Improving adult asthma care: emerging learning from the national improvement projects
NHSCANCER NHS Improvement LungDIAGNOSTICSHEARTLUNGSTROKENHS Improvement - Lung: National Improvement ProjectsImproving adult asthma care: Emerginglearning from the national improvementprojects
CONTENTS 3NHS Improvement - Lung National Improvement Projects -Improving adult asthma care: Emerging learning from thenational improvement projectsContentsForeword by Professor Martyn Partridge 4Professor of Respiratory Medicine, Imperial College London and Senior ViceDean, Lee Kong Chian School of Medicine, Singapore (A joint school byImperial College London and Nanyang Technological University)Introduction 5The case for improvement work and a summary of the emerginglearning from the sitesCase studies 9Acute TrustsGuys and St Thomas NHS Foundation Trust 10Reducing re-attenders at Accident and EmergencyMid Yorkshire Hospitals NHS Foundation Trust 12Asthma Care BundlesUniversity Hospital of North Staffordshire NHS Trust 14An Integrated Care Pathway for Accident and EmergencyCommunity Respiratory TeamsSandwell Community Respiratory Team 17Reducing admissions and increasing community supportClinical Commissioning Groups and Primary CareDurham Dales Clinical Commissioning Group 20Pharmacists and Medicines Use ReviewsESyDoc Clinical Commissioning Group 22An integrated approach to asthma careNHS South West Essex Primary Care Trust 24Targeted Medicines Use Reviews through a Local Enhanced ServiceReferences 26Acknowledgements 27
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)
INTRODUCTION 5IntroductionBackground – the case for waste) to the NHS of these types of The improvement workimprovement 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 towhich affects between 3 and 5.4 condition in which patients will work in partnership on projectsmillion 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 addressStrategy for Chronic Obstructive With optimal self-management the the variation in care that patientsPulmonary Disease and Asthma: goal for nearly all people with receive. Projects plans were2011) with approximately 80% of asthma should be to lead a normal, submitted from a number of sitesthose 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 communityinflammation of the airways leading the healthcare professional and the organisations to work in four keyto 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 medicinesoften be managed by the patient for COPD and Asthma (DH: 2011) optimisation, transforming acutethrough medication and lifestyle noted that asthma is a condition care, chronic disease managementmodification but from time to time which is very poorly controlled. It and integrated care.can require treatment in Accident also highlighted the high number ofand Emergency or an admission to preventable admissions and lack of The primary aims of the projects inhospital. 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- SIGNasthma at a cost of £61 million to Asthma Guideline: 2011), despite • Define the patient’s pathwaythe NHS, however it is currently the UK being a world leader in this • Identify and reduce variation in theestimated that three quarters of field. delivery of carethese are preventable (Right Care • Challenge the system and test theAtlas of Variation: 2011). The aim of the NHS Improvement – components of care that lead to Lung asthma work stream is to test consistent and effectiveBecause asthma symptoms have which interventions have the biggest management of the conditionmany similarities with other impact on patient outcomes and • Identify the success principles thatrespiratory conditions there is often experience. This will help to ensure other organisations and teamsdual or misdiagnosis with other that people with asthma are could learn from and adopt.illnesses such as COPD. Asthma is managed optimally in both primarytreated through a mixture of inhaled care and secondary care, to improve‘preventer’ steroids which are taken patient outcomes and reduce theon a constant basis and ‘reliever’ demands placed on emergency care.bronchodilators which are inhaled inthe event of worsening symptoms.Due to the plethora of drugs anddifferent combinations available forrespiratory patients the cost (and
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, Guys 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
INTRODUCTION 7Summary of emerging learning • There is significant variation in the • There is recognition amongstThe emerging learning from the delivery of care and the both primary and secondary careproject sites to date demonstrates configuration of and access to clinicians that there are manysome of the practical challenges asthma care services around the opportunities for meeting thearound implementing those country. One example of this was productivity and preventionelements of good asthma care that significant disparity in proactive agenda whilst improving thewe already know to be effective. follow up by GPs following receipt quality of services and outcomesThis highlights not only what works of discharge summary issued from for asthma patients. Data fromand how people are doing it, but the acute Trust (which in itself sites has identified opportunitiesalso what barriers still exist and varied from within 24 hours to for reductions in use of resourcewhere 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 - throughpractice. 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 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.
