Key Facts at a Glance• 21% reduction in emergency admissions to hospital

for acute asthma1

• 154 additional asthma patients being identified1

• Increase patient recognition of having a formal self-management plan up to 73%1

Through a joint working project with AstraZeneca, East Surrey Clinical Commissioning Group (CCG) developed a fully integrated asthma pathway focusing on continuous standards of care from case finding to diagnosis to chronic and acute disease management. This led to additional asthma patients being identified, a reduction in emergency admissions to hospital for acute asthma and an increase in patient recognition of having a formal self-management plan.

The ChallengeThe prevalence of asthma in the UK is amongst the highest in Europe, estimated to affect 5.4 million people.2 Asthma is managed predominately in primary care with patients taking responsibility for much of the management of their own condition.

Across the East Surrey CCG’s patient population, it was recognised that the care patients received from the 18 practices was variable leading to the potential of suboptimal patient outcomes and ultimately unnecessary spending. The main objective was therefore to reduce unwarranted variation and deliver consistent standards of care across the entire pathway for patients with asthma from the CCG’s 18 practices. To do this, AstraZeneca worked together with NHS Improvement, practices, patients, local commissioner pharmacists, the Local Pharmaceutical Committee (LPC) and secondary care specialists to create centralised guidance, education and resources to allow practices to autonomously manage their asthma patients in the most effective and efficient manner.

The Steps TakenConsistent patient cohortingAstraZeneca provided a data interrogation tool which defined specific cohorts to help practices group and manage their patients. Four cohorts were identified and profiled, the largest being patients who were receiving asthma medications but had not received a formal diagnosis. These cohorts were used to inform the types of other resources required.

Creating central resourcesFrom the cohort profiling, the team developed standardised read codes and two types of formal self-management plans — one pictorial and one text-based – for use by practices with their patients. Local asthma diagnostic guidelines and a treatment pathway were developed in line with the BTS/SIGN (British Thoracic Society / Scottish Intercollegiate Guidelines Network) Guidelines, in a collaboration between the medicines management team, local commissioner pharmacists, LPC representatives and patients from each practice.

Engaging and upskilling practicesAn asthma education day was held with guest speaker, Professor Martyn Partridge, and attended by 60 GPs and nurses. Each practice received a specific cohort breakdown alongside the management resources to enable and empower them to make appropriate plans of action.

AstraZeneca nurses mentored local practice nurses on optimal management for different cohorts and local commissioner pharmacists visited practices to carry out medication reviews and went into care homes to perform patient medication reviews. A monthly newsletter was developed by the project team to keep all practices up to date on project progress.

Working with secondary careData sharing between the hospital trust and practices was established to allow proactive case management by GP practices following A&E attendance. Standardisation of hospital paperwork was agreed and that a discharge summary would be sent by the hospital to a patient’s practice to allow primary care follow up within 7 days.

What We AchievedThe project led to willing and engaged practices across the CCG, allowing the new tools and guidelines to become the natural way of consulting, and standardised optimal care becoming the norm. The following outcomes were achieved:

• 154 additional asthma patients being identified1

• 21% reduction in emergency admissions to hospital for acute asthma1

• An increase in patient recognition of having a formal self- management plan of up to 73%1

• Within the identified high risk group, improvement from 24.6% to 73.1% who were aware of having a self-management plan1

1. Pulse Practical Commissioning, Raising the Asthma Care Bar, Dr Vijaykumar, December 2012. Available at http://www.pulsetoday.co.uk/home/practical-commissioning/raising-the-asthma-care-bar/20001070.article. Last Accessed April 2018.

2. Asthma UK website. Available at: https://www.asthma.org.uk/about/media/facts-and-statistics/ Last accessed April 2018.

Improving Asthma Care in Partnership with NHS East Surrey CCG

Veeva: GB-9495 | Date of preparation: April 2018

The ChallengeThe prevalence of asthma in the UK is amongst the highest in Europe, estimated to affect 5.4 million people.2 Asthma is managed predominately in primary care with patients taking responsibility for much of the management of their own condition.

Across the East Surrey CCG’s patient population, it was recognised that the care patients received from the 18 practices was variable leading to the potential of suboptimal patient outcomes and ultimately unnecessary spending. The main objective was therefore to reduce unwarranted variation and deliver consistent standards of care across the entire pathway for patients with asthma from the CCG’s 18 practices. To do this, AstraZeneca worked together with NHS Improvement, practices, patients, local commissioner pharmacists, the Local Pharmaceutical Committee (LPC) and secondary care specialists to create centralised guidance, education and resources to allow practices to autonomously manage their asthma patients in the most effective and efficient manner.

The Steps TakenConsistent patient cohortingAstraZeneca provided a data interrogation tool which defined specific cohorts to help practices group and manage their patients. Four cohorts were identified and profiled, the largest being patients who were receiving asthma medications but had not received a formal diagnosis. These cohorts were used to inform the types of other resources required.

Creating central resourcesFrom the cohort profiling, the team developed standardised read codes and two types of formal self-management plans — one pictorial and one text-based – for use by practices with their patients. Local asthma diagnostic guidelines and a treatment pathway were developed in line with the BTS/SIGN (British Thoracic Society / Scottish Intercollegiate Guidelines Network) Guidelines, in a collaboration between the medicines management team, local commissioner pharmacists, LPC representatives and patients from each practice.

Veeva: GB-9495 | Date of preparation: April 2018

Engaging and upskilling practicesAn asthma education day was held with guest speaker, Professor Martyn Partridge, and attended by 60 GPs and nurses. Each practice received a specific cohort breakdown alongside the management resources to enable and empower them to make appropriate plans of action.

AstraZeneca nurses mentored local practice nurses on optimal management for different cohorts and local commissioner pharmacists visited practices to carry out medication reviews and went into care homes to perform patient medication reviews. A monthly newsletter was developed by the project team to keep all practices up to date on project progress.

Working with secondary careData sharing between the hospital trust and practices was established to allow proactive case management by GP practices following A&E attendance. Standardisation of hospital paperwork was agreed and that a discharge summary would be sent by the hospital to a patient’s practice to allow primary care follow up within 7 days.

What We AchievedThe project led to willing and engaged practices across the CCG, allowing the new tools and guidelines to become the natural way of consulting, and standardised optimal care becoming the norm. The following outcomes were achieved:

• 154 additional asthma patients being identified1

• 21% reduction in emergency admissions to hospital for acute asthma1

• An increase in patient recognition of having a formal self- management plan of up to 73%1

• Within the identified high risk group, improvement from 24.6% to 73.1% who were aware of having a self-management plan1

‘The project has been a real success for the 18 practices across the CCG and has clearly demonstrated that case finding, standardised management and medicines optimisation improves asthma care for patients, joins up the efforts of healthcare professionals working with asthma patients across the healthcare spectrum and has the potential to result in important cost savings for the NHS.’

Dr Elango Vijaykumar Respiratory Lead, East Surrey CCG (January 2013)

‘We have now worked on a number of successful Joint Working projects with AstraZeneca and the outcomes have been extremely valuable to the CCG. More importantly however, they have had a real impact for patients and healthcare professionals in the East Surrey community. The amount that we can achieve when we pull together, pooling resources and expertise, is really impressive and proves we can do things better together.’

Dr Joe McGilligan, Chair of East Surrey CCG and Co-Chair Surrey Health and Wellbeing Board (January 2013)