Primary Care Respiratory UPDATE - pcrs-uk.org · Primary Care RespiratoryUPDATE Volume 1 Issue 1...

Primary Care Respiratory UPDATE

Volume 1 Issue 1

July 2014

HIGHLIGHTS ...

Editor’s welcome

Why people die from asthma –have we become complacentin primary care?

Top tips for getting the basicsright in asthma care

Delivering respiratory excellence locally – get involved

New resources to support youto deliver high quality care inasthma and COPD

www.pcrs-uk.org/pcru

This journal has been produced for members of PCRS-UK and is intended for healthcare professionals only

Relvar Ellipta is indicated for patients ( 12 years) uncontrolled on inhaled corticosteroids and as needed short acting beta2-agonists1

Because I simplyfor asthma

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The fi rst ICS/LABA combination to deliver continuous 24-hour effi cacy in a practical, once-daily dose1,2

Delivered in a straightforward device3

That offers value to the NHS

Relvar is generally well tolerated in asthma1

Asthma Relvar® Ellipta® (fluticasone furoate/ vilanterol [as trifenatate]) Prescribing information(Please consult the full Summary of Product Characteristics (SmPC) before prescribing)Relvar® Ellipta® (fluticasone furoate/vilanterol [as trifenatate]) inhalation powder. Each single inhalation of fluticasone furoate (FF) 100 micrograms (mcg) and vilanterol (VI) 25mcg provides a delivered dose of 92mcg FF and 22mcg VI. Each single inhalation of FF 200mcg and VI 25mcg provides a delivered dose of 184mcg of FF and 22mcg of VI. Indications: Asthma: Regular treatment of asthma in patients 12 years and older not adequately controlled on inhaled corticosteroids

and ‘’as needed” short-acting inhaled 2-agonists, where a long-acting

2-agonist and inhaled corticosteroid combination is appropriate. COPD:

Symptomatic treatment of adults with COPD with a FEV1<70% predicted

normal (post-bronchodilator) and an exacerbation history despite regu-lar bronchodilator therapy. Dosage and administration: Inhalation only. Asthma: Adults and adolescents 12 years: one inhalation once daily of: Relvar 92/22mcg for patients who require a low to mid dose of inhaled corticosteroid in combination with a long-acting beta2-agonist. If patients are inadequately controlled then the dose can be increased to one inhalation once daily Relvar 184/22mcg. Relvar 184/22mcg can also be considered for patients who require a higher dose of inhaled cortico-steroid in combination with a long-acting beta2-agonist. Regularly review patients and reduce dose to lowest that maintains effective symptom con-trol. COPD: one inhalation once daily of Relvar 92/22mcg. Contraindica-tions: Hypersensitivity to the active substances or to any of the excipients (lactose monohydrate & magnesium stearate). Precautions: Pulmonary tuberculosis, severe cardiovascular disorders, chronic or untreated infec-tions, diabetes mellitus. Paradoxical bronchospasm – substitute alterna-tive therapy if necessary. In patients with hepatic with moderate to severe impairment 92/22mcg dose should be used. Acute symptoms: Not for acute symptoms, use short-acting inhaled bronchodilator. Warn patients to seek medical advice if short-acting inhaled bronchodilator use increas-es. Therapy should not be abruptly stopped without physician supervision due to risk of symptom recurrence. Asthma-related adverse events and exacerbations may occur during treatment. Patients should continue treat-ment but seek medical advice if asthma symptoms remain uncontrolled or worsen after initiation of Relvar. Systemic effects: Systemic effects of inhaled corticosteroids may occur, particularly at high doses for long peri-ods, but much less likely than with oral corticosteroids. Possible Systemic effects include: Cushing’s syndrome, Cushingoid features, adrenal sup-pression, decrease in bone mineral density, growth retardation in children and adolescents, cataract, glaucoma. More rarely, a range of psycho-logical or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children). In-creased incidence of pneumonia has been observed in patients with COPD receiving Relvar. Risk factors for pneumonia include: current smokers, patients with a history of prior pneumonia, patients with a body mass index <25 kg/m2 and patients with a FEV

1<50% predicted. If pneumonia occurs

with Relvar treatment should be re-evaluated. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose- galactose malabsorption should not take Relvar. Interactions with other medicinal products: Interaction studies have only been performed in adults. Avoid -blockers. Caution is advised when co-administering with strong CYP 3A4 inhibitors (e.g. ketoconazole, ritonavir). Concomitant ad-ministration of other sympathomimetic medicinal products may potentiate the adverse reactions of FF/VI. Relvar should not be used in conjunction with other long-acting

2-adrenergic agonists or medicinal products containing

long-acting 2-adrenergic agonists. Pregnancy and breast-feeding:

Experience limited. Balance risks against benefits. Side effects: Very Common ( 1/10): Headache, nasopharyngitis. Common ( 1/100 to <1/10): Candidiasis of the mouth and throat, dysphonia, pneumonia, bron-chitis, upper respiratory tract infection, influenza, oropharyngeal pain, si-nusitis, pharyngitis, rhinitis, cough, abdominal pain, arthralgia, back pain, fractures, pyrexia. Uncommon ( 1/1,000 to <1/100): Extrasystoles. Legal category: POM. Presentation and Basic NHS cost: Relvar® Ellipta®. 1 inhaler x 30 doses. Relvar Ellipta 92/22 - £27.80 . Relvar Ellipta 184/22 - £38.87. Marketing authorisation (MA) nos. 92/22mcg 1x30 dos-es [EU/1/13/886/002]; 184/22mcg 1x30 doses [EU/1/13/886/005]. MA holder: Glaxo Group Ltd, 980 Great West Road, Brentford, Middle-sex TW8 9GS, UK. Last date of revision: November 2013. Relvar® and Ellipta® are registered trademarks of the GlaxoSmithKline group of com-panies. All rights reserved. Relvar® Ellipta® was developed in collaboration with Theravance,Inc.

Adverse events should be reported. For the UK, reporting forms and information can be found at www.mhra.gov.uk/yellowcard. For Ireland,

adverse events should be reported directly to the IMB; Pharmacovigilance Section, Irish Medicines Board, Kevin O’Malley House, Earlsfort Centre,

Earlsfort Terrace, Dublin 2, Tel: +353 1 6764971. Adverse events should also be reported to GlaxoSmithKline on 0800 221 441 in the UK

or 1800 244 255 in Ireland.

References: 1. Relvar Ellipta Summary of Product Characteristics. GlaxoSmithKline; 2014. 2. Bleecker ER et al. Fluticasone furoate/vilan-terol 100/25mcg compared with fluticasone furoate 100mcg in asthma: a randomized trial. JACI In Practice 2014. 3. Svedstater H et al. Ease of use of a two-strip dry powder inhaler (DPI) to deliver fluticasone furoate/vilanterol (FF/VI) and FF alone in asthma. ERS. 2013.

UK/FFT/0077/13(1) Date of preparation: May 2014

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www.relvar.co.uk

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Editorial Office and Publishers

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PCRS-UK also offers licencing opportunities for bulk reproduction of this journal.

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Printed in the UK by Caric Print Ltd, Bournemouth, Dorset in association with Stephens & George Magazines Ltd. Printed onacid-free paper

www.pcrs-uk.org/pcru

EditorDr Hilary Pinnock, Reader, Asthma UK Centre for Applied Research, Allergy and Respiratory Research Group, Centre for Population Health Sciences, University of EdinburghGeneral Practitioner, Whitstable Medical Practice, Whitstable, Kent

Editorial boardIan Culligan, Specialist Respiratory Physiotherapist, WirralDr Stephen Gaduzo, Chair PCRS-UK Executive, StockportDr Laura Ingle, PCRS-UK Education Committee, and GP, OxfordDr Basil Penney, GPwSI in Respiratory Medicine, DarlingtonAnne Rodman, Independent Respiratory Advanced Nurse Practitioner and Education for Health Regional Trainer, LichfieldDr Iain R Small, General Practitioner, Peterhead, Co-chair PCRS-UK Quality Award Development GroupRuth Thomas, Senior Community Respiratory Nurse, Milton KeynesSteph Wolfe, Independent Respiratory Nurse Specialist (Primary Care)

PCRS-UK Chief ExecutiveAnne Smith

PCRS-UK Operations TeamRed Hot Irons Ltd

Competing interests are declared to PCRS-UK and this information is kept on file.