10 CASE STUDIES - ACUTE TRUSTSGuys and St Thomas NHS Foundation TrustReducing adult asthma re-attenders atAccident and EmergencyBackgroundSet in the heart of the capital city St Re-attenders - May 2010 to April 2011Thomas’ A&E is one of the busiest andlargest departments of its kind in 30England, seeing hundreds of emergencypatients every day. 25 20Early in 2010 the respiratory nursing Patientsteam at St Thomas’ undertook a 15snapshot audit of asthma attendances toA&E, and this revealed a surprisingly high 1030 day re-attendance rate of just below30% and this highlighted a problem 5which they wanted to improve upon. 0 MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APRKaren Newell, Respiratory Nurse 2010 2011Specialist and project lead, felt that in Monthorder to reduce re-attendances theyneeded to work more proactively withtheir asthma patients on discharge andhelp healthcare professionals in A&Eincrease their knowledge to feel more Data Ethnically most patients were white andconfident 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 ofThis project is supported by a myriad of order to help the project understand the presentation from the data available astakeholders including: the respiratory problem it is aiming to solve prior to significant proportion were brought in bynursing team, Accident and Emergency implementing any potential solutions. ambulance and then went on to bestaff, the London Ambulance Service discharged from the A&E (60%).(LAS), Lambeth and Southwark GPs and Quantitative data was derived from theAsthma 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 interviewsProject aims attended at A&E for primary diagnosis of with a random sample from the 75The primary aim of this project is to asthma. Of these, 19 were deliberately patients cohort. This revealed fascinatingreduce adult asthma re-attendances at excluded form the targeted cohort data around individual approaches toA&E within 30 days by 20% of 2010/11 because they were always admitted due self-management, sources of informationbaseline by May 2012 as an indicator of to the severe nature of their asthma (and and guidance, why patients attendedbetter 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.
CASE STUDIES - ACUTE TRUSTS 11Achievements 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 email@example.com 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 CASE STUDIES - ACUTE TRUSTSMid Yorkshire Hospitals NHS Foundation TrustAsthma care bundlesBackgroundPinderfields General Hospital is one of Baseline re-admissions for Pinderfields 2010/11three district general hospitals in theregion (along with Pontefract General 8and Dewsbury General Hospital). The 7hospital has recently moved into a new Number of Patients 6building which has created theopportunity for respiratory patients to 5enjoy state-of-the art facilities. 4The respiratory team recently decided to 3look at ways in which they could 2improve care for asthma patients. Theyhad already established a designated 1difficult asthma service and wanted to 0impact upon admissions (Wakefield has APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MARthe highest admission rates in the Monthregion). Therefore the respiratory Patientsprogramme manager for NHS Wakefieldand District, Lisa Chandler, and a newrespiratory consultant, Dr JamesMcCreanor, considered this an ideal timeto 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%) wereQuality and Innovation payment - • To reduce asthma readmissions within readmitted for acute exacerbation ofCQUIN) to streamline and standardise 28 days of discharge by 20% from asthma within 28 days of previouscare asthma patients received at A&E, on 2010/11 discharge. A more recent audit (June andthe 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.
CASE STUDIES - ACUTE TRUSTS 13The Mid Yorkshire project team (l-r) Jacqui Pollington,Lisa Chandler and Dr James CreanorAchievements 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. firstname.lastname@example.org
14 CASE STUDIES - ACUTE TRUSTSUniversity Hospital of North Staffordshire NHS TrustAn integrated care pathway for A&EBackgroundUniversity Hospital of North Staffordshire Reason for A&E attendanceNHS Trust is currently spread across threesites in Stoke-on-Trent serving apopulation of approximately half amillion people in urban and semi-rural 12% 6% Increased symptomsareas.Within North Staffordshire a ‘Fit for the ViralFuture’ transformation project and anexciting move into a new Private Finance Infection 25% 38%Initiative hospital have been developedto improve people’s access to high Out of medsquality healthcare. As part of thereorganisation of emergency services an Severe patientsUrgent Care Centre has been embeddedwithin the A&E department and theClinical Decision Unit is expanding with 19%the move with the potential to changethe usual care for adult asthma patients.The UHNS emergency department wasone of 147 departments that took partin 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 wereresults of the audit showed there were • To understand the current adult 48 attendances for asthma at A&E inareas for improvement and the asthma asthma patient journey through A&E, that period. Thirty patients had notclinical nurse specialist, Angela Cooper, the Clinical Decision Unit (CDU) and accessed a medical review immediatelyand consultant physician, Dr Martin the Urgent Care Centre prior to attending the emergencyAllen, felt that the modernisation of the • To identify delays in patient care, department, 14 had experienced a mildhospital facilities signalled the including those that can increase exacerbation, 33 experienced aopportunity to begin looking at ways in length of stay and lead to admission moderate/severe exacerbation and onewhich asthma care within acute to the Clinical Decision Unit had a life threatening exacerbation.medicine, respiratory wards and the • Introduce a new adult asthma carecommunity as well as A&E could be pathway for use in A&E and across the The majority of attendances were femaleimproved 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.
