialist
content for the new integrated care clinical staff and more are planned up Email: angela.cooper@uhns.co.uk
pathway which conforms to the to December 2012. Work is also
BTS/SIGN Asthma Guideline. underway to support the education

19. CASE STUDIES - COMMUNITY RESPIRATORY TEAMS 19
Sandwell Community Respiratory Team
Back to basics for asthma
What was the problem? What has been achieved? Asthma Guideline for asthma patients. A
Sandwell has the third highest admission To achieve their first aim the team mined demand and capacity exercise was also
rate within the UK and a high prevalence local data on admissions and held a completed to determine the impact
rate of asthma in the area of 7.5% with process mapping event to understand increasing referrals might have on
approximately 21,233 people having been the current pathway for referrals. They workload and refresher sessions were
diagnosed. Despite this low numbers of then put together a plan for raising held. An electronic ‘SystmOne’ template
referrals for asthma were being received awareness with GPs e.g. referral was then created which clinical staff use
to the Community Respiratory Service algorithm, promotional materials, visits for all patient assessment and follow-up
from GPs and secondary care. The team to the practice etc. They also spent time appointments (which contains the gold
decided the time was right to heighten in A&E with staff offering support and standard features) and any patients with
their profile for asthma and emulate the highlighting their service in order to aid an unconfirmed diagnosis are now
good work they already did in other ease of referral. referred for spirometry.
respiratory diseases.
For the second aim one year’s worth of
What was the aim? case notes were audited to determine
The main aims for this project were: current compliance with the BTS/SIGN
• To increase the number of asthma
referrals into the service by 50% by
improving links with the acute sites (to 2010/11 2011/12 % change
receive more referrals following Admissions 180 143 ↓21%
patients attending A&E and
admissions) and GP practices which Attendances in A&E 520 368 ↓29%
had high admission rates. Total referrals into CRS 106 185 ↑75%
• To ensure 80% of the patients on their
Self –management plans given to patient 19 35 ↑21%
asthma register were managed in
accordance with the BTS/SIGN Asthma Self-management plan amended for patient 13 31 ↑22%
Guideline on managing asthma in Diagnosis confirmed with spirometry 26 17 ↓6%
adults, to include ensuring all patients:
were diagnosed with the preferred Asthma education given to patients 44 52 ↑16%
initial test of spirometry, had an easy to Inhaler technique reviewed 62 60 ↑8.2
understand self-care plan in place,
received appropriate asthma education
and had inhaler technique check.

20. 20 CASE STUDIES - COMMUNITY RESPIRATORY TEAMS
Key learning points • The team will continually target GP
• The relationships that the team have practices that have a high proportion
developed with those in the Trust that of registered patients attending A&E as
can provide and help them understand well as high admission rates.
data has been invaluable.
• Electronic templates not only Contact details
standardised their care and processes Kelly Redden-Rowley
but also assisted the team in data Respiratory Physiotherapist/Clinical Lead
collection. Email: kelly.redden-rowley@nhs.net
• The team conceded they didn’t really
utilise the media as much as they
might have and would improve upon
this next time.
• The whole team have improved their
skills in delivering care and treatment
to those with asthma through applying
the BTS/SIGN Asthma Guideline to
clinical practice.
• Although the project did not meet the
target with regards to confirming a
diagnosis through spirometry the
reason was mainly due to patients not
attending their appointments. It may
not have been appropriate for some
patients to attend clinic, possibly due
to an exacerbation, and the team are
now in the process of looking at
additional ways in which to improve
clinic attendance.

21. CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE 21
Durham Dales Clinical Commissioning Group
Durham Dales Clinical Commissioning Locality, local
pharmacists and medicines use reviews
What was the problem? What was the aim? The key outcomes related to the
Durham Dales has an asthma prevalence The aims of the project were to: completion of 174 MURs.
of 6.6% (5.93% national prevalence) • educate pharmacists to deliver high • 60 patients were recorded as non-
which equates to 5,957 patients. quality, asthma-specific, MURs to compliant and pharmacist
Durham Dales currently spends £64,918 increase patient awareness and interventions were delivered as
on asthma hospital admissions all of understanding of their condition and appropriate.
which are non elective. Work between improve their own management of • Patient education was delivered to
community pharmacies and GP practices the disease; 32% of patients.
was sporadic and the Medicines Use • improve relationships between • Device check and advice was given
Review (MUR) services were not practices and pharmacists to ensure was to 32% of patients.
consistently utilised in a coordinated way. more asthma patients are treated • 14% of patients were referred back to
consistently in line with the BTS/SIGN GP practice for further intervention.
In 2010, a small scale pilot between one Asthma Guideline; and • 19 patient surveys were received back
GP practice and one pharmacy was • improve patient quality of life and (11% response rate) and the feedback
undertaken over a three month period in health outcomes by ensuring patients was that patients found the service
Bishop Auckland where pharmacists understand their condition and very beneficial with 57% of patients
offered an MUR to asthma patients who prescribed medicines thereby rating the service as excellent and 57%
had missed their annual review and who improving self management. finding the service extremely valuable.
were over using reliever inhalers. The
resulting data suggested that over half What has been achieved? Other measures are still being reviewed
the patients benefited from the service A monthly steering group met from the e.g. Asthma Control Test (ACT) scores,
and this evidence supported a bid to roll outset to determine the target cohort of reduction in inhaler use (via a case note
the project out to other surgeries in the asthma patients, formulate standard audit) and a pharmacist / practice
locality through a joint working paperwork for the pharmacists to feedback survey.
agreement between GlaxoSmithKline complete (MUR template, reporting
and Durham Dales Clinical form, schematic) and which pharmacists
Commissioning Group (CCG). to target. Pharmacists were also given
training at two events (September 2011
and January 2012) and were individually
mentored and supported with
appropriate equipment for the duration.

22. 22 CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE
Key learning points This may have been in part due to the
• There were initial problems with additional activity the New Medicines
patient confidentiality as the Primary Service had created which also began
Care Trust (PCT) would not allow on 1 October 2011.
practices to generate patient lists of • The number of MURs was changed
the three target cohorts of patients for from the original target of 500 to 200
the pharmacists to work from. in February when it became clear that
Pharmacists had to produce their the 500 would not be reached. It was
own lists for over use of reliever also decided to focus on the
inhalers by patients and high dose pharmacists who had already
steroid use patients and each practice conducted the greatest number of
was asked to write to patients who MURs.
hadn’t attended their annual review to • The steering group decided to remove
explain the MUR was available at their the completion of Self Management
local pharmacy. Plans from the MUR criteria in February
• Educational meetings (one in as it was observed that very few were
September and one in January) were being completed and they took a
well attended and the pharmacists substantial time to complete.
appeared to find them useful. One-to-
one mentoring, delivered by a local Contact details
pharmacist with an asthma specialism, Vikki Reed
received very positive feedback. Project Manager – Durham Dales Clinical
• Engaging with the pharmacists was Commissioning Group
challenging as email communication Email: victoriareed@nhs.net
did not generate a wide response so it
was difficult to ascertain the level of Alison Newbolt
engagement. The team began to use Area Business Manager -
other communication methods e.g. GlaxoSmithKline
phone calls and pharmacy visits early in Email: alison.j.newbolt@gsk.com
2012 when it was clear that the
number of MURs were not being
delivered.

23. CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE 23
ESyDoc
Whole system approach to improving care for patients
with asthma within East Surrey locality
What was the problem? What was the aim? What has been achieved?
ESyDoc had successfully completed an The guiding principles which informed 1. Diagnosis
improvement project for COPD patients the aims were that: asthma is Practice registers were searched to
and decided to apply the principles they controllable, there should be no identify the number of patients who
had established in this work to their unnecessary deaths from asthma and have received asthma medication, but
asthma service. that a secondary care respiratory clinician were without a formal diagnosis (Cohort
should be consulted if there is a decision 4 – see table for figures). In order to
The 18 GP practices who form the to admit an asthma patient who presents have a standardised approach, the
Commissioning Group were aware that at the Emergency Department. workstream lead produced an invite to
prevalence in practice lists was around review template letter for practices and
5.3% (national average 5.8%) and that The project was focussed on four key also an algorithm to enable consistency.
the majority of their 9285 registered work streams with their own aims. These Those patients identified were targeted
asthma patients did not have a self- were: by letter to a review appointment.
management plan. Diagnosis was obtained following
1. Diagnosis – increasing the prevalence prescribed spirometry and/or peak flow
Working in conjunction with of asthma from 5.3 to 5.8%. pathway and the patient was stabilised
AstraZeneca (through a joint working 2. Chronic disease management – accordingly and received an asthma
agreement) and Surrey and Sussex stratifying patients into three cohorts action plan in line with the BTS/SIGN
Hospitals NHS Foundation Trust also and performing structured reviews in Guideline. Early evidence suggests that
supported an opportunity to address line with the BTS/SIGN Asthma by implementing this targeted approach
admissions and medicines as part of a Guideline. of identified patients local prevalence has
whole systems approach. 3. Medicines optimisation. increased to 5.5% and at least 154
4. Transforming acute care – patients were diagnosed with asthma
standardising care pathways and during the project duration.
reducing admissions by 10% in the
acute trust.

