Healthy London Partnership Transforming London’s health and care together A collaborative approach to population-based management of asthma for children and young people in London Sara Nelson (Programme Lead’ Healthy London Partnership, RGN, MSc, QN) Donal Markey (Pharmacy Advisor, Healthy London Partnership and NHS England, MRPharms, MPH), RCN/RPS event 4.12.2016
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Healthy London Partnership
Transforming London’s health and care together
A collaborative approach to population-based management of
asthma for children and young people in London Sara Nelson (Programme Lead’ Healthy London Partnership, RGN, MSc, QN)
Donal Markey (Pharmacy Advisor, Healthy London Partnership and NHS England,
MRPharms, MPH), RCN/RPS event 4.12.2016
Aims of session
2
• Background to Healthy London Partnership transformation programme
• Why is a collaborative approach to transforming asthma services needed?
• What we have done so far – asthma standards for London
• Pharmacy programme and asthma campaign
• Audit
• Results
• Next steps & Group exercise
Background: London-wide transformation
In 2014, two publications set out London’s transformation priorities
3
Better Health for
London
NHS Five Year
Forward View
Healthy London Partnership was formed by 32 London CCGs and NHS England London to
respond to the strategy and recommendations for London.
The NHS Five Year Forward View set out a broad strategy for health and care
improvement and Better Health for London provided detailed recommendations on
how to deliver this within the London context.
Children and young people
Giving London’s children the best start in life
4
Children and young people living in London generally have
poorer health than those in other parts of the country and the
care they receive is also not so good. Using services for
children can be confusing, services are not joined up and the
care quality varies from place to place.
Healthy London Partnership is working with healthcare organisations and children’s
charities on five priorities for the children and young people:
Work with public health, commissioners and providers to link up care across
geographical boundaries.
Develop London-wide quality standards for commissioners covering acute
care, community care and children and adult mental health services.
Develop new models of care that join up children’s services provided by GPs
through to multispecialty community providers and hospitals.
Ensure those models of care are innovative and take advantage of 21st
century technology.
Support and develop commissioners to ensure clear and effective pathways
of care across different healthcare settings
1
2
3
4
5
01
Transforming London’s health and care together
Why the need for a collaborative
approach in asthma
management for children and
young people?
5
The evidence: facts about asthma in the UK
6
• Asthma is common:1 in 11 children have it, on average, there
are two children with asthma in every classroom.
• There’s a large variation in care and how people access care
across the capital
• The average cost of emergency admission is £951
• There were 25,073 emergency hospital admissions for children
in 2011-2012. On average that’s one every 21 minutes.
• There were 1,167 deaths from asthma in 2011 (18 of these
were children aged 14 and under).
• 90% of the deaths from asthma are preventable.
• Patients with a personal asthma action plan (PAAP) were 4
times less likely to die from an asthma attack.
• 77% of patients had no record of having a PAAP (National Review of
Asthma Deaths)
• 75% of hospital admissions for asthma are avoidable.
Source http://www.asthma.org.uk/asthma-facts-and-statistics
The case for change
Despite over 16 documents in the last five years, there’s still high mortality, emergency admissions and variation in care: we don’t need more
7
The problem: mortality rates from asthma in the
UK are higher than in Western Europe
8
0
5
10
15
20
25
30
0.00
0.05
0.10
0.15
0.20
0.25
Proportion (%) 10 year mortality rate per 100,000 population
10 year mortality rate
Proportion aged 6-7 withwheezeProportion aged 6-7 withasthmaProportion aged 13-14 withwheeze
Directly standardised asthma mortality rate in children aged 0-14 years and proportion aged 6-7 and 13-14
Source: WHO European Mortality Database (2000-10) and the International Study of Asthma and Allergies in
Childhood (2000-03)
Asthma prevalence in London
Recorded prevalence of asthma in London (all ages) 2011/12 (Quality and Outcomes Framework)
9
Asthma Prevalence
3.7 to 4.5
4.5 to 4.7
4.7 to 4.9
4.9 to 5.4
5.4 to 5.7
Richmond CCG
Camden
CCG
Tow er Hamlets
CCG
Islington
CCG
City and
Hackney
CCG
Central
London CCG
West
London
CCG
Waltham
Forest CCG
Brent CCG
Haringey CCG
Southw ark
CCG
Lambeth
CCGWandsw orth CCG
Greenw ich CCG
New ham CCG
Lew isham CCG
Hammersmith
and Fulham
CCG
Ealing CCG
Barking and
Dagenham CCG
Redbridge CCGHarrow CCG
Hounslow CCG
Barnet CCG
Bexley CCG
Merton CCG
Croydon CCG
Bromley CCG
Sutton CCG
Kingston CCG
Hillingdon CCG
Havering CCG
Enfield CCG
London emergency admissions for asthma
10
0
50
100
150
200
250
300
350
400
450
500
Count ofadmissions
Admissionsper 100,000
Bed days per100,000
Source: Hospital Episode Statistics (HES) Copyright © 2013, Re‐used with the permission of The Health and Social Care Information Centre. All
rights reserved.