The opinions, data and statements that appear in this journal are thoseof the contributors. The publisher, editor and members of the editorialboard do not necessarily share the views expressed herein. Althoughevery effort is made to ensure accuracy and avoid mistakes, no liabilityon the part of PCRS-UK, the editor or their agents or employees is accepted for the consequences of any inaccurate or misleading information. © 2014 Primary Care Respiratory Society UK. All rightsreserved. Apart from fair dealing for the purposes of research or private study, criticism or review, and only as permitted under theCopyright, Designs and Patent Act 1988, this publication may only beproduced, stored or transmitted, in any form or by any means, withthe prior permission in writing of Primary Care Respiratory SocietyUK. Enquiries concerning reproduction outside those terms shouldbe submitted to Primary Care Respiratory Society UK via [email protected]

The Primary Care Respiratory Society UK is a registered charity(Charity No: 1098117) and a company limited by guarantee registeredin England (Company No: 4298947). VAT Registration Number: 866 1543 09. Registered offices: PCRS-UK, Unit 2 Warwick House, Kingsbury Road, Sutton Coldfield B76 9EE. Telephone: +44 (0)1675 477600 Facsimile: +44 (0) 121 336 1914Email: [email protected] Website: http://www.pcrs-uk.org

The Primary Care Respiratory Society UK is grateful to its corporatesupporters including Almirall Ltd, AstraZeneca UK Ltd, BoehringerIngelheim Ltd, Chiesi Ltd, GlaxoSmithKline, Napp Pharmaceuticals,Novartis UK, Orion Pharma (UK) Ltd and TEVA UK Ltd for theirfinancial support which supports the core activities of the Charityand allows PCRS-UK to make its services either freely available or atgreatly reduced rates to its members. See http://www.pcrs-uk.org/sites/pcrs-uk.org/files/files/PI_funding.pdf for PCRS-UK statement on pharmaceutical funding.


The Primary Care Respiratory Update is publishedquarterly and distributed to members of the PrimaryCare Respiratory Society UK.

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The premier respiratory conference for primary care – offering essential clinical updates, focussing on what works, and helping you take small steps to make a big difference to patient care

Plenary sessionsWhose health is it anyway? Don't forget about me: successful approaches to working with patients l The untapped potential of our patients - Paul Hodgkin, FRCGP, Founder and Chair, Patient

Opinion Limited l A journey with your patient - Dr Liz Moulton, GP trainer, Pontefractl The evidence for personalised respiratory care Dr Hilary Pinnock, Allergy and Respiratory

Research Group, University of Edinburgh and GP, Whitstablel Panel discussion with speakers and invited guests from the British Lung Foundation and

Asthma UK

Where is care going wrong: lessons from the National Review of Asthma Deaths l Where is care going wrong: lessons from the National Review of Asthma Deaths -

Dr Mark Levy, GP and Clinical Research Fellow, London l Putting the lessons into practice - Professor Mike Thomas, Professor of Primary Care

Research, University of Southampton and GP

Making the most of what we've got in asthma and COPD: how does it all stack up?l Making the case for inhaled drug treatments - Dr Jon Miles, Consultant Physician and Director

for Medicine, Rotherhaml Making the case for smoking cessation - Dr Noel Baxter, GP, Londonl Making the case for action plans - Professor Martyn Partridge, Professor of Respiratory

Medicine, Imperial College London, National Heart and Lung Institute

Grand round - lessons from the ERDr Iain Small, GP, Peterhead and Dr Jon Miles

Clinical symposial Improving COPD care in your practice: The National

COPD Auditl Wake up to sleep apnoeal Is chronic cough an effective screening tool for lung

cancer?l The single most important thing you can do for your

patients l npj Primary Care Respiratory Medicine: Round up

Quality in practice sessionsl Successful strategies for identifying and addressing

individuals at high risk for admission across a healthcare community

l Developing a successful pulmonary rehabilitationservice

l Developing a successful home oxygen and reviewassessment service

l Successes in comissioning spirometry servicesl Should you consider a breathlessness service?

npj Primary Care Respiratory Medicine: Research sessionsAbstract presentation sessions on asthma, service delivery and COPD. Plus a poster walk around session.

REGISTER Online NOW http://www.pcrs-uk.org/pcrs-uk-annual-conferenceThe Primary Care Respiratory Society (PCRS-UK) is grateful to the following sponsors of the 2014 conference: Almirall Limited, Boehringer Ingelheim Limited, Novartis UK Limited, GlaxoSmithKline, Chiesi Limited and Orion Pharma (UK) Limited.

Join the PCRS-UK - http://www.pcrs-uk.org/join

Sharing success: inspiring excellence in respiratory care26th-27th September 2014, Hinckley Island Hotel, Leicestershire

PCRS-UK membership is the easy way to help ensure you are delivering high valuepatient-centred care and to support your own professional development

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Great reasons to join the PCRS-UK today

Volume 1 Issue 1 July 2014 5


CONTENTS

Welcome to this PCRS-UK inaugural edition of Primary Care Respiratory UpdateHilary Pinnock ..................................................... 7

Chair's perspective: Why do people die from asthma – have we become complacent in primary care?Stephen Gaduzo .................................................. 9

Policy Round-Up Bronwen Thompson .............................................11

Getting the Basics Right Why Asthma Still Kills – Actions you can take now to help reduce asthma deathsHilary Pinnock, Tricia Bryant ....................................13

Journal Round-UpPaul Stephenson, Aziz Sheikh ..................................15

PCRS-UK News Round-Up .......................... 20

Delivering Excellence Locally June Roberts , Steve Holmes, Sara Askew .................... 21

Unlock, explore and achieve your leadership potential with the Respiratory Leaders Programme Noel Baxter, Sara Askew ........................................ 22

Set up (or join) a local respiratory group and make a real difference in respiratory care in your areaSara Askew, Carol Stonham .................................... 22

PCRS-UK Quality Improvement Programmes:Equipping you to deliver excellence locally

NEW … PCRS-UK Practice Improvement WorksheetsIain Small, Morag Reilly ........................................ 24

NEW… Effecting Quality in Practice (EQUIP)Tricia Bryant, Anne Smith ........................................ 25

PCRS-UK Quality Award – Get recognised for the difference you make in respiratory care ...... 27

Update your clinical practice: excerpt of educational item from npj Primary Care Respiratory Medicine ............30



March 2014 was the last edition of the PrimaryCare Respiratory Journal. Last month, at the con-ference of the International Primary Care Respi-ratory Group (IPCRG) in Athens, it wasre-launched in partnership with the Nature Pub-lishing Group, a top international academic pub-lisher, as npj Primary Care Respiratory Medicine.This important step is tribute to just how far ourJournal has come.

Some of us remember the journal’s very humblebeginnings. I have copies of a newsletter de-scribed as the ‘GPIAG news’ (at the time, GPIAGstood for General Practitioners in Asthma Group)which aimed to update the membership on theactivities of the group and other relevant nationalevents. In November 1992, as Asthma in GeneralPractice it began to publish review articles andclinical summaries along with some audit reportsand, gradually over the years, an increasing num-ber of research articles. It could be relied uponas a useful source of practical clinical informationas well as original research which reflected ourday-to-day practice and stimulated ideas (includ-ing, in 1999, the paper from Kevin Gruffydd-Jones and colleagues entitled ‘Why don’tpatients attend the asthma clinic?’ which trig-gered my interest in telephone consultations forasthma reviews).

