There are over 25,000 patients currently diagnosed with asthma in Wakefield and over 10,000 diagnosed with COPD.
The MSO was assigned to lead on respiratory within the MOT and is a key member of the Wakefield Respiratory Partnership Group. The Group consists of Primary, Secondary and Community Care clinicians and managers that work together to improve respiratory outcomes in Wakefield. As part of the Group’s work, the MSO supported the development of local care pathways and guidelines that include recommendations for prescribing and supporting the delivery of respiratory education events in Wakefield, alongside providing bespoke support to GP practices.
In 2014, the National Report of Asthma Deaths (NRAD) was published. The report stimulated work locally which focused on safety recommendations, with the MSO’s role focusing on highlighting patients that may be at risk alongside recommending options to optimise medication regimes.
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The MSO has remote access to local GP clinical computer systems, which means that practices can be supported with running safety-based searches.
Prompted by the NRAD, the initial work focused on identifying patients who were prescribed a long acting beta agonist (LABA) without an inhaled corticosteroid (ICS), commonly termed as LABA monotherapy, alongside excessive short acting beta agonist use and the generic prescribing of combination inhalers.
The MSO has also worked with the Specialist Respiratory Team at The Mid Yorkshire Hospitals NHS Trust to review the use of nebulised medication in the community, due to safety concerns raised about clinical appropriateness, nebuliser maintenance and patients who purchase their own machines. Local guidance, education and a clear pathway for assessment have been implemented and the MSO has identified patients for review.
Whilst performing the respiratory prescribing safety reviews, the MSO also identified excessive rescue medication use in some COPD patients. This identification directly influenced the most recent update to the COPD pathway, which is used across four CCGs, with advice added to the pathway specifying that rescue packs should not be routinely provided without assessment for suitability.
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Whilst the number of patients on LABA monotherapy was relatively small (approximately 70 patients), there are now less than five people prescribed a LABA alone with a diagnosis of asthma and zero patients with COPD diagnosis prescribed a LABA monotherapy across the Wakefield district.
Generic prescribing of combination ICS/LABA inhalers was also highlighted as a risk in the NRAD. Prescribing data for April 2016 identified that approximately 4,000 ICS/LABA inhaler items were dispensed against generic prescriptions. In February 2018, this has reduced by more than two thirds.
Initial searches for excessive issues of a short acting beta agonist (SABA) in patients with asthma identified that there were a large volume of patients that fulfilled the criteria for excessive use (more than three issued over a period of three months). A sensible priority approach was taken to target the highest users e.g. patients who were seen to be ordering more than 20 per annum.
The below case study was forwarded from a local GP practice to the MSO which highlights the positive outcome initiated through the MSO’s intervention:
MSO highlighted a patient to a GP due to concerns over excessive SABA use (not prescribed an inhaled corticosteroid). The GP completed a review in the practice with the patient. Following the review, the GP received a telephone call from the patient which informed them:
- Patient is completing their breathing exercises and measuring peak flow
- Patient has only used her reliever inhaler twice in the last three days, which is the least she has used it in years
- Patient feels great since taking preventer inhaler and wishes she had done this sooner
- Patient is experiencing less panic attacks and wishes to thank the MSO for their help.
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Lisa Chandler, Public Health Principal and Lead Commissioner for Respiratory at NHS Wakefield CCG expresses how every Primary Care organisation needs an MSO as the role is invaluable in educating clinicians to ensure safe and effective prescribing. The voice of the MOT is extremely important and the intelligence and information they possess is vital.
Proactively supporting GP practices, by highlighting patients for review on an ad-hoc basis, is popular with clinicians due to its safety rationale, which is not just based on cost efficiency. The MSO believes the key to the success of this work is partly due to the strong relationships the MOT has built with practices over many years. The clinician is able to respond to the MSO to inform of any outcomes of the review and further seek advice if necessary. This mechanism builds trust as it does not focus on identifying poor practice, but instead concentrates on implementing best practice and improving patient safety.
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Next steps and contact information
Primary care really benefits from someone who is able to implement searches away from the pressure of everyday practice, to prioritise actions and reduce risk in a managed way.
The MSO continues to work on further respiratory-based safety initiatives and SABA prescribing safety is part of the local GP contract for 2018. The MSO has searches planned and work lined up to review SABA prescribing without ICS for those diagnosed with asthma.
For more information on the template, please contact: Lyndsey.firstname.lastname@example.org or email@example.com
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