Data are for 2012/13, and relate to emergency admissions for asthma ; ICD10: J45 or J46
London asthma standards
For children and young people (CYP)
11
• Developed through the children and young people’s asthma leadership group
• Prepared by collating a collection of standards already in existence, building on London Quality Standards, Primary Care Strategic Commissioning Framework and London Acute Care Standards for CYP
Purpose
• Essential guide for commissioners and providers
• Ensure responsible lead for asthma in each organisation
• Improve consistency and quality in CYP services and reduce variation
• Minimum standards of care in one place
It cuts across all organisations and covers: patient and family support; schools; acute and high risk care; integration and co-ordination; discharge planning; transition; effective and consistent prescribing; workforce education and training
Visit
www.londonscn.nhs.uk/publications
to find out more
The answer:
Improving the pathway (using drivers of 5 year forward view)
12
Network system approach with
child at the centre
Home
School Nurse
School
Multispecialty providers with
community development
initiatives Hospital
care
Primary care
HV
Integrated out of
hospital and in
hospital services
London Asthma delivery
programme
Standards
Communication
Education
• Health professionals
• Schools
• Pharmacy programme
Prevention programme
• Schools
• Smoking
Commissioning strategy
• Commissioning
development
Identified lead responsible for asthma within each service, with
MEASURABLE TASKS and EFFECTIVE AUDIT
02
Transforming London’s health and care together
London pharmacies
supporting children and
young people to breathe
easy: public health
campaign and audit
13
Background
Pharmacy services in the England
14
• Every day community pharmacy is the
primary health contact for 1.6 million patients – a total of 438 million contacts per annum in England alone
• The pharmacy workforce is expanding, with a potential oversupply of between
11,000 and 19,000 pharmacists by 2040
• Between 30% and 50% of prescribed medicines for long-term conditions are not taken as recommended
• 1.1 billion prescription items dispensed in 2014, which is a 3.3% increase on 2013
• This represented a with a net ingredient
cost of £8.9 billion.
The NHS England contract framework for community pharmacies involves:
Essential services
• Dispensing
• Signposting
• Promoting a health lifestyle
• Audit
Advanced services
• Medicine Use Reviews ( MUR)
• New Medicine Service
• Seasonal Flu Immunisation
Local services
• Stop smoking
Patient Medication Records:
access to Summary Care Record 2016
Background
Community pharmacy public health campaign 2015
15
• There are 1,858 pharmacies across London.
• All London pharmacies were asked to take part in a campaign To provide key public health messages in relation to asthma management and gather information on current levels of awareness of asthma management in children and young people in London between 24 July and 2 October 2015
• They were asked to carry out a mandatory, brief intervention for a young person (0 to 18), when their parent or carer visited their pharmacy to request a prescription be filled or repeated, purchased an over-the-counter medicine, required emergency supplies or asked for advice on general health and wellbeing.
• An additional, voluntary element - to record the responses of a brief intervention using online survey - was also requested.
Governance: Pharmacy Asthma
Steering Group
Membership:
Pharmacists, Nurses, Doctors, NHS England
(London), HLP representative, LPC representative
Aim
To provide support and advise on the role of
pharmacy and medicines optimisation in the delivery
of London asthma standards for children and young
people.
Asthma and seasonality
16
Week 38 peak!
Audit design
17
Requirements
• Deliver within the NHS Contract
• Simple to administer for pharmacies and easy for patients to understand
• Structured consultation
• “Part of the flow” of a consultation
• Anyone in the pharmacy could administer the audit
• Paperless
• Clearly defined patient cohort
• Anonymised
• Support and CPD provided
• Worthwhile for patients and the pharmacy…”so what” defined
Result
• Public Health campaign within the NHS Contract
• Voluntary additional audit ( outside core contract)
• Audit = 7 questions
• Administration fee
• Supporting all online platforms and also paper
• Real time or retrospective data collection option
• Supporting information pack & CPD
• Opportunities for internal pharmacy referrals for MUR, Flu Vac or stop smoking
• Comms strategy using email
What we asked pharmacies to do
The questions
18
1. Does the child or young person have an asthma action plan or “wheeze plan”?
2. In the last 12 months, has an assessment of inhaler technique by a doctor, nurse
or pharmacist occurred?