The launch as the Primary Care Respiratory Jour-nal in 2000 signalled the broadened respiratoryagenda as well as encompassing multidisciplinaryprimary care. The quality and quantity of re-search articles that it attracted improved year byyear, though it still maintained a core function ofupdating its readers on developments in the res-piratory world. Later, the association with theIPCRG and an ever increasing quality of researchsubmissions maintained the journal’s remarkablerise as a global academic journal, gaining Medlinelisting in 2006 and its first impact factor in 2012.This ranked it as the second primary care specialistjournal globally and nearly half way up the league

table of respiratory journals. An amazing achieve-ment, which reflects the vision of PCRS-UK andIPCRG realised by the determination of the editorsover the last two decades: Mark Levy and morerecently Paul Stephenson and Aziz Sheikh.

npj Primary Care Respiratory Medicine will con-tinue to publish open-access, primary care rele-vant research articles, as online access only(http://www.nature.com/npjpcrm). It will con-tinue to commission editorials, clinical reviewsand perspectives that we know from surveys arevalued by practising clinicians. Education@pcrmwill still be published quarterly, covering a rangeof practical subjects such as diagnosing breath-lessness, managing ‘difficult’ asthma and the clin-ical implications of the new GOLD classificationof COPD. If you haven’t seen all these, they areavailable on the PCRJ website http://www.thepcrj.org/journ/education.php

But whilst the move to partnership with NaturePublishing Group is excellent news for securingthe future success of npj Primary Care Respira-tory Medicine, it leaves a gap in our hands – formany of you tell us that you like a paper journalthat you can browse. We may live in a digitalage, but reading a paper journal is still a conven-ient way of learning about the latest research andkeeping up to date with clinical knowledge aboutrespiratory disease. There is also a need for ameans of communicating news about PCRS-UK,hearing about UK-based events and perhaps avehicle for sharing our activities with colleagues.

All of this and more is to become the remit of thePrimary Care Respiratory Update. I will be lead-ing a multidisciplinary editorial team of generalpractitioners, practice nurses, physiotherapistsand, with the help of the PCRS-UK editorialoffice, we will be producing a quarterly paperpublication for PCRS-UK members.

• Read about Emerging Ideas. We know thatsummaries of research articles are popular as

Welcome to this PCRS-UK inaugural editionof Primary Care Respiratory Update Hilary Pinnock, Editor



a means of hearing about new ideas andcutting edge practice. npj Primary CareRespiratory Medicine plans to produceshort summaries of all their original re-search papers. We will be selectingthose of most relevance to UK practiceand publishing them in Primary CareRespiratory Update the following quar-ter.

• Journal Round-Up. This first edition in-cludes the familiar Journal Watch, a se-lection of the 'best of the rest' written byPaul Stephenson and Aziz Sheikh but,from September, Basil Penney will beleading the journal round-up by high-lighting key papers of relevance to pri-mary care.

• Update your Clinical Practice. We willbe publishing in full one or two articles– typically clinical reviews, perspectivesor education@pcrm – from the previousquarter’s npj Primary Care RespiratoryMedicine. These will be articles of prac-tical clinical relevance which we hopewill be useful in day-to-day practice –see pages 30-32.

• Policy Round-Up. Each quarter Bron-wen Thompson will update us on thelatest developments in the UK healthservices, including any major new re-ports, guidelines and other documentsrelevant to primary care respiratorymedicine. In this first edition, Bronwenhighlights the findings of the National

Review of Asthma Deaths: essentialreading for everyone who provides carefor people with asthma.

• News Round-Up. Keep up with devel-opments from the PCRS-UK and othergroups with this short digest of the lat-est news from PCRS-UK.

• Delivering Excellence Locally. This sec-tion will highlight the activities of PCRS-UK regional leads, champions andaffiliated groups across the UK and willbring you the latest developments inthe resources and programmes avail-able to support you, as a PCRS-UKmember, to improve care in your prac-tice or locality. In short, this will be thenewsletter of the PCRS-UK and will re-place group newsletters with informa-tion about the Respiratory LeadersProgramme, the Quality Award andlocal groups.

• Getting the Basics Right. In each editionof Primary Care Respiratory Update wewill highlight a key clinical area (thisquarter we are focusing on at-riskasthma in the light of the National Re-view of Asthma Deaths) and illustratehow PCRS-UK resources can help youand your colleagues ensure you havethe basics of care right. From time totime we may publish some of our onlineresources, such as new ‘Opinion sheets’and ‘Practice tools’.

• … and for the future? This is a new proj-ect and offers exciting opportunities.Ideas which we have discussed includepublishing reports of innovative serv-ices or audits that have changed yourpractice.

The aim is for the Primary Care RespiratoryUpdate to become ‘the essential update’ forthose working in UK primary care respira-tory healthcare. It does not replace thePCRJ, but complements our newlylaunched scientific journal, npj Primary CareRespiratory Medicine, by bringing togethersome of the academic and clinical highlightswhilst also acting as a conduit for newsabout primary care respiratory medicine inthe UK. Our survey last year suggested thatthis is what you, as members of the PCRS-UK, want from a regular paper journal – butif you have other ideas please tell us! Com-munication works both ways, and we wouldlike to hear from you with ideas, contribu-tions, and letters – and maybe in the futurewe will move into social media with tweetsand blogs.

And finally, don’t keep it to yourself! One ofthe other advantages of a paper journal isthat, when you have read it, you can leaveit for colleagues in your practice to browsethrough over cups of coffee. Use it tospread the news about important develop-ments in respiratory medicine, and howPCRS-UK can support quality primary carepractice.



‘Why Asthma Still Kills’, the report of the NationalReview of Asthma Deaths (NRAD) published onWorld Asthma Day (6th May 2014), hit the head-lines and features strongly in this inaugural editionof Primary Care Respiratory Update. My initial re-actions to it were mixed.

The report is based on data from 195 peoplethought to have died from asthma over a 12-monthperiod and about whom there was sufficient infor-mation to review the circumstances of the death.That is only a proportion of the deaths certified asbeing due to asthma and, thankfully, a very smallnumber compared with the 5.3 million people who,according to Asthma UK, are treated for asthma.

The headline ‘Asthma killing people needlessly’grabbed my attention; any death from a treatablecondition is a tragedy, particularly if there wereshortfalls in that individual’s care. Statements suchas ‘a damning indictment of current routine prac-tice’ really got me thinking, given that the majorityof routine asthma care takes place in primary care.The implication was that GPs and nurses in primarycare are to blame, which feels tough as we areworking under ever greater constraints and pres-sures and increasingly being told we need to do‘more for less’.

Does the NRAD report tell us anything new? Thefindings are depressingly similar to those found inlocal audits and studies for the last 3–4 decades. ‘70%of deaths from asthma are preventable’ is a statisticthat has been cited for as long as I can remember.

I am somewhat bemused when I think about theadvances in drug treatments, the availability ofevidence-based guidelines, the establishment ofasthma clinics and asthma trained nurses since I havebeen in practice (and that’s quite a long time now) –but have we really made no progress in preventingasthma deaths? Could it be that, by consistently and

systematically doing things right and doing the rightthings (www.rightcare.nhs.uk), we could improveoutcomes and reduce avoidable asthma deaths?NRAD would tend to suggest that we could.

Complacency in primary care?

‘Complacency costs lives’ was the headline state-ment from the Royal College of Physicians and, forme, best summarises what the report is telling us.The 195 people who died and on whom the reportfocused – two-thirds of whom tragically had avoid-able factors that might have prevented the death –are the tip of the iceberg. The Compare Your CareCampaign launched by Asthma UK on WorldAsthma Day 2013 suggests that a staggering 86%of people with asthma may not be getting the carethey need. Perhaps the complacency has arisen be-cause of a feeling that asthma was ‘sorted’ with theadvent of guidelines and asthma clinics? The NRADreport suggests we have a way to go.

It is by no means solely the fault of primary care thatpeople continue to die needlessly from asthma; thereport shows failings in every part of the healthcaresystem – from emergency services, through sec-ondary and primary care and with patient factorsalso playing a key part. Nonetheless, it highlightsthe fact that there is a huge amount that can bedone in primary care to improve routine care (seepage 13 for some basic steps all practices can take).