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 HCPAchievements 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 email@example.comSuccesses 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
CASE STUDIES - COMMUNITY RESPIRATORY TEAMS 17Sandwell Community Respiratory TeamReducing admissions and increasingcommunity support“I was eventually referred Baseline data on referrals 2010/11to the CRS and since then, Ihave received a brilliant, Inhaler checkpersonalised service by Educationvarious members of the Number of Patientsteam. Their skills and SMP issuedprofessionalism performed Result - COPDwith a seven day per week Result - Asthmahome-visit service, has Sprirometryenabled me to manage the Total Referralscondition and lead a 0 20 40 60 80 100 120relatively normal life.” InterventionsSandwell CRS Patient (2011)Background Although the CRS were well utilised by DataThe Community Respiratory Service (CRS) the NHS for other respiratory conditions Sandwell’s GP registered population isin Sandwell is a multidisciplinary team they felt that the time was right to do approximately 320,000. The boroughproviding assessment, treatment and more to support the management of has a large ethnic minority populationmanagement to those with respiratory asthma patients in the locality. with high levels of deprivation. There areillnesses. The aims of the service (which 69 practices including three new Darziis 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 theavoidable admissions, minimise hospital project are: Sandwell and West Birminghamlength of stay and provide care closer to • To reduce adult hospital admissions of Hospitals NHS Foundation Trust providehome 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 orPreviously 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 toreceived from GPs and secondary care - using spirometry CRS. Baseline data showed room fordespite 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 byOutcomes Framework) and high • receive appropriate education spirometryadmission rates for asthma. • have a review and ensure correct • 19 were given a self-management plan inhaler technique • 62 had their inhaler technique checkedInitial thoughts were that high asthma • regular reviews to ensure patients and were given educationattendance 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 asthmaprofessionals in the area not referring patients into the service by 50%.their patients to the team due to lack ofawareness of the service available.
18 CASE STUDIES - COMMUNITY RESPIRATORY TEAMSThe number of admissions between 1 Successes and challenges • Electronic care plan to be uploaded toMay 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 willadmissions lasting for two days or less. that is actually a true representation of enable the team to report outcomesBetween 1 May 2010 and 30 April 2011 what has happened was challenging • Begin to audit case notes of the CRSthere were 638 A&E attendances due to and work is still in progress to ensure from May 2011 onwards to ensureasthma. 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. firstname.lastname@example.org 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
CASESTUDIESCLINICALCOMMISSIONINGGROUPS ANDPRIMARY CARE
20 CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CAREDurham Dales Clinical Commissioning GroupPharmacists and Medicines Use ReviewsBackgroundDurham Dales Clinical Commissioning Process mapping event at the Durham DalesGroup are a consortia of 12 GP surgeriesin the North East serving a population ofover 90 000.In 2010, a small scale pilot between oneGP practice and one pharmacy wasundertaken over a three month period inBishop Auckland where pharmacistsoffered a Medicines Use Review (MUR)to asthma patients who had missed theirannual review and were over usingreliever inhalers. The initial datasuggested that over half of the patientsbenefited from the service and thisevidence supported a bid to roll theproject out in other surgeries in theconsortia as an improvement project.In May 2011, seven practices agreed totake part and a joint working agreementwas established with pharmaceuticalcompany GlaxoSmithKline as a result of Project aims Achievements to datetheir previous work in the locality on The high level aims of the project are: • This project was greatly aided by theCOPD. The lead pharmacist, Patricia • To up skill health care professionals in introduction of the new nationalKing, from the original pilot work then the participating practices in their pharmacy contract which came intoapproached pharmacists which understanding and management of force on 1 October 2011 which meantneighboured participating practices and asthma patients consistent with the that respiratory patients became oneas a result 15 pharmacies are now taking BTS/ SIGN Guidelines and to ensure all of four key groups pharmacists arepart. 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%).
