Three years on: better care for all

We made recommendations about improving the management and treatment of lung disease. Here’s what’s happened in 2021.

Comment from the Medicines Optimisation Working Group Co-Chairs

It has been a difficult year for patients, many of whom have struggled to receive the support they need to manage their treatment of lung disease appropriately. The pandemic has continued to interrupt healthcare services ability to deliver annual checks and inhaler technique training, as borne out in the worrying results of the Taskforce’s new survey of patients’ experiences of inhaler technique checks. COVID-19 modifications to services have also seen a switch to remote checks and in response we have published our recommendations for when and how these remote reviews should be used.

However, against this backdrop, there have been some important developments towards achieving our ambitions to improve the use of medicines. In particular, this year has seen NHS England take up our concerns regarding the over-prescribing of short-acting beta-2 agonist (SABA) e.g. salbutamol inhalers in people with asthma. We are pleased that our analysis of the problem has been included in NHS England’s information packs that have been sent out to local areas pressing them to take action.

We have also made a strong case for an enhanced role for community pharmacists in supporting patients to have the right technique when using inhalers. This has seen us recently establish a Taskforce subgroup to drive forward this work in 2022. We are disappointed that incentive payments for pharmacists to undertake inhaler technique checks were not made part of the Pharmacy Quality Standard (PQS), part of the Community Pharmacy Contractual Framework (CPCF), except when done as part of the more limited New Medicines Service (NMS), and we will continue to push for inhaler technique optimisation to be included.

There has been good news from NICE with regards to improved access to ninetdanib for progressive fibrising ILD patients and dupilumab for people with severe asthma and we hope that in 2022 there will also be changes to the eligibility for antifibrotics for treating idiopathic pulmonary fibrosis (IPF).

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

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

Recommendation 3c: All surgery units to employ enhanced recovery after surgery (ERAS) guidelines with a specific focus on lung health

During 2021, Taskforce has supported a funding bid by Dr Babu Naidu to the National Institute for Health Research for a randomised controlled trial to investigate an app-based pre-habilitation programme (Fit4Surgery) to enhance physical function and reduce complications after lung surgery. We supported the bid because with support to ‘prehabilitate’ before surgery and rehabilitate after surgery, patients can get home from hospital sooner and in a better condition.

Unfortunately, access to appropriate support is currently extremely limited. The Fit4Surgery app has the potential to increase uptake and improve outcomes for patients, in line with our existing recommendations. Robust evidence is therefore needed to understand how well this digital intervention works. If successful, we expect that this research would inform practice for the benefit of all patients with lung disease requiring surgery across the country.

This year also saw the publication of an audit survey carried out in 2020 at all 36 centres that perform lung surgery in the UK and Ireland. The results provide useful insights into the use of enhanced recover after surgery (ERAS) as well as identifying current barriers to wider implementation.

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

There are a number of important components to improving inhaled therapy that need to be considered and progressed in order to secure progress of this recommendation.  The Taskforce has analysed SABA prescribing rates, finding worrying variations between regions, with some rates suggesting areas are significantly overprescribing SABA.

We set out a strong case for why this needs to be addressed and we are pleased that NHS England have agreed to take this up as a priority area. They have developed and distributed information packs to support each respiratory clinical network to tackle the issue and the packs include our analysis of the data. An example of this data can be found here. In 2021, we intend to increase public awareness of SABA overuse through targeted media work and support the respiratory networks to make changes.

Another dimension of our work towards this recommendation is improving patients’ technique when using their inhalers. To achieve this Taskforce want to see healthcare services undertake more timely and accurate consultations to confirm patients are using the correct technique. As a consequence of the pandemic many checks that would previously have taken place face-to-face have had to be switched to take place remotely.

To help to optimise the value of these remote checks, we published a position paper which sets out recommendations for when remote reviews should be used, as well as providing examples of how virtual consultations can be carried out in practice. We were pleased our paper was supported by the NHS England and Improvement Consolidated Inhaler Working Group and it is also being included in their resource packs for all local clinical networks.

