Case study – Greener Respiratory Care
Project:
Improving respiratory care whilst reducing the environmental impact of inhaler prescribing – innovative strategies in two Liverpool PCNs
Organisations:
Central Liverpool PCN and North Liverpool PCN,
Cheshire and Merseyside Greener Practice,
Cheshire and Merseyside Respiratory Network
SEE Sustainability – Matt Sawyer – who provided the carbon footprint data.
What was the issue?
The prevalence of asthma and COPD in Cheshire and Merseyside is higher than the averages in England. A Cheshire and Merseyside Inhaler Steering group, supported by the regional Respiratory Network, identified training opportunities for Primary Care Network (PCNs) professionals as important to promoting effective greener respiratory care. The project explored whether the education model used is effective in achieving this at a large scale across 2 PCNs.
What action was taken?
Education of nurses, pharmacists and other clinicians around improving respiratory care for asthma and COPD patients whilst achieving carbon savings, using mostly existing resources and through innovative partnerships.
The education model involved,
- A training session for pharmacists and nurses, delivered by a Greener Practice GP and the PCN lead pharmacist.
- Why low carbon prescribing is important.
- Which inhalers to switch from/to.
- Focus on asthma review aspects that impact on the environment and contribute to patient care: addressing patient understanding of inhalers and technique, overuse, disposing of finished inhalers safely at the pharmacy.
- Using new amended asthma and COPD templates
- Identification of patient target groups, provided to nurses and pharmacists to do patient reviews.
- Identification of stable patients on Ventolin or salbutamol generic MDIs for switching to salamol MDI.
- Allocation of 1 session fortnightly for pharmacists to review patients only on a SABA and address overuse. If complex they will refer to the nurse.
- Nurses incorporated greener respiratory targets as part of their annual reviews and review complex patients from pharmacists.
- For those who switch follow up review at 4-6 weeks.
- Identify one lead pharmacist and nurse per PCN to supervise and review progress.
- Adapt existing asthma and COPD templates to incorporate environmental aspects of inhaler prescribing (with training as above).
- Reaudit outcomes at 5 months.
- Patient and staff survey
What was the ‘Delivering a Net Zero NHS’ benefit?
Both NLPCN and CLPCN have made significant changes to their prescribing of SABA inhalers resulting in a lower average emissions per inhaler[1].
North Liverpool PCN
April 21 5,907 * 23.63 = 139,582 kg CO2e
April 22 5,704 * 14.66 = 84,865 kg CO2e
40% reduction in carbon emissions
Central Liverpool PCN
April 21 4,005 * 23.45kg/inhaler = 93,917 kg Co2e
April 22 4,221 * 12.63 = 53,311 kg co2e
43% reduction in carbon emissions
Data is taken from the greener NHS dashboard.
What were the wider benefits?
Patient satisfaction with the review process
- There was majority satisfaction with the experience of the review and inhaler switching.
- 71% felt switching was well explained.
- 67% agreed the new inhalers were easy to use (20% neutral, 8% disagreed).
- 82% said the switch gave them similar (34%) or improved (48%) asthma/COPD control.
- Comments from patients suggested that discussion of environmental impacts of respiratory care was welcome.
Capacity building
- Improved confidence of nurses and pharmacists in greener prescribing.
- Upskill pharmacists in auditing and survey techniques.
Learning identified.
Challenges
- SABA overuse skilled clinicians and prescribing strategies needed.
- Pharmacist/Nurse Reviews
- takes 5-10 mins
- Low levels of reviews of poor respiratory control needs addressing.
- Stakeholders:
- Importance of identified nurse and pharmacy leads.
- Network pharmacy teams need upskilling in data collection/ analysis.
- Communication difficulties across the PCN practices
- There is a need to engage further with nurses to clarify barriers and issues in delivery.
- Behaviour changes difficult to achieve in a short time, needs repetition.
Opportunities
- Salamol switch
- Roll out of salamol switch will lead to big carbon savings.
- Roll out and promotion of education package including new Pan Mersey guidance
- Increased stakeholder engagement:
- Increased support from Place leads, secondary care and CRT needed to standardise protocols/ templates etc and promote Greener respiratory care in the community.
- Involvement community pharmacy
- Increased patient engagement and education
- Development of respiratory nurse and pharmacy leads needed at Place and PCN level
- Strategies to address SABA overuse spanning across primary and secondary care.
- Centralising data searches and increased input from MOT to enable communications / alerts/ pop-ups etc
Link for further information:
Guide for Healthcare Professionals:
NICE patient information:
Asthma and Lung UK, patient materials:
https://www.asthmaandlung.org.uk/inhaler-choices
Key contact and email:
Nicki Dowling, GP Jubilee Medical Centre, North Liverpool PCN (NLPCN) Nicola.dowling@livgp.nhs.uk;
and Nadja van Ginneken, GP Brownlow Health, Central Liverpool PCN (CLPCN) Nadja.vanginneken@livgp.nhs.uk