3. Does the child or young person use a spacer device?
4. Does the child or young person smoke?
5. Does the child or young person live with someone who smokes?
6. Did the child or young person have a flu vaccination last year?
7. In the last 12 months, have you had to make an emergency request for an inhaler
from your pharmacy, GP, Out of hours services, Walk-in Centre or A&E?
Carers, parents and patients presenting in the pharmacy with a prescription for an
inhaler/spacer, requesting a prescription, requesting an emergency supply, making
an over the counter purchase of medicines or a known diagnosis of asthma.
03
Transforming London’s health and care together
What we found
19
Highlights
Interim results
20
9,462 responses
1,858 Community pharmacies
across the whole of London
were invited to a take part
1,101 Pharmacies
responded
48% Do have an
asthma action
plan or wheeze
plan
70% Had a inhaler
technique
assessment in
the last 12
months
64% Have a spacer
device
96% Do not smoke
23% Live with
someone who
smokes
64% Did not have a
flu jab last year
25% Had to make an
emergency request
for an inhaler in the
last 12 months
60% of the total
number of
pharmacies
32 boroughs
(all) took
part
Campaign
extended to 10 weeks
till 2 October
9.4 Average age
of participant
9 Average
entry per
pharmacy
1 in 4 Entries were
using a smart
device
Participation per
borough
Results
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
Bark
ing a
nd D
age
nham
Hackney
Lew
isham
New
ham
Islin
gto
n
Lam
beth
City o
f Londo
n
To
wer
Ha
mle
ts
Bro
mle
y
Gre
enw
ich
Redb
ridge
Cam
den
Mert
on
Wa
lth
am
Fo
rest
Cro
ydon
Bexle
y
South
wark
Kin
gsto
n u
pon T
ham
es
Sutton
Wa
ndsw
ort
h
Haverin
g
Ric
hm
ond
upo
n T
ham
es
Barn
et
Hill
ingd
on
Enfield
Kensin
gto
n a
nd
Che
lsea
We
stm
inste
r
Ham
mers
mith a
nd F
ulh
am
Harin
gey
Ealin
g
Harr
ow
Bre
nt
Houn
slo
w
Only 4% did not want to
participate
0
10
20
30
40
50
60
70
80
90
100
Ba
rnet
Be
xle
y
Bre
nt
Bro
mle
y
Cam
den
City o
f London
Cro
ydon
Ea
ling
En
fie
ld
Gre
enw
ich
Hackney
Harin
gey
Harr
ow
Haverin
g
Hill
ingd
on
Hounslo
w
Islin
gto
n
Lam
beth
Lew
ish
am
Me
rton
New
ha
m
Redbridg
e
So
uth
wark
Su
tton
To
wer
Ham
lets
Waltha
m F
ore
st
Wa
ndsw
ort
h
Westm
inste
r
Ba
rkin
g a
nd D
agenham
Ham
mers
mith a
nd F
ulh
am
Ke
nsin
gto
n a
nd C
hels
ea
Kin
gsto
n u
pon T
ham
es
Ric
hm
ond u
pon T
ham
es
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
0-4 5-18
Number of pharmacies in borough Average age per participant
12.14% (46)
87.86% (333)
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
0-4 5-18
% of Contacts - Reponded 'No' for all 7 Questions by Age Cohort
% participation of pharmacies by borough
Number of contacts by borough
Question 1
Does the child or young person have an asthma action plan or wheeze plan?
2%
51%
47%
Don't know
No
Yes
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Don't know No Yes
By age
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%
Don't know No Yes
By borough
4%
29%
67%
Don't know
No
Yes
Question 2
In the last 12 months has a doctor, nurse or pharmacist provided an inhaler technique assessment?
25
-
100
200
300
400
500
600
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Don't know No Yes
0%10%20%30%40%50%60%70%80%90%
100%
Yes No Don't know
By age
By borough
Question 3
Does the child or young person use a spacer device?
1%
35%
64%
Don't know
No
Yes
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Don't know No Yes
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
Yes No Don't know
By borough
By age
Question 4
Does the child or young person smoke?
By borough
By age
0.0%1.0%2.0%3.0%4.0%5.0%6.0%7.0%
1%
96%
3%
Don't know
No
Yes
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
20.0%
13 14 15 16 17 18
Question 5
Does the child or young person live with someone who smokes?
By borough
By age 2%
75%
23%
Don't know
No
Yes
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Don't know No Yes
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Yes No Don't know
Question 6
Did you the child and young person have a flu vaccination last year?
