CCG aims to improve asthma care by improving staff and patient knowledge and creating awareness of inhaler technique, achieving patient satisfaction and saving cost

In 2014, Barnet CCG spent £4.8 million on medications for respiratory conditions, 62% of which was spent on inhaled corticosteroids (ICS). As a result, the CCG identified a number of areas for improvement in asthma care across primary and secondary care, including comprehensive patient review, highlighting the importance of prescribing inhalers by brand name and summarising the outcomes from choosing a pressurised metered dose inhaler.

The results have been marked:

•Year-on-year, prescribing of low dose ICS/LABA prescribing has increased;

•The level of branded prescribing has increased;

•The overall number of items prescribed has increased, but with lower costs

Challenges

•An above average spend on medications for respiratory conditions (£4.8 million in 2014, 62% of which was spent on inhaled corticosteroids ICS)

•A lack of consistency in diagnosis, management (including a need to increase the use of self-management plans), and treatment as well as a need for more frequent review

•A need for guidance on the use of devices and medication in a way that minimises risk to patients

•A need to improve the assessment of patient inhaler technique

•Our work informed a second study, involving 18 pharmacies, in and around NW London, including one from Barnet CCG, which further demonstrated that patient engagement in managing their condition improved including improved compliance and devise use occurred when patients improved their understanding of how their condition might be managed including inhaler training, Medicines Use Reviews, and guidance regarding rescue packs

Actions

•Communicating the initiative through a series of locality meetings and through GP / nurse bulletins. Then, subsequently visiting practices to provide training on advanced inhaler techniques and to discuss the local guideline and the rationale for the treatment choices for new and existing patients. We have also conducted inter-professional training on a number of occasions to further clarify the process. Certain Health Care Professionals have attended these educational events multiple times in order to refresh their knowledge and keep up to date. This has been supported with a checklist and further intranet resources

•Practice support pharmacists identified appropriate patients by performing searches on EMIS of people receiving high-strength ICS / LABA

•Holding a review for patients to confirm the diagnosis, provide education on their condition, check inhaler technique, and choosing the most appropriate device, active ingredients and dose. We have worked to educate patients so that they better understand their condition, and why medications are prescribed and maintained at the lowest possible dose to control symptoms

•Highlighting the importance of prescribing inhalers by brand name through communication streams such as the ‘Right Care Bulletin’

•Summarising the outcomes from choosing a pressurised metered dose inhaler (pMDI) – e.g. Flutiform (fluticasone propionate / formoterol fumurate) or Sirdupla (fluticasone propionate / salmeterol), and also the use of Budesonide and Formoterol in a Dry Powder Device

Results

•Year-on-year, prescribing of low dose ICS/LABA prescribing has increased; it is currently at 37.8% in 2015/16

•The level of branded prescribing has increased from 30% to 52%

•The overall number of items prescribed has increased, but with lower costs:

o in 2014/15, 13,957 items were prescribed with costs of £912,000

o in 2015/16, 14,369 items were prescribed with costs of £860,000

•We have increased the number of skilled nominated professionals in practice and pharmacy settings. Currently in Barnet, 130 GP practice staff and 40 community pharmacy staff are Advanced Inhaler Trained

•Feedback from those patients who were surveyed demonstrates 99% thought the support / feedback they were given was ‘good’ or ‘very good’

Value

A comparison of data from Barnet CCG for 2014/15 and 2015/16 for combination fluticasone / LABA treatment demonstrated that:

•the overall number of items prescribed has increased, but with lower costs:

o in 2014/15, 13,957 items were prescribed, with costs of £912,000

o in 2015/16, 14,369 items were prescribed with costs of £860,000

The proportion of patients on inhalers making mistakes with technique is well documented. Selecting the right device and teaching correct use improves lung deposition and potentially reduces side effects because less drug will get into the systemic circulation.

As a result of this programme of work, more patients have been reviewed and at a higher frequency than planned to ensure that they were using the correct inhaler and patients benefited from the inhaler training sessions that formed part of the review. Alongside patient education, we have increased the number of skilled nominated professionals in practice, pharmacy, hospital, care home, mental health and community outreach settings increasing the likelihood the programme will be sustained into the future. Currently in Barnet, 130 GP practice staff and 40 community pharmacy staff are Advanced Inhaler Trained.

In detail

Ambition

In 2014, Barnet CCG spent £4.8 million on medications for respiratory conditions, 62% of which was spent on inhaled corticosteroids (ICS). This, as well as the influx of novel inhalers and the absence of up-to-date local guidance stimulated the CCG to develop a local guideline. This was provided to clinicians with a local prescribing guideline on managing patients with newly diagnosed and existing asthma and which includes guidance on the use of ICS/long-acting β2 agonist combination treatments.