Responding to the challenge

Reading the NRAD report left me more determinedthan ever to continue the fight for improved respi-ratory care. PCRS-UK has had ‘Optimal respiratoryhealth for all’ as its overall goal for many years now.I am inspired to do more, and reassured that PCRS-UK is heading in the right direction with our focuson delivering excellence locally. Once we haveidentified and shared best practice, only by embed-

Chair's perspective: Why do people diefrom asthma – have we become complacent in primary care?Stephen Gaduzo, PCRS-UK Executive Chair



ding it into our routine care will it make adifference.

The first of the 19 recommendations in theNRAD report is that ‘every general practiceshould have a designated, named clinical leadfor asthma’. My ambition is that this clinical leadis not just someone nominated reluctantly totake a lead in ensuring respiratory Quality andOutcome Framework (QOF) points areachieved, but a specifically trained GP or nurse(or preferably both) who are members of theappropriate professional society (yes, the Pri-mary Care Respiratory Society UK!) which cansupport them in ensuring the appropriateprocesses and systems are in place to optimisecare in the practice. PCRS-UK currently hasabout 750 paid/active members – that is farshort of the 10,000 or so GP practices in theUK. In secondary care it is assumed that all res-piratory specialists are members of the BritishThoracic Society. Why is PCRS-UK member-ship not the norm in primary care? Please useyour contacts locally to ensure practices inyour area are aware of PCRS-UK and, on theback of the NRAD report, urge them to en-sure they have a respiratory lead who isproperly trained and supported.

Few of the findings in the NRAD report arenew, but they come at a time when we havenew opportunities to address them using, forexample, computerised prescribing, powerfulreporting facilities in our computerised recordssystems, medicines management teams advis-ing us at the Clinical Commissioning Group(CCG)/Health Board level and data sourcessuch as the Association of Public Health Obser-vatories, Inhale website and the RespiratoryAtlas of Variation. Martyn Partridge got it rightin his foreword to the NRAD report in sayingwe must use the findings to ‘unequivocallyshake up the system’. How many nurses doyou know who are given the responsibilityfor respiratory care but have no support ortraining (see PCRS-UK skills document formore information on minimum standards:http://www.pcrs-uk.org/resource/Nurse-tools/skills-levels-delivering-high-quality-respiratory-care-nurses-primary-care)? Howmany practices do you know where asthma

care has been virtually ‘abdicated’ to nursesand where the GPs no longer have essentialclinical skills needed to manage asthma?

PCRS-UK: supporting its members toachieve NRAD recommendations

Spurred on by the NRAD report, PCRS-UKwill continue to fight for appropriate NHS in-centives and levers to drive improvements inroutine respiratory care. PCRS-UK already of-fers a wealth of clinical resources to supportpractices to improve the quality of routineasthma and COPD care. What NRAD showsis that, if more professionals adoptedguideline standard care, we may save somelives as well as keep people out of hospitaland improve the lives of many more peoplewith respiratory conditions. If you ask pri-mary care health professionals what theywould want from a society like ours (and wehave), the ‘wish list’ matches very well withthe resources and support we give. That iswhy the PCRS-UK Executive and Trustees re-cently decided to make most of our resourcesfreely available online (see news piece onpage 20). I am convinced this decision willhelp more people to see what we have tooffer and use the opinion sheets, quick refer-ence guides, Patient Group Directions, etc, todrive improvements in the care and outcomesof their respiratory patients.

Best practice in asthma management is set outclearly in the British Thoracic Society/Scottish Intercollegiate Guideline Network(BTS/SIGN) Asthma Guideline, QOF, AsthmaQuality Standards for England and in respira-tory strategies in Wales and Northern Ireland.But, as the NRAD report has shown, theyneed embedding into routine practice. I’msure the same principle applies to COPD.Guidelines, strategies and quality standardsare only useful if patients, nurses and doctorsalike are aware of them, understand them andimplement them. They have to make sense ina practical way that is also realistic and achiev-able in everyday busy practice life.

The launch of the new PCRS-UK EffectingQuality in Practice (EQUIP) simple modular-

based tool (see page 25) for practices, CCGs,Health Boards and other groups, following im-mediately on from the NRAD report, is verytimely. EQUIP provides a structured, system-atic way of reviewing the respiratory care beingdelivered and identifies ways in which the stan-dards of care can be optimised within a prac-tice, or group of local practices, using our newpractice improvement work sheets (see page24) and other PCRS-UK resources. New im-provement tools are freely available toPCRS-UK members and my hope is thatthey will convince many more practice res-piratory leads that they cannot afford not tojoin PCRS-UK.

In summary, PCRS-UK’s strategy – focusingon delivering excellence locally – is aboutbuilding a network of networks, from regionalleads to CCG/Health Board leads to individualleads at practice level, who can encourage ex-cellence in respiratory care in their own localarea. This could mean a small audit of respira-tory care in one practice, a wider CCG initia-tive, or a joint project with secondary carecolleagues. The launch of the EQUIP im-provement modules and the practice im-provement worksheets adds to thearmamentarium our leads and championshave to support them in that quest. Contactyour regional lead (http://www.pcrs-uk.org/pcrs-uk-regional-leads) to find outmore.

By joining PCRS-UK, you’ve already shownyou have a respiratory interest. If you are amember of a local respiratory interest groupyou may already be acting as a local lead.PCRS-UK resources can help your group.Download the resources from the websiteand share them at your meetings. Why notjoin us in seeking to improve respiratory careand get the backing of PCRS-UK by becom-ing a PCRS-UK champion? Together we canstart to overcome the complacency in theNHS towards asthma and respiratory condi-tions more generally, and ensure that any fu-ture studies of asthma death do not highlightsuch tragic gaps in routine care.



Why Asthma Still Kills: The National Review ofAsthma Deaths (NRAD) led by the Royal College of Physicians andinvolving a consortium ofasthma professional and patientbodies including PCRS-UKpublished its report on 6th May2014 – World Asthma Day. Itconsists of a year-long collationof data on all asthma deathsacross the UK, with detailed in-formation on 195 deaths. Thereare 19 recommendations forchanges in asthma care whichcould reduce the number ofdeaths. PCRS-UK, a partner inthe study, provided a succinct summary of key findings and recom-mendations for primary care in Chapter 8 of the report(http://www.pcrs-uk.org/sites/pcrs-uk.org/fi les/fi les/Chapter8_Keyrecommendationsfor%20PrimaryCareNRAD.pdf).You can view the full report at http://www.rcplondon.ac.uk/pro-jects/national-review-asthma-deaths.

Read PCRS-UK’s Executive Chair, Stephen Gaduzo's perspectiveon the NRAD report (page 9) and see how PCRS-UK resources canhelp you address some of the key recommendations (page 13). Atthe launch of the NRAD report, Professor Mike Morgan – NationalClinical Director for respiratory disease at NHS England – commit-ted to:

• Forming an implementation task force to look at how to roll outthe recommendations in the report, many of which are relevantfor primary care.

• Developing resources to support improvements in care includ-ing an Asthma CQUIN (Commissioning for Quality and Innova-tion), an asthma acute care bundle, alerts on GP computersystems to flag potentially dangerous over-prescribing of short-acting beta-agonists, long-acting beta-agonists and inhaled cor-ticosteroids, a template to guide regular asthma review

• Considering adding asthma to the ongoing national audit pro-gramme. COPD is part of this programme, and asthma is oneof five in the shortlist being considered for future addition tothe programme.

NICE defines the role of FeNOtesting in asthma diagnosis andmanagement: NICE has recommended that FeNO (nitricoxide) testing is a useful additional tool for confirming suspectedasthma when the diagnosis is unclear, alongside the other diagnos-tic approaches in the BTS/SIGN Asthma Guideline. It is also recom-mended as an option to support the management of asthma inpeople who still have symptoms despite being treated with inhaledcorticosteroids. People with asthma often have inflamed lungs andbreathe out higher than normal levels of nitric oxide, so FeNO test-ing helps to identify the presence of inflammation. NICE evaluatedthree pieces of FeNO testing equipment: NIOX MINO and NIOXVERO (Aerocrine) and NObreath (Bedfont Scientific Ltd).