24. 24 CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE
2. Chronic disease management
Practice registers were searched by
Quintiles and patients with an asthma
read code were stratified into three
cohorts in descending order of priority.
Cohort ESyDoc Total 3. Medicines optimisation
Collaboration was encouraged between
1: Asthma QOF, Age >18, Read Code hospitalisation, Read Code 1,765 community pharmacy colleagues who
Exacerbation, >1 Oral Steroids, >2 Respiratory antibiotics. have provided strategic support when
implementing the NHS Surrey asthma
2: Asthma QOF, >12 SABA, >8 SABA <12 SABA, >6 SABA <8 SABA 378 guidelines. Pharmacy colleagues have
also assisted with reinforcing effective
3: Asthma QOF, SAMA, LAMA, LABA only (no ICS) 222
inhaler technique when implementing
4: No Respiratory Read Code, >1 SABA, >1 ICS, >1 LABA/ICS 2,761 a medicines use review within that
combination specific setting.
Total 5,126 4. Acute care
An Integrated Care Pathway has now
been introduced at Sussex and Surrey
Patients were invited by letter to attend a • BTS step recording went from 4% Hospitals NHS Trust and usage is being
nurse-led review which was conducted to 20%; monitored. In addition, the Respiratory
using a standardised template. The • compliance recording increased Consultants notified GP practices on
review adhered to the BTS/SIGN Asthma by 7%; patient discharge in order for timely
Guideline and included inhaler technique • Recording of inhaler technique follow up as per the BTS/SIGN Asthma
check and a self-management plan. increased by 813 patients; Guideline. This primary and secondary
Although there were high DNA rates for • 454 extra patients had a self- care combined approach has
the clinics final data from 15 practices management plan; and demonstrated that, in comparison with
(92% of the asthma population) showed • 58 additional patients were referred the previous 12 months, admissions have
there had been a big impact. Highlights for smoking cessation. dropped by 21%.
included:

25. CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE 25
Key learning points Contact details
• Initial data between the QOF and Dr Vijay Kumar
Quintiles search conflicted and needed GP - Birchwood Practice
re-running to enable increase in data Email: Vijay.Kumar@gp-h81037.nhs.uk
integrity. This was vital to establishing
the correct patients to target in
cohorts but did create unforeseen
delays in starting the review clinics.
• A&E data was not easily visible
creating difficulties defining baselines,
benchmarking and monitoring.
• Poor standardisation and utilising of
clinical management plans prompted
all the practices to have and utilise a
standard self-management.
• The buy-in from all 19 (initial) practices
and a motivated project group which
met regularly created the highly
successful and focussed workstreams.

26. 26 REFERENCES
References
COPD and Asthma Outcomes Strategy for England and Wales (DH: 2011)
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicy
AndGuidance/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. ACKNOWLEDGEMENTS 27
Acknowledgements
NHS Improvement - Lung would like to Prof Martyn Partridge, Professor of Respiratory Medicine Imperial College
thank all national improvement project London, Senior Vice Dean, Lee Kong Chian School of Medicine Singapore and
sites for their hard work and Chairman DH Asthma Steering Group
dedication to improve quality and care
for people with asthma, and for their Professor Sue Hill, National Clinical Director for Respiratory Services
contributions to this document.
In addition, the following people have Dr Robert Winter, National Clinical Director for Respiratory Services
provided a source of expertise and
Members of the Asthma Clinical Project Steering Group: Dr Bernard Higgins,
support and their help is gratefully
Jan Gould, Dr Dermot Ryan, Dr Mike Thomas and Simon Selo (Asthma UK)
acknowledged:
Kevin Holton, Department of Health Head of Policy for Respiratory, Kidney,
Diabetes and Liver
Bronwen Thompson, Department of Health Policy Lead for Asthma
For more information please contact Hannah Wall, National Improvement Lead
Email: hannah.wall@improvement.nhs.uk

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