The goal was to address:

•A lack of consistency in diagnosis, management, and treatment as well as a need for more frequent review

•A need for guidance on the use of devices and medication in a way that minimises risk to patients

•A need to improve the assessment of patient inhaler technique

•A need to increase the use of self-management plans

•Above average costs

The programme operated within national best practice guidance as outlined by the British Thoracic Society / Scottish Intercollegiate Guidelines Network. Value and outcomes The initiative has delivered significant cost savings. A comparison of data from Barnet CCG for 2014/15 and 2015/16 for combination fluticasone / LABA treatment revealed that:

•Year-on-year, prescribing of low dose ICS/LABA prescribing has increased; it is currently at 37.8% in 2015/16

•The level of branded prescribing has increased from 30% to 52%

•The overall number of items prescribed has increased, but with lower costs:

o in 2014/15, 13,957 items were prescribed with costs of £912,000

o in 2015/16, 14,369 items were prescribed with costs of £860,000

However, the impact goes beyond the item price. There is a significant correlation between compliance and patient’s satisfaction with their inhaler. Ensuring that patients are involved in the decision-making process and that they understand the rationale for any decisions behind their treatment will improve adherence and health outcomes, and lead to potential cost savings for the CCG (selecting the right device and teaching correct use improves lung deposition and potentially reduces side effects because less drug will get into the systemic circulation). Recognising this we have increased the number of skilled nominated professionals in practice and pharmacy settings.

Currently in Barnet, 130 GP practice staff and 40 community pharmacy staff are Advanced Inhaler Trained. As a result more patients have been reviewed and at a higher frequency than planned; patients also benefited from inhaler training as part of the review. Impressively, 99% of patients surveyed thought the support / feedback they were given was ‘good’ or ‘very good’.

Involvement

This project involved a wide variety of stakeholders.

Barnet CCG medicines management team

The team are responsible for communicating consistent message to individual practices and local community pharmacies including relaying messages around branded prescribing.

Barnet CCG has 130 GP practice staff and 40 community pharmacy staff who have received training on advanced inhaler technique—the training tends to occur on an interprofessional basis, so that individuals understand the importance of each other’s role, with the community pharmacy staff reinforcing but not replacing primary care.

Training is usually done in small groups (6 to 12), and each pharmacy and practice that attends is given free patient aids. Barnet CCG communications department Information on initiatives, such as the one described here, is posted on the local intranet and in the local GP/nurse and community pharmacy news bulletin. Respiratory consultants at the Royal Free NHS Foundation Trust Barnet CCG is fortunate to have several respiratory consultants who work both at and outside hospital settings (integrated service) and have also been working closely with the CCG.

The consultants and the medicines management team meet on a regular basis to discuss local guidelines and to ensure that there is a general consensus among healthcare professionals on the preferred medicines and device options.

We also explore training needs for healthcare professionals and make sure that we have a joined‐up approach to care. Nurse/GP/pharmacy forum leads Barnet CCG has three main nurse, GP, and pharmacy forum locality leads who hold regular meetings. Pharmacists have an ideal opportunity to check patient understanding when a patient is prescribed a new treatment or collects a repeat prescription for asthma.

Pharmaceutical industry

There are many companies that manufacture medicines for respiratory conditions, including products to treat tobacco dependency. Barnet CCG has worked transparently and constructively with the pharmaceutical industry to source devices to improve inhaler technique, patient educational resources, and educational grants to support training of healthcare professionals on a larger scale.

Patients

We have made sure to involve the patient in the decision-making process and clearly explained the rationale behind any decisions.

Spread

The work is easily replicable elsewhere and is cost-effective. The London Respiratory Network, for example, have developed steroid cards which were used in this initiative to increase healthcare professional and patient awareness of ICS potency and potential side-effects, and also to help patients understand that treatment should be maintained at the lowest possible strength. These are available in NHS England guidance. The programme has also been designed to be sustainable, increasing the number of skilled nominated respiratory healthcare professionals in practice and pharmacy settings and improving patient awareness and understanding.

Indeed, a number of Health Care Professionals have attended educational events on more than one occasion in order to stay refreshed, and inter-professional training has taken placed on a number of occasions to improve team working and clarify roles.

Conclusion

This was a successful project that delivered significant cost savings whilst improving staff and patient knowledge and awareness of inhaler technique and branding. The approach is readily scalable and widely applicable. The initiative was recognised at the 2016 Pharmacist’s awards for respiratory service of the year.