NICE guidance: Measuring fractional exhaled nitric oxide concen-tration in asthma (DG12) (http://guidance.nice.org.uk/DG12)

Wales launches respiratory deliveryplan: Wales follows Northern Ireland in publishing a compre-hensive respiratory strategy – Together for Health(http://wales.gov.uk/newsroom/healthandsocialcare/2014/140429respiratoryplan/?lang=en). This outlines the actions neededto make a difference to the lives of the one inseven people living in Wales who have arespiratory condition. Importantly, Walesplans a comprehensive roll out of the planin its seven Health Boards. Members inWales should consider getting in-volved.

Policy Round-Up Bronwen Thompson, PCRS-UK Policy Advisor

A summary of the latest developments in the UK health services, includingany major new reports, guidelines and other documents relevant to primarycare respiratory medicine



Breathlessness tips for cliniciansfrom IMPRESS: (http://www.impressresp.com/index.php?option=com_content&view=article&id=172:impressions-31-breathlessness&catid=11:impressions&Itemid=3).This fully referenced paper offers guidance for clinicians who assessand care for adults with long-term breathlessness. It also providesaccompanying notes to the IMPRESS breathlessness interactive al-gorithm (Dec 2013). It is a tool that can be used by commissioners,clinicians and patients to discuss how to integrate assessment andcare for people who may have more than one condition causingtheir breathlessness, such as COPD, heart failure, asthma, anxiety,obesity and anaemia. The appendices offer examples of easy-to-use validated assessment tools. It was produced by a cross-specialtyand multidisciplinary IMPRESS working party, including membersof PCRS-UK.

Medicines optimisation for asthma:(http://www.rpharms.com/promoting-pharmacy-pdfs/mo-briefing---asthma.pdf). The Royal Pharmaceutical Society of GreatBritain has produced a briefing on medicines optimisation in asthma(link), a useful evidence-based two-page document to help you in-volve your local pharmacists as members of the primary care team.

A planned approach for the mostvulnerable and complex patients: NHSEngland has launched Transforming primary care(https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/304139/Transforming_primary_care.pdf):This document sets out how primary care needs to change to sup-port the most vulnerable patients with personalised proactive care.Reducing admissions continues to be a high profile area across theNHS. To support the enhanced service on unplanned admissionsin England in 2014/15 (http://www.nhsemployers.org/your-workforce/primary-care-contacts/general-medical-services/enhanced-services/enhanced-services-201415), there is a range oftools – templates, letters, practice report, care plan – designed toassist practices in reducing unplanned admissions by, for example,proactive care planning, improving discharge processes and im-proving telephone access.

NEW… Quality standard for pulmonary rehab from BTS

Launched in May 2014, the new British Thoracic Society Quality Standard for Pulmonary Rehabilitation – visit https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/pulmonary-rehabilitation-quality-standards/ for more information.

Don’t forget to download your copy of our opinion sheet on pulmonary rehabilitation written by Dr Rupert Jones available athttp://www.pcrs-uk.org/resource/Opinion-sheets/pulmonary-rehabilitation-opinion-sheet

In brief...Future of general practice: Useful reports include:

• Improving General Practice – a call to action from NHSEngland sets out the future challenges and direction ofprimary care (http://www.england.nhs.uk/2014/03/11/cta-emerging-findings/).

• Commissioning and funding general practice from theKing’s Fund (http://www.kingsfund.org.uk/publications/commissioning-and-funding-general-practice),

• The Nuffield Trust (http://www.nuffieldtrust.org.uk/blog/influencing-gps-and-expanding-role-clinical-commissioning-groups) has commented on ongoingrumblings about whether CCGs should have a greaterrole in determining what general practice does, and indeveloping primary care.

• And finally – a slideset outlining the challengesfor primary care (http://www.pcc-cic.org.uk/article/transforming-primary-care).

A collaborative strategy to tackle TB is out to consulta-tion from Public Health England (https://www.gov.uk/government/news/phe-commits-to-tackling-tb) – see PCRS-UK opinion sheet for helpful information on how to diagnoseand manage TB in primary care http://www.pcrs-uk.org/resource/Opinion-sheets/tuberculosis-opinion-sheet.

Respiratory case studies:

• Developing an Enhanced Pulmonary Rehabilitation Pro-gramme to promote self-management from Cambridge- designed to improve patients’ self-management skills(http://personcentredcare.health.org.uk/resources/developing-enhanced-pulmonary-rehabilitation-programme-promote-self-management).

• Telephone follow-up for COPD patients completing therehab programme from Ayrshire and Arran (http://personcentredcare.health.org.uk/resources/telephone-follow-copd-patients-completing-rehab-programme).



The National Review of Asthma Deaths (NRAD) report(http://www.rcplondon.ac.uk/projects/national-review-asthma-deaths),launched on World Asthma Day, 6th May 2014, highlighted 19 recommendationsfor improvements in care, many of which are relevant to primary care.

Why Asthma Still Kills – Actions you can take nowto help reduce asthma deathsHilary Pinnock, Tricia Bryant

GETTING THE BASICS RIGHT

Some important findings from NRAD:

• In 43% of people who died there was no evidence of an asthma review in the previous12 months and 22% had missed a routine GP appointment.

• Of those seen in primary care in the 12 months prior to death, only 24% had receiveda personalised asthma action plan, though British asthma guidelines have emphasisedthe importance of asthma self-management as a core component of a regular reviewfor two decades.

Download our asthma review opinion sheet (http://www.pcrs-uk.org/resource/Opinion-sheets/asthma-review-opinion-sheet) andasthma assessment and review protocol (http://www.pcrs-uk.org/resource/Nurse-tools/protocol-asthma-assessment-and-review-primary-care-pdf) and asthma checklist (http://www.pcrs-uk.org/resource/Nurse-tools/asthma-clinic-checklist-pdf) for informa-tion on what constitutes a good asthma review. Why not use this as ateaching aid in the practice to ensure the whole practice team are fa-miliar with the essentials for asthma review?

Download our opinion sheet on personal asthma actionplans (http://www.pcrs-uk.org/resource/Opinion-sheets/personal-asthma-action-plans-opinion-sheet). This conciseguide provides useful information and advice on the use ofasthma action plans in practice

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• 45% of people died without seeking medical assistance and50% of the deaths took place between 8am and 6pm whenGP practices are open, implying that these patients werenot aware of how ill they were, or were unable to accesscare until it was too late to get help.

• 21% of those who died had attended an Accident and Emer-gency Department (A&E) in the previous 12 months, andover half of these had presented more than once. Practicesneed to monitor A&E visits as an indicator of risk.

• 86% of those who died had been prescribed inhaled corti-costeroids (either as a single agent or in combination with along-acting beta-agonist). However, 80% of these had re-ceived fewer than 12 inhalers a year and 38% had receivedfewer than four inhalers, which suggests considerableunder-use.

• 56% of those prescribed short-acting beta-agonists had hadmore than six and 39% had received more than 12 inhalersin the 12 months prior to death, which constitutes significantover-use and is another indicator of risk.

Download our post-acuteasthma care bundle from ourwebsite at http://www.pcrs-uk.org/resource/Improve-ment-tools/post-acute-asthma-care-bundle to help you planand implement appropriatecare for patients who have re-ceived unscheduled or emer-gency care for their asthma

Authors: Iain Small, Aberdeen; Morag Reilly, Aberdeen; June Roberts, Cheshire

Editor: Dr Iain Small

© Primary Care Respiratory Society UKThe Primary Care Respiratory Society is a registered charity (Charity No: 1098117) and a company limited by guarantee registered in England (Company No: 4298947). VAT Registration Number: 866 1543 09. Registered Offices: PCRS-UK, Unit 2, Warwick House, Kingsbury Road, Curdworth, Sutton Coldfield, B76 9EETelephone: +44 (0)1675 477600 Facsimile: +44 (0) 121 336 1914 Email: [email protected] Official Publication: Primary Care Respiratory Medicinehttp://www.nature.com/npjpcrm/

The Primary Care Respiratory Society UK (PCRS-UK) is grateful toAstraZeneca UK Ltd, Boehringer Ingelheim Ltd/Pfizer Ltd, ChiesiLtd, GlaxoSmithKline, MSD UK, Napp Pharmaceuticals and Teva UK Ltd for the provision of educational grants to establishthe development of the PCRS-UK Quality Improvement Programmes and its resources. The PCRS-UK wishes to acknowledge he ongoing support of AstraZeneca UK Ltd,Boehringer Ingelheim Ltd, Chiesi Ltd and GlaxoSmithKline in thecontinued development of this programme in 2014.