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 ClinicalSuccesses and challenges Commissioning Group• Confidentiality issues with GP practices email@example.com 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.firstname.lastname@example.org 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 CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CAREESyDocAn integrated approach to asthma careBackgroundESyDoc is a Clinical CommissioningGroup of 19 practices in Surrey coveringa population of around 170,000.Dr Vijay Kumar, a GP at BirchwoodPractice, had already led a successfulproject on improving COPD care withinthe consortia during 2009. Throughfurther analysis of the COPD data theydiscovered that variation in asthma careexisted across the ESyDoc patientpopulation and felt the time was right toaddress the issues.Given the success of their earlier jointwork in 2010 they decided to undertakean improvement project in conjunctionwith Sussex and Surrey Hospitals NHSTrust. The project is also supportedthrough a formal joint workingagreement with pharmaceuticalcompany AstraZeneca. As an extension of these beliefs the DataProject aims project is focussed on four key work ESyDoc have 18 practices which eachESyDoc and their partners firmly believe streams with their own aims. These are: hold an asthma register. The registersthat: asthma is controllable, there should have been searched for patients who arebe no unnecessary deaths from asthma 1. Diagnosis – increasing the prevalence aged 18 years or over and potentially falland that a secondary care respiratory of asthma from 5.3 to 5.8% through into one or more of the four cohorts (seeclinician should be consulted if there is a proactive case finding and analysis of pyramid above – red, amber or greendecision 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.
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 registersAchievements 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 CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARENHS South West EssexTargeted Medicines Use Reviews (MURs)using a Local Enhanced Service (LES)Background Project aims • Generated, proofed and preparedThere is currently a high prevalence of The overarching aims are to: improve standard proformas for the directedasthma and significant asthma related care, reduce morbidity and impact on MUR, generation of a care plansecondary 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 andto 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 challengesmedicines management driven by asthma treatment regimen through a • Since the initial project plan in Mayfeedback from GP practices and number of extended education and 2011 there have been changes in thecommunity providers regarding the sorts support interventions community pharmacy national contractof problems they were having in • Reduce asthma medicines waste, (introduction of the New Medicinesreviewing and following up some hard- including through poor compliance Service and the MUR targets into-reach asthma patients. and prescription management October 2011). This development has • Reduce inappropriate prescribing, delayed the start of the asthma projectIt 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 outcomesUse Reviews - would ease difficulties • Reduce avoidable unscheduled and planned for project sites are met bypractices were having in accessing secondary care activity for primary care the training workshops andcertain 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 eligiblearea and are engaged in a whole range Data clinical conditions for both NMS andof service delivery. They also speak a In 2009/10 there were 400 056 people targeted MURs participants will haverange of languages which will assist in registered with the 78 GP surgeries in completed relevant continuingtargeting some of the hard to reach South West Essex. The asthma professional development on this topicgroups. prevalence in the PCT was just over 6% • The inclusion of South Essex as a and there were 309 emergency Healthy Living Pharmacy Pathfinder siteThe project itself is a collaborative admissions. has again delayed the implementationbetween the Local Pharmaceutical of the project but it does mean thatCommittee (LPC), the PCT, Medicines Achievements to date the sites involved in both projects willManagement, GP practices, community • Process mapping of current pathway in have Health Champions among theirservices and consultants from the acute June 2011 support staff who may be well placedhospital. Eight pharmacies in the local • Undertaken a ‘world café’ (a method to approach customers and initiatearea who are already part of the which makes use of an informal cafe conversations about the service, andDepartment of Health ‘Healthy Living’ for participants to explore an issue by the pharmacists involved will haveinitiative have signed up to a local discussing in small table groups) with completed appropriate leadershipenhanced service (LES) agreement to community pharmacists to canvass the training to consider best use of skilldeliver at least 400 MURs to asthma level of interest and willingness to mixpatients 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
CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE 25Patient and Public InvolvementThe service has a built in element forboth patient satisfaction and datacapture of patient reported outcomemeasures (e.g. shortness of breath,difficulty with normal activities, numberof times patient has had to resort to useof 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 detailsBalbir (Bill) Singh SandhuAssociate Director /Head of MedicinesManagementBalbiremail@example.com
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/
ReferencesAcknowledgementsNHS Improvement - Lung would like to thank all national improvement project sitesfor their hard work and dedication to improve quality and care for people withasthma, and for their contributions to this document.In addition, the following people have provided a source of expertise and supportand their help is gratefully acknowledged:Professor Martyn PartridgeProfessor Sue Hill – National Clinical Director for Respiratory ServicesDr Robert Winter - National Clinical Director for Respiratory ServicesMembers 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 ServicesBronwen Thompson, Department of Health Policy Lead for AsthmaPhil Duncan, Director, NHS Improvement - LungCatherine Blackaby, National Improvement Lead, NHS Improvement - LungOre Okosi, National Improvement Lead, NHS Improvement - LungCatherine Thompson, National Improvement Lead, NHS Improvement - LungZoë Lord, National Improvement Lead, NHS Improvement - LungAlex Porter, Senior Analyst, NHS Improvement - LungFor more information please contactHannah Wall, National Improvement Lead for AsthmaEmail: firstname.lastname@example.org