Four years on: better care for all

We made recommendations about improving the management and treatment of lung disease. Here’s what’s happened in 2022.

Comment from the Medicines Optimisation Working Group Co-Chairs

This year there have been some important national developments regarding improvements in the utilisation of medicines to better help people manage their lung condition. Firstly, we are encouraged by NHS England’s ambitions to reduce the over-reliance on medications, like short-acting beta-2 agonists (SABA), which provide relief of symptoms but do not address the underlying inflammation of the airways. This over-reliance on SABA and under-use of anti-inflammatory medicine may lead to a large portion of asthma patients living with daily uncontrolled symptoms. We look forward to continuing to collaborate on this issue.

In terms of improving access to new or better medicines, there have been several positive steps in 2022. One exciting development has been the recommendation by NICE to extend the lung capacity set range for antifibrotic drug Nintedanib to those in the earlier stages of idiopathic pulmonary fibrosis. Taskforce member Action for Pulmonary Fibrosis has campaigned tirelessly on this issue and the news will be very welcome for those people with IPF who were previously unable to access this vital drug, which is one of very few that can slow down progression of the disease. The Taskforce will continue to make the case for greater access to antifibrotics for pulmonary fibrosis patients in 2023. Another development has been the publication of an Accelerated Access Collaborative consensus pathway on greater access to biologics for people with uncontrolled and severe asthma, which aims to improve access to asthma biologics, by supporting improvements in treatment pathways so that more patients receive specialist care at the right time.

In support of a shift towards the prescribing of more environmentally-friendly dry powder inhalers for people with lung conditions, 2022 has seen the introduction of two Investment and Impact Fund (IIF) incentives: to encourage the prescribing of preventer inhalers and the reduction of SABA prescribing.

The Taskforce will continue to work to ensure patients receive meaningful annual reviews and inhaler checks, as well as information about their medication that is clear and fit for purpose. We have some concerns about NICE’s Asthma inhalers and climate change decision aid and will produce a blog highlighting our concerns. This blog will set out the importance of shared decision making and reinforces the need for inhaler technique checks when switching devices.

We continue to make a strong case for an enhanced role for community pharmacists in supporting people with lung conditions and this includes influencing the scheme that will follow on from the current Community Pharmacy Contractual Framework when it ends in 2024. We share members’ concerns about the financial incentives for community pharmacies and closures in areas where health needs and health inequalities are greatest. We think that there is much more community pharmacy can do for people with lung conditions, and we will set out our vision for their role in 2023.

It will be interesting to see what, if any, influence Prime Minister Rishi Sunak’s upbringing – his father is a GP and his mother is a pharmacist – might have on the community pharmacy agenda moving forward, especially given he has previously spoken out in support of local pharmacies.

Co-Chairs of the Taskforce for Lung Health medicines optimisation working group:

Dr Anna Murphy, Consultant Pharmacist, British Pharmaceutical Society
Darush Attar-Zadeh, Community Pharmacist, Primary Care Respiratory Society

Recommendation 3d: Improve inhaled therapy, by developing a clear pathway for accurate prescribing and adherence, and promoting new technology such as smart inhalers

In 2021, NHS England distributed information packs that included Taskforce analysed data, to support each respiratory clinical network to tackle the issue of high prescribing rates for short-acting beta-2 agonist (SABA). We have continued to raise awareness of the issue throughout 2022. In 2023, we hope to get feedback from respiratory networks to understand how useful these packs were, with a view to providing more support as appropriate. It is encouraging that this issue is supported by NHS England, and we await evidence to see if there is the start of a downward trend.

In April 2022, two new indicators were introduced as part of the Investment and Impact Fund (IIF) to support a reduction in carbon emissions from inhalers (given that NHS England estimate that inhalers alone represent around 13% of total emissions in primary care). Primary care networks (PCNs) are now rewarded for more regular prescribing of inhaled corticosteroid for asthma patients and reductions in avoidable short acting beta-agonist prescribing. Our member, Asthma + Lung UK, has worked hard to ensure that these incentives place patient choice right at the heart of any decision to change inhaler. We intend to continue to press the importance of patient centred decision making to NHS England and NICE. We currently have some concerns regarding NICE’s decision aid for patients regarding inhalers and climate change. We feel it doesn’t go far enough to recommend inhaler techniques checks and could be stronger in highlighting that switching should occur only when clinically appropriate.

Recommendation 3e: The government and pharmaceutical industry should work together to improve access to antifibrotic drugs for idiopathic pulmonary fibrosis (IPF), cystic fibrosis transmembrane conductance regulator (CFTR) modulators for cystic fibrosis and monoclonal antibody treatments for severe asthma

Following the good news in 2021 that NICE recommended dupilumab for treating some people with severe asthma and nintedanib for treating progressive fibrosing interstitial lung disease, other than idiopathic pulmonary fibrosis (IPF), we are pleased that in 2022 NICE have recommended extending the lung capacity range for nintedanib to those in earlier stages of IPF. Taskforce for Lung Health responded to the consultation along with our member, Action for Pulmonary Fibrosis, who have campaigned tirelessly for this change. We are delighted by this news and now intend to work with partners to ensure that once the guidance is published in February 2023, that patients with IPF receive clear communications about what it means to them.

In June 2022, we welcomed the publication of the NHS Accelerated Access Collaborative’s Consensus Pathway for Severe Asthma. This aims to improve access to asthma biologics, as to date, too few people are receiving them. This will be achieved by supporting improvements in treatment pathways so that more patients receive specialist care at the right time. We are monitoring implementation of the pathway and how well it promotes the uptake of biologic therapies, and hope to see it deliver better outcomes for people with uncontrolled and severe asthma.

The NICE/SIGN/BTS diagnosis, monitoring and chronic asthma management guidance is in development and publication is expected in 2024. The Taskforce will continue to support our member, Asthma + Lung UK with any engagement it has in the consultation process.

Recommendation 4e: Expand the delivery of NHS Medicines Use Review and NHS New Medicine Services in pharmacies and remove the cap on the number of these they can deliver

Taskforce’s Community Pharmacy sub-group, established in November 2021, continues to make the case for a greater role for pharmacists in the diagnosis and management of people with lung conditions. This work builds on the workshop we co-hosted with NHS England in 2020 and the results of our survey of more than 2,000 participants revealed the extent to which community pharmacies currently support people living with lung conditions and of their untapped potential. We’re delighted that representation on the sub-group has grown to include more practising community pharmacists, and we have also welcomed further expertise from members experienced in service design for community pharmacies.

It is encouraging that several respiratory measures have been included in the Pharmacy Quality Scheme announcement for 2023. However, we know that serious funding and workforce concerns remain, and these will need to be addressed for community pharmacies to realistically meet demand and deliver high quality services. Unfortunately, there is a worrying trend in pharmacy closures, with a net loss of 110 pharmacies in 2021/22 and recent evidence from the Company Chemist’s Association (CCA) revealing that between 2015 and 2022, 40% of the pharmacies permanently closed were in the 20% most deprived areas of England. We are calling for a reform of the current funding settlement so that community pharmacies can continue to deliver for their local populations.

We are pleased to have been invited onto the advisory board of the Pharmaceutical Services Negotiating Committee’s (PSNC) project to develop a vision for community pharmacy. We intend to feed into PSNC content from Taskforce’s own policy position paper which we will be developing in early 2023. This will set out our ambitions for how community pharmacists can support the prevention of lung disease, smoking cessation, early diagnosis, getting the most out of medicine, and support for self-management. We intend to also use our vision paper to influence NHS England and other policy makers.

“Pharmacists are ‘the responsive, local heartbeat of our healthcare system’.”
Rishi Sunak, March 2022