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Introduction
This toolkit is designed for use by healthcare professionals and can help UK general practices improve asthma outcomes whilst also reducing the carbon footprint of asthma care. First published in 2021, this updated version incorporates changes to asthma management as per the joint 2024 BTS/NICE/SIGN asthma guidance.
Why is this needed?
In the UK, poorly controlled asthma is common and leads to avoidable asthma symptoms, attacks and deaths. The UK has one of the worst mortality rates from asthma in Europe. Unfortunately, many people with asthma are still not taking enough preventer medicine (inhaled corticosteroid) or using their inhaler correctly. Getting the right medicine to the right place, is a framework that can be used with patients in the consultation.
Better asthma care is greener asthma care, as well controlled asthma has a carbon footprint which is one-third of the carbon footprint of as asthma that is not controlled. This is largely due to fewer numbers of rescue inhalers being needed as well as less healthcare use due to exacerbations. Furthermore, ensuring that patients are on the most appropriate inhaler for them (as illustrated in this visual guide) can improve care and will often lead to choosing a lower carbon inhaler.
The NHS has set the target of reaching net zero by 2040 for the greenhouse gas emissions which it can directly control (‘NHS Carbon Footprint’). Pressurised metered dose inhalers (pMDIs) contributed 13% of this carbon footprint in 2019. pMDIs contain hydrofluorocarbons (HFC) propellants which are potent greenhouse gases, 1530 – 3600 times more potent than carbon dioxide. In England, approximately 70% of inhalers prescribed are pMDIs. Dry powder inhalers(DPIs) have a much lower carbon footprint and can be safely and effectively used by many patients. Most neighbouring European countries prescribe a far greater proportion of DPIs, and consequently, their respiratory treatments have a far smaller per capita carbon footprint.
Projects
The toolkit contains 10 step-by-step QI projects on asthma and inhalers which can be found in the project library. These help to improve asthma diagnosis, asthma disease control, inhaler device choice and inhaler disposal. Search under ‘medicines and treatment’ to find them. There is also a project on air pollution. We have developed new resources to support improved asthma reviews and have updated lots of resources including the guide on How to Reduce Carbon Footprint of Inhaler Prescribing, downloadable searches, educational videos, patient videos and leaflets.
Tips for success
Look at your baseline data
Have a look at your practice data on asthma care. This will help you decide where to focus your efforts.
In England, the NHS Business Services Authority gives clinicians working in general practice access to ePACT2 data. This data comes from prescriptions that have been dispensed. A respiratory dashboard helps identify patients at risk of poor asthma control (e.g., SABA overuse and oral corticosteroid courses) and a Respiratory – Carbon Impact dashboard looks at prescribing data of low carbon inhalers. You can compare your practice data to practices in your area, region or nationally. You can even request the NHS numbers of patients flagged by dashboards.
Open Prescribing has prescribing data under “Greener NHS” measures. You can view how your practice compares to others in your sub-ICB region or nationally.
Whole team approach
Quality improvement (QI) requires a whole team approach. How is asthma care and inhaler prescribing currently managed within your practice? Think about the patient journey through diagnosis, management and review. Consider the diagram below which shows how the whole practice team is involved in the patient care journey.
Create a team to steer your practice’s QI, with a named lead and regular updates. Everyone in the practice needs to be on board with why QI in asthma care is needed as well as how to improve it. In our educational videos section we have lots of short videos that we recommend are viewed by the whole practice team.
Understand new asthma guidance
The joint 2024 BTS/NICE/SIGN asthma guidance advises a change in diagnosis and treatment approach with combination ICS-Formoterol inhalers offered first line to patients 12 year and over. If implemented this guidance can drive transformative improvements in asthma care. This webinar explains the key changes.
Develop confidence with different inhaler devices
There are many different inhaler devices available to treat asthma and it is crucial that clinicians are familiar with how to use the ones recommended in their local guidance. We strongly advise obtaining placebo inhaler devices, available for free for pharmaceutical companies, to build confidence of the clinical team in how to advise and prescribe these. You may also wish to consider obtaining inhaler training devices.
Educational Videos
In this section we have teamed up with experts to create short videos with the knowledge you need to undertake QI work.
Diagnosis
In this 10-minute video, Dr Katherine Hickman explains what to consider when we suspect a patient may have asthma. The video covers the 2024 BTS/SIGN/NICE asthma guidance recommended tests that may aid diagnosis. There is one project to help implement this work in practice.
Disease Control
In this 15-min video, Professor Michael Crooks explains what you need to know to improve disease control for patients with asthma. This includes the evidence for combination ICS-Formoterol inhalers in AIR and MART regimes, the importance of spotting SABA over-reliance and promoting adherence to preventer therapy. There are 5 projects to help implement this work in practice.
Device Choice
In this 15-min video, Dr Alex Wilkinson, Respiratory Consultant, takes us through the clinical knowledge we need to help patients select the right inhaler device for them. There are two projects to help implement this work in practice.
Disposal
In this 2-min video Wendy Tyler-Batt, Clinical Pharmacist, explains how we can inform patients to know when their inhaler is empty and how to dispose of it safely. There are two projects to help implement this work in practice.
Improving Asthma Reviews
This 10-min video by Carol Stonham, Respiratory Nurse Specialist, conducts an asthma review demonstrating the key elements of a high quality asthma review that incorporates the latest asthma guidance. She explains what asthma is and how to treat it through a drawing which is explained in our video “explaining asthma to patients.”
Explaining asthma to patients
In this video, Carol Stonham, Respiratory Nurse Specialist, explains how she explains what asthma is and how treatments work through a simple airways drawing. You can also use an airways diagram (located in the Greener Practice Resources library) for this explanation.
Resources
We have created and collated lots of useful resources to help support improved asthma care. Many of these resources, (searches, SMS/AccuRx text messages, patient videos and leaflets) are embedded within the QI projects. They can also be found here.
For healthcare professionals
How to reduce the carbon footprint of inhalers: We have two guides, one for adults and adolescents >12 years and another for children and young people. These set out key priorities and principles, and have a handy table of inhalers by carbon footprint category.
Visual aid for optimising asthma reviews: One-page visual aid to support a person-centred asthma review. Ensuring patients get the right medicine (preventer) to get the right place (airways). It has hyperlinks to various resources.
Illustration from the severe asthma toolkit website. A larger version of this diagram can be found here by clicking on the image. It can help to explain to patients that the underlying problem in asthma is swelling in the lining of the airways due to inflammation and hence the importance of inhaled corticosteroid as the main treatment for asthma.
Obtaining Placebo inhaler devices: information on how to obtain placebo devices for demonstrating inhaler technique.
IT Resources
Primary Care IT have collaborated with us to develop bespoke searches for all our Asthma Toolkit projects. Instructions on how to request these are contained within each project. We are also working with Ardens on a Greener Practice folder with the searches they already have that best match our asthma toolkit projects. Our visual aid is linked into Ardens asthma template in the inhaler page.
Patients videos and leaflets
We have created two short 3-minute long animated videos and two patient leaflets. These explain to patients ‘What asthma is and how to treat it’ and the different inhaler devices types. These can be found in the resources library. We have also linked these resources into text messages within our projects.