Correct at date of revision: April 2014.

Sponsorship details correct at time of publication

Post-acute asthma care bundle

Practice Improvement Worksheets, DRAFT version 01,Date of Expiry 10 September 2014

This series of practice improvement worksheets are prepared in DRAFT format, for members to use withintheir practice as part of a PILOT test. Feedback is soughtfrom users of these tools based on effectiveness, accuracy, completeness, usefulness and outcomes.

Please submit your feedback direct to [email protected]

The asthma discharge care bundle is a short list of evidence-basedpractices which should be implemented prior to discharge for allpatients who have been admitted with an acute exacerbation ofasthma. It is based on a review of national guidelines and otherrelevant literature, expert opinion and consultation with patients.The bundle is being adopted in various hospitals across the UKand could also be used in practice to follow on from an unscheduled episode of Asthma care. Practice organisations should ensure that there is an effective wayof identifying patients who have been admitted to hospital or received unscheduled care for their asthma.This practice improvement worksheet covers the four key pointsof review.

Delivering excellence locally…

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�� Improved care planning

�� Better anticipatory care/reduced readmissions

�� Management in line with national guidance

�� Reducing the impact ofunscheduled care in the practice

PCRS-UK Resources:

� PCRS-UK Opinion sheets - Smoking cessation, Inhaler devices, High risk asthma, Asthma action plans, Asthma in adolescence, Managing acute exacerbations, Optimal asthmacontrol, Tailoring inhaler choice

� PCRS-UKQuick Guide to the diagnosis and management of asthma in primary care

� PCRS-UKAcute asthma protocol, Asthma assessment and review

� PCRS-UKAsthma checklist

Other Resources:

� Implementing an acute care bundle. J E McCreanor, J Pollington, T Stocks, L Chandler. Thorax 2012;6677:A183 doi:10.1136/thoraxjnl-2012-202678.363

� BTS/SIGN Guideline for the management of asthma - see http://www.sign.ac.uk/guidelines/fulltext/101/index.html

PCRS-UK Practice Improvement Worksheets

Equipping you to improve respiratory care

Download our opinion sheeton high risk asthma athttp://www.pcrs-uk.org/resource/Opinion-sheets/high-risk-asthma-opinion-sheet . Why not use this as atool at your next practice teammeeting to discuss how youcare for people with high riskasthma and what steps you cantake to ensure you are identify-ing and managing people withasthma effectively

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Take a look at our nurse proto-col on telephone consultationsavailable at http://www.pcrs-uk.org/resource/Nurse-tools/te lephone-consultat ions-routine-asthma-review-protocol-pdf. Have you considered morenovel ways of engaging withyour younger asthma patientsand those unwilling to comeinto the practice for a formal re-view? Rather than ‘exceptionreporting’ non-attenders, con-sider phoning them and review-ing their control andmanagement. They probablystill need to be encouraged toattend (e.g. to check inhalertechnique), but at least contacthas been made and arrange-ments can be made for a face-to-face review.

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Why not participate in our simple AsthmaAudit to check how you perform on achievingasthma concordance and compliance (seehttp://www.pcrs-uk.org/pcrs-uk-2014-asthma-audit-information)



Delayed antibiotic prescribing strategies for respiratory tractinfections Little et al. Delayed antibiotic prescribing strategies for respiratorytract infections in primary care: pragmatic, factorial, randomisedcontrolled trial. BMJ 2014;348:g1606. Published online 6 March2014. http://dx.doi.org/10.1136/bmj.g1606

Acute respiratory infections are the commonest reason for acuteconsultation in primary care. Patients’ expectations and GPs’ re-sponse to these have contributed to increased antibiotic prescribingrates over the last 5 years or so. In order to reduce antibiotic pre-scribing, a strategy of delayed antibiotic prescription can be usedand this is recommended in guidelines. However, there are differ-ent ways of providing a ‘delayed’ prescription. This open, parallelgroup, randomised controlled trial is the first to compare the effectof different delayed prescription strategies on symptom control andantibiotic use whilst controlling for other factors such as analgesiaand steam inhalation. A total of 889 patients were recruited; 333required immediate antibiotics and so were excluded from randomi-sation. The remaining 556 patients were randomised to a ‘no an-tibiotic prescription’ control group or to one of four delayedprescription groups – re-contact for a prescription, post-dated pre-scription, collection of the prescription, or being given the prescrip-tion (‘patient-led’). Primary outcome measures included meansymptom severity (on a 0–6 scale) at days 2–4, antibiotic use, andpatients’ beliefs in the effectiveness of antibiotic use. Secondaryoutcomes included comparison with immediate antibiotic use. Fol-low-up was for at least one month. There was no significant differ-ence in symptom severity between the no prescription group andthe four delayed prescription groups [crude mean symptom score(SD) = 1.62 (0.88) for no prescription; 1.60 (0.91) re-contact; 1.82(0.94) post-dated prescription; 1.68 (0.88) collection; and 1.75(0.88) patient-led; P=0.625]. There was also no significant differ-ence between the groups in terms of symptom duration, consulta-tion satisfaction or antibiotic use. Antibiotic use ranged from 26%in the no prescription group to 38% in the patient-led group. Pa-tients given immediate antibiotics almost invariably used them (an-tibiotic use 97%) and strongly believed in them (93%), but showed

no benefit in terms of symptom severity or duration. Therefore,strategies for delayed antibiotic prescription reduced antibiotic useto less than 40%, resulted in similar symptom scores to patientsgiven immediate prescription, and there was no significant differ-ence between the four delayed prescription strategies.

Wheezing phenotypes in young childrenCano-Garcinuno et al. Wheezing phenotypes in young children: anhistorical cohort study. Prim Care Respir J 2014;23(1):60-66.http://dx.doi.org/10.4104/pcrj.2014.00008

This interesting cohort study involved a detailed medical recordsreview of 3,739 preschool children from 29 primary care centres innorthern Spain. The records were reviewed for wheezing episodesin the first 36 months of life. The aim was to clarify the natural his-tory of early childhood wheezing by identifying wheezing pheno-types, describing their incidence trends, and investigating anyrelationship with asthma at the age of 6 years. The authors usedfairly innovative statistical techniques such as latent class analysisand linear joinpoint regression in order to obtain a ‘high resolutionanalysis of incidence’. They identified four different phenotypes: a‘never/infrequent’ (NIW) wheezing phenotype (65.4%); ‘transientwheeze’ (TW), with a fast rise in incidence of wheezing from birthup to a median age of 6 months followed by a fast drop in incidence(18.3%); ‘persistent wheeze’ (PW), again with a fast rise in wheezingincidence to a peak at 6 months followed by a slow descent, andcharacterised by recurrent episodes (6.6%); and finally a ‘latewheeze’ (LW) phenotype which exhibited delayed onset wheezingonly perceptible from the age of 4 months with a median age of firstonset at 19 months, a slow constant rise in incidence up to the ageof 3 years, and a significant relationship with allergic asthma at theage of 6 years (9.7%). The three wheezing phenotypes showed anincreased risk of asthma, but this was most evident for the LW phe-notype. The authors conclude that the TW and PW phenotypeshave an identical early onset, so it is virtually impossible to give aprognosis for wheezing children presenting in the first year of life;furthermore, the LW phenotype eventually becomes the most com-mon type of wheezing and shows an increased risk of persistent al-

Journal Round-Up

Summary reviews of relevant papers from the top respiratory and general medical journals worldwideselected and written by Dr Paul Stephenson and edited by Professor Aziz Sheikh, Editors-in-Chief, npjPrimary Care Respiratory Medicine

Each summary contains the name of the first author, the title of the paper, the Vancouver referenceand/or doi number and a link to the abstract of the paper. Some of the papers are open-access but othersare published in subscription journals so, to view the full text, you or your organisation will need to sub-scribe to the journal or pay to view on an individual article basis.

These reviews were originally published by the Doctors.net.uk Journal Watch service, which covers otherspecialties as well as respiratory medicine. Doctors.net.uk is the largest network of GMC-registered doc-tors in the UK. To find out about membership, visit http://www.doctors.net.uk.



lergic asthma. The excellent linked editorial by Brand(http://dx.doi.org/10.4104/pcrj.2014.00010) puts these findingsinto context; however, he concludes that predicting the outcomeof wheeze in preschool children still remains ‘mission impossible’.

Hospital resources for acute COPD care: the EuropeanCOPD Audit Lopez-Campos et al. Variability of hospital resources for acute careof COPD patients: the European COPD Audit. Eur Respir J2014;43:754-62. http://dx.doi.org/10.1183/09031936.00074413

This ERS-funded COPD audit was designed as a pilot study to eval-uate clinical practice variability and factors which relate to variousoutcomes following hospital admission for COPD across Europe. Ineffect, it is a prospective, observational, non-interventional cohortstudy. The first phase was for 8 weeks, during which all consecutivepatients admitted with a COPD exacerbation to 425 hospitals from13 countries were identified. Data were collected on clinical prac-tice and the hospital resources and organisation devoted to COPDacute care. This paper reports on the hospital resources and organ-isation component, with particular emphasis on hospital size, re-sources, organisation of care and adherence to clinical guidelines.Participating hospitals were categorised into tertiles based on thesedata. The mean number of beds per tertile was 220 (lower), 479(middle) and 989 (upper). As expected, there was considerablevariability between different sizes of hospitals and between coun-tries. Larger hospitals were more likely to have more resources andmore staff, but this did not imply better access to services or a sig-nificant difference in adherence to guidelines. The authors expressparticular concern about those hospitals where strongly evidence-based services are not available – for example, intermediate careunits, and invasive and non-invasive ventilation. This study hasshown huge variation in both the resourcing and organisation ofcare amongst European hospitals caring for acute COPD admis-sions. The hope is that this information will help managers and pol-icy makers to evaluate the resources available and to makeappropriate changes to improve acute COPD care.

Adherence determines asthma control in preschool children Klok et al. It’s the adherence, stupid (that determines asthma con-trol in preschool children)! Eur Respir J 2014;43:783-91.http://dx.doi.org/10.1183/09031936.00054613

The aim of this prospective observational study from Groningen inthe Netherlands was to explore the relationship between adherenceto inhaled corticosteroids (ICS) and long-term asthma control inyoung children aged 2–6 years with asthma. 81 children wereclosely followed-up in an extensive ‘management programme’ afterhaving been referred by their GP to the hospital-based paediatricclinic. Demographic and clinical data were collected, as well as dataon lung function, asthma control (using the Asthma Control Ques-tionnaire, ACQ) and parental quality of life. Adherence was meas-ured daily using the Smartinhaler, a validated electronic devicewhich logs the date and time of each ICS actuation. Follow-up wasfor 12 months. Median [interquartile range] adherence was 87%[70–94], and 64 (79%) had well-controlled asthma throughout theyear. Adherence of >80% was associated with better asthma control,and children with persistent mild symptoms had lower adherencerates [P=0.028]. Therefore, as expected, adherence to ICS was anindependent strong predictor of long-term asthma control, with the

highest levels of control being in children with adherence rates>80%.

Diagnosing obstructive sleep apnoea: the value of the ElbowSignFenton et al. The utility of the Elbow Sign in the diagnosis of OSA.Chest 2014;145:518-24. http://dx.doi.org/10.1378/chest.13-1046

The ‘Elbow Sign’ – this has to be the best named clinical sign in res-piratory medicine [though we will be delighted to receive your com-ments on this!]. These authors devised an obstructive sleep apnoea(OSA) prediction questionnaire consisting of only two questions:(1) Does your bed partner ever poke or elbow you because you aresnoring? (2) Does your bed partner ever poke or elbow you be-cause you have stopped breathing? They administered the ques-tionnaire prospectively to 128 patients attending a sleep disordersclinic prior to their sleep study. Data were also collected on age,sex, body mass index (BMI), and Epworth Sleepiness Scale (ESS)score. The odds ratio (OR) of having mild OSA (apnoea-hypopnoeaindex [AHI] >5/hour) after answering ‘Yes’ to the first questionabout snoring was 3.9. Similarly, the OR was 5.9 after answering‘Yes’ to the second question about apnoeic spells. These odds ratioswere irrespective of sex, BMI, or ESS score, though age >50 yearsdemonstrated weaker association. Subgroup analysis showed that,in men with a BMI >31, a positive Elbow Sign had a specificity of96.6% for a diagnosis of OSA. An interesting study, and a very sim-ple user-friendly two-question questionnaire which warrants furtherevaluation in primary care contexts.

Are there missed opportunities for diagnosing COPD in gen-eral practice?Jones et al. Opportunities to diagnose chronic obstructive pul-monary disease in routine care in the UK: a retrospective study ofa clinical cohort. Lancet Respir Med 2014;2:267-76.http://dx.doi.org/10.1016/S2213-2600(14)70008-6

This is an interesting retrospective cohort study analysing patternsof healthcare use and co-morbidities present in patients prior to adiagnosis of COPD. Using 20 years’ primary care data from the UKGeneral Practice Research Database and the Optimum Patient CareResearch Database, the authors analysed the electronic records of38,859 patients aged 40 or over for at least 2 years before and 1year after the diagnosis of COPD. A number of clinical scenarioswere considered to be potential ‘missed opportunities’ if they didnot lead to a diagnosis of COPD: these included infective and non-infective lower respiratory tract infections, other lower respiratoryconsultations culminating in a prescription for antibiotics or oralsteroids, and requests for a chest X-ray. According to these criteria,missed opportunities for diagnosis occurred in 32,900 of the 38,859patients (85%) in the 5 years before diagnosis, in 12,856 out of22,286 patients (58%) in the 6–10 years before diagnosis, and in3943 of 9351 patients (42%) in the 11–15 years before diagnosis.Over the 20-year period, there was a reduction in the age at diag-nosis of 0.05 years per year [95% CI 0.03 to 0.07], and the preva-lence of all co-morbidities increased except for bronchiectasis. Inthe 2 years before diagnosis 6897 patients had a chest X-ray and,of these, 2296 (33%) went on to have spirometry. The authors con-clude that opportunities to diagnose COPD are being missed. Ofcourse, these primary care data go back to 1990, well before anyCOPD guidelines were published, so it is hardly an up-to-date rep-



resentation of current UK primary care practice. And whether ornot these clinical scenarios were truly ‘missed opportunities’ is opento debate. Nevertheless, it does highlight once again the need forCOPD case-finding strategies to maximise the efficiency of the di-agnostic process.

Risk stratification for primary care-based screening ofimmigrants for latent TBPanchal et al. The effectiveness of primary care based stratificationfor targeted latent tuberculosis infection screening in recent immi-grants to the UK: a retrospective cohort study. Thorax 2014;69:354-62. http://dx.doi.org/10.1136/thoraxjnl-2013-203805

We have recently published a ‘case-based learning’ article on tuber-culosis (TB) presenting as indolent pneumonia in an Israeli immigrantfrom Ethiopia (http://dx.doi.org/10.4104/pcrj.2014.00001), togetherwith an accompanying article focusing on TB management and im-migrant screening (http://dx.doi.org/10.4104/pcrj.2014.00019).This is an 11-year retrospective cohort study on the effectivenessof a targeted screening programme for latent TB infection at thetime of primary care registration for recent immigrants to Leicester-shire, UK. The authors constructed a cohort of 59,007 new immi-grant patient registrations in the county since January 2000. Ofthese, 28,438 (48%) were from countries with a WHO TB incidenceof >150/100,000. Following registration, patients’ details appear onthe NHS Patient Registration Data System (PRDS). The PRDS con-tains a specific code, ‘Flag-4’, which signifies a first registrationepisode for individuals having either a previous address outside theUK or residence abroad of >3 months; the authors have used thisFlag-4 PDRS data as a resource for identifying immigrants. TB di-agnosed >6 months after new patient registration was consideredpotentially preventable with screening. The primary outcomes werethe potentially preventable proportion of foreign-born TB cases,and the number needed to screen (NNS) to identify one potentiallypreventable case, stratified by age and region of origin. The mediantime to Flag-4 primary care registration after UK entry was 181 days[IQR 25–950 days], but this was significantly longer for immigrantsarriving from high TB incidence countries. There were 857 foreign-born TB cases over the 11 years; 810 of these (94.5%) were regis-tered on the PRDS and 458 (53.4%) were captured on the Flag-4code. 250 cases (29%) were potentially preventable in Flag-4 codedimmigrants, and overall 511 cases (60%) were potentially prevent-able amongst PDRS-registered immigrants. Targeted screening wasmost effective for 16–35 year-olds from regions of WHO mediumTB incidence (150–499/100,000); NNS was 65 [95% CI 57 to 74],preventing 159 (18.7%) cases. The authors conclude that screeningfor latent TB at primary care registration is an effective strategy foridentifying immigrants at high risk of developing TB. The use of the‘Flag-4’ registration is an original idea which they propose warrantsfurther evaluation.

UK general practice COPD distribution according to ABCDgroups Haughney et al. The distribution of COPD in UK general practiceusing the new GOLD classification. Eur Respir J 2014;43:993-1002.http://dx.doi.org/10.1183/09031936.00065013

This retrospective cohort study is the first to describe the distribu-tion of COPD patients in a representative sample of UK primary careaccording to the new GOLD 2011 ‘ABCD’ groups rather than the

old ‘1234’ grades. As we commented in our January Journal Watchreview on the paper by Boland et al. (which compared the two dif-ferent GOLD classifications in terms of their association with healthstatus and costs) (http://dx.doi.org/10.4104/pcrj.2014.00002),the rationale behind the new classification is that it incorporates as-sessment of symptoms (using the modified MRC dyspnoea scaleand the COPD Assessment Test (CAT)) as well as exacerbation risk,unlike the old ‘1234’ grades which were based on lung functiononly. The authors used the UK National Service for Health Improve-ment (NSHI) database as well as electronic and paper records from80 general practices to construct a cohort of 9219 patients with aRead code diagnosis of COPD; of these, 7480 had spirometry dataavailable, 6283 had a valid FEV1 and modified MRC (mMRC) scoreavailable, and 221 had a valid FEV1 and valid CAT score. The patientdistribution according to the new ‘ABCD’ groups was: Group A (lowrisk, few symptoms) 36.1%; Group B (low risk, more symptoms)19.1%; Group C (high risk, few symptoms) 19.6%; Group D (highrisk, more symptoms) 25.3%. This was in contrast to the distributionaccording to the old ‘1234’ grades: Grade I (mild) 17.1%; Grade II(moderate) 52.2%; Grade III (severe) 25.5%; Grade IV (very severe)5.2%. The key findings are that a greater proportion of COPD pa-tients were identified as being at high risk of adverse health out-comes by the new ‘ABCD’ group classification, and the newclassification had more patients in both the milder and more severegroups compared with the old one. Groups B and D, the twogroups with high levels of symptoms, also had higher levels of co-morbidities, and there was a discrepancy between FEV1 and exac-erbation risk: 20% of patients with FEV1 >50% had >2 exacerbationswhereas 70% of patients with FEV1 <50% had either no or only oneexacerbation in the previous 12 months.

Changes in classification and treatment of preschoolwheezing since 2008 Brand et al. Classification and pharmacological treatment ofpreschool wheezing: changes since 2008. Eur Respir J2014;43:1172-7. http://dx.doi.org/10.1183/09031936.00199913

This is a short and very readable review relevant to all GPs and pae-diatricians. It reviews the evidence published since the original 2008ERS Task Force report on the classification and management of pre-school wheezing, and the authors have updated some of the origi-nal 2008 recommendations. Many preschool children with wheezebecome symptom-free between the ages of 3 and 8, which differ-entiates them from those who have persistent asthma in later child-hood and in adulthood. The original 2008 report distinguishedbetween ‘episodic viral wheeze’ and ‘multiple-trigger wheeze’, andthis distinction has become widely accepted in clinical care. How-ever, given the heterogeneity of preschool wheezing in this agegroup, it has since become clear that this distinction is not as clear-cut as suggested in 2008. Wheeze patterns vary over time and withtreatments, there is a large overlap between episodic viral wheezeand multiple-trigger wheeze, and the severity and frequency ofepisodes seems to be at least as important as trying to distinguishbetween the two groups. In general, inhaled corticosteroids (ICS)remain first-line treatment for multiple-trigger wheeze, but ICS ormontelukast may be considered for episodic viral wheeze with fre-quent or severe episodes. Controller treatment with ICS or mon-telukast should be given as a trial of treatment, and should bediscontinued if shown to have no benefit. Once on controller treat-ment, the lowest effective dose should be used and, if the child has



been symptom-free for 3 months on low-dose treatment, then treat-ment should be stopped. Oral corticosteroids should not be usedfor mild-to-moderate wheezing episodes and should only be usedfor severe episodes in children who are admitted to hospital – infact, even in these children, the evidence for oral steroid use is notrobust. The presence of atopy does not predict the response to con-troller therapy. Regular review of these children to evaluate the re-sponse to treatment and any changes in symptom pattern is the keyto sound management.

Rapid lung function decline in smokers may be attenuatedby ACE inhibitorsPetersen et al. Rapid lung function decline in smokers is a risk factorfor COPD and is attenuated by angiotensin-converting enzyme in-hibitor use. Chest 2014;145:695-703. http://dx.doi.org/10.1378/chest.13-0799

Using longitudinal data on 1170 ever-smokers who were recruitedinto the Lovelace Smokers cohort, all of whom had repeat lungfunction tests over at least 3 years, these authors set out to charac-terise the rate of post-bronchodilator FEV1 decline in ever-smokers.They also sought to compare the risk of COPD between those withrapid FEV1 decline and others, and to see if a number of pre-se-lected drugs might influence this rate of FEV1 decline. The 1170subjects included 809 ever-smokers who had no spirometric abnor-mality at baseline. Mean follow-up was 5.9 years. From the FEV1values performed at all examinations during follow-up, the longitu-dinal absolute decline in post-bronchodilator FEV1 was annualisedand subjects were categorised into those with rapid decline(>30mL/year), normal decline (0–29.9mL/year), or no decline. 32%of ever-smokers exhibited rapid decline. In the subjects with nobaseline spirometric abnormality, rapid decline was associated withan increased risk of incident COPD [P=0.003]. The use of an-giotensin-converting enzyme (ACE) inhibitors at baseline was pro-tective against rapid decline, particularly if patients hadcardiovascular disease, hypertension or diabetes [P<0.02 for allanalyses]. It will be interesting to see further research on this po-tentially protective role of ACE inhibition.

Nebulised budesonide ineffective in preventing hospitaladmission of children with acute severe asthma Alangari et al. Budesonide nebulization added to systemic pred-nisolone in the treatment of acute asthma in children; a double-blindrandomized, controlled trial. Chest 2014;145:772-8.http://dx.doi.org/10.1378/chest.13-2298

The aim of this double-blind, placebo-controlled, randomised trialwas to assess the efficacy of nebulised budesonide in addition tostandard treatment in the management of moderate-to-severeasthma in children aged 2–12 years in the emergency departmentsetting. Standard treatment included salbutamol, ipratropium, anda single dose of oral prednisolone (at a dose of 2mg/kg) at the startof treatment. The primary outcome was hospital admission within4 hours. In order to determine the degree of asthma severity, chil-dren were assessed immediately and graded according to a clinicalscore of 5–15, with 15 signifying the most severe acute asthma.Data were collected on 906 emergency department visits, and pa-tients were randomised to receive either nebulised budesonide1500mcg [n=458] or placebo [n=448]. Overall, 75 children in thebudesonide group (16.4%) and 82 children in the placebo group

(18.3