By borough
By age
8%
59%
33% Don't know
No
Yes
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Don't know No Yes
0%10%20%30%40%50%60%70%80%90%
100%
Yes No Don't know
Question 7
In the last 12 months, has the child or young person had to make an emergency request for an inhaler from any healthcare provider (Walk-in Centre, GP, out-of-hours service, pharmacy or A&E)?
By borough
By age 3%
72%
25%
Don't know
No
Yes
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Don't know No Yes
0%10%20%30%40%50%60%70%80%90%
100%
Yes No Don't know
Comparing questions 1 and 7
Does having an asthma action plan relate to an emergency inhaler request?
31
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Q1-Asthma Action Plan-Yes Q7-Inhaler Emergency Request-Yes
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0% Q1-Asthma Action Plan-Yes Q7-Inhaler Emergency Request-Yes
By borough
By age
Comparing questions 1 and 6
Does having an asthma action plan relate to having a flu vaccination?
32
By borough
By age
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Q1-Asthma Action Plan-Yes Q6-Flu Vacc-Yes
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%Q1-Asthma Action Plan-Yes Q6-Flu Vacc-Yes
Comparing questions 2 and 7
Does having a recent inhaler technique assessment relate to making an emergency request for an inhaler?
33
By borough
By age
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%
Q2-Inhaler Technique Assessment-Yes Q7-Inhaler Emergency Request-Yes
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Q2-Inhaler Technique Assessment-Yes Q7-Inhaler Emergency Request-Yes
Comparing questions 5 and 7
Does living with a smoker relate to child and young person making an emergency request for an inhaler?
34
By borough
By age
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Q5-Lives with Smoker-Yes Q7-Inhaler Emergency Request-Yes
0.0%5.0%
10.0%15.0%20.0%25.0%30.0%35.0%40.0%45.0%50.0% Q5-Lives with Smoker-Yes Q7-Inhaler Emergency Request-Yes
04
Transforming London’s health and care together
Next steps
35
Further analysis and sharing results
36
• Significantly more analysis of data – age,
borough
• Established a collaborative of 8 CCGs to
develop commissioning asthma
management services from pharmacies in
2016
• CCG commissioners pack: CYP, Out of
hospital care & urgent care
• Qualitative analysis of the audit format –
future audits
• Dissemination strategy
• School nurses/schools /pharmacies
“buddy” project across London
Next steps
37
Special thanks to….
38
London Community Pharmacies
Collette Datt, Nurse Consultant Asthma/Allergy, Whittington Health NHS Trust
Steve Tomlin, Consultant Pharmacist, Evelina London Children’s Hospital NHS Trust
Brian Mackenna, Prescribing Advisor, Islington CCG
Ash Soni, RPS President & LPN Pharmacy Chair (London)
David Tamby Rajah, Head of Community Pharmacy Contracts - NHS England London Region
Alice Benton, Regional Lead Dental, Optometry and Pharmacy, NHS England London Region
Lila Thakerar, Community Pharmacist, Shaftesbury Pharmacy
Virginia Chachati, Community Pharmacist
Tolu Adams, Community Pharmacist, Day Lewis
Ali Patel, Community Pharmacist & independent prescriber
Linnea Lindqvist, Community Pharmacist, Boots
Dr John Moreiras, Consultant Paediatrician, Whittington Health NHS Trust
Tracy Parr, Paediatric Nurse Specialist & HLP Programme Lead, Children & Young People’s Programme
Nickola Rickard, School Nurse & Asthma Friendly Schools Project Lead Islington
Katrina Swanston, Communications Manager, NHS England
Rekha Shah, Bhavin Patel & All London Local Pharmaceutical Committee (LPC) Leads
Annette Kimber, Primary Care Commissioning Manager Dental, Optometry & Pharmacy, NHS England
Adaeze Analyst, Operational Information for Commissioning, NHS England
Sabrina Rahman, Operational Information for Commissioning, NHS England
Dr David Finch, Medical Director NHS England London North West
Darush Attar- Zadeh, Clinical Lead Medication Optimisation ( COPD & Asthma) , Barnet CCG
Members of the London Respiratory Network
Thank you!
39
Sara Nelson RGN MSc Qni
Programme Lead, Children and
Young People’s Transformation
Programme
Healthy London Partnership
Bromley CCG
Governing Body Nurse
07960 046611
Donal Markey MRPharmS MPH
Pharmaceutical Advisor, Healthy
London Partnership
Pharmacy Advisor
NHS England London Region
Chair, Pharmacy CYP Asthma
Steering group
07796934519
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