To build understanding of how patients currently experience inhaler technique checks Taskforce undertook a survey this year of 1,075 people with a wide range of lung diseases. We are deeply concerned by the findings which reveal that almost one quarter (23%) had never had, or don’t remember ever having, an inhaler technique check. In addition, three quarters (76%) stated that they hadn’t had their inhaler technique checked in the last 12 months, including those people who had newly prescribed with an inhaler.

There are also worrying health inequalities, with the results showing that those from the most deprived third of our society are around 30% more likely to have never had an inhaler technique check, as compared to those from the least deprived third. We intend to use the results to strengthen our case for improved inhaler technique checks and services.

There is a government commitment to reducing the negative climate impact of prescribed medicines. As part of the Investment and Impact Fund (IIF), in October 2021 incentives were introduced for switching to more environmentally-friendly inhalers, where clinically appropriate. Our member, Asthma + Lung UK have worked hard to ensure that these incentives take into consideration patients being actively involved in the decision-making process regarding any prescription change, and the importance of patient choice. In April 2022, two other incentives for asthma prescribing will also be launched as part of the IFF; these support an increase in preventer prescribing and decreasing SABA prescribing. The Taskforce supports use of these incentives to help deliver improved treatment for people with lung disease and better health outcomes.

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.

In October 2021, NICE finally recommended dupilumab for treating some people with severe asthma and nintedanib for treating progressive fibrosing interstitial lung disease, other than IPF. We applaud the effort of our members, including Action for Pulmonary Fibrosis, for their commitment in campaigning for this change. NICE have also agreed to review the 80/50% rule that determines eligibility for antifibrotics for treating IPF. We hope 2022 will see a positive ruling being made for the huge benefit of patients across the country.

In other good news, biologics have been included as part of the Accelerated Access Collaborative treatment for severe asthma. Asthma biologic medicines can contribute to reducing asthma attacks, asthma-related hospital admissions and long-term side effects of other treatments such as oral steroids. We expect to see outputs from this programme very soon and Taskforce will look to support uptake of biologics for people with severe asthma in 2022.

We’re also encouraged that the NICE/SIGN/BTS asthma guideline scoping began in September 2021. Taskforce will continue to support Asthma + Lung UK in making the case for including clear referral criteria for people with suspected severe asthma.

Recommendation 3f: Fully implement British Thoracic Society (BTS) home oxygen therapy guidelines to improve use of home and ambulatory oxygen. Fully implement the National Institute for Health and Care Excellence (NICE) quality standard on idiopathic pulmonary fibrosis (IPF) to ensure patients have access to beneficial home and ambulatory oxygen therapy

The British Thoracic Society and the Respiratory Futures programme continue to promote uptake of their Quality Improvement tools and best practice examples to support health care professionals to be aware of, and apply best practice in the use of home oxygen.

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

We have established a new Taskforce Community Pharmacy sub-group that met for the first time in November 2021. This builds on the workshop we co-hosted with NHS England in 2020 and the results of our 2020 survey of more than 2,000 participants, that revealed how much community pharmacies currently support people living with lung conditions and of their untapped potential. The sub-group are now working on setting out our vision for how respiratory health can be supported by community pharmacies and they will establish a baseline service requirement.

Our work with pharmacy also includes influencing the content of the next contractual framework for community pharmacists and the Pharmacy Quality Standard (PQS). In September 2021, the PQS was published and included a requirement for healthcare professional training to be required for all pharmacists delivering inhaler technique checks. Unfortunately, a payment for pharmacists to undertake routine inhaler technique checks was not included within the PQS funding. Instead, these checks are only funded as part of the existing New Medicines Service (NMS), so pharmacists are only paid to do them with patients prescribed a new kind of inhaler, rather than also including patients receiving repeat prescriptions. Next year we will be continuing to make the case for routine inhaler technique checks to be included as an essential service for all patients on relevant medication.

Medicines Use Reviews (MURs) have now been phased out in the NHS in England. The Taskforce remains committed to enhancing the role of pharmacists in managing and supporting respiratory patients. Our newly established Taskforce Community Pharmacy sub-group will be taking forward our work to ensure people with lung disease can access medicines reviews and inhaler technique checks through their community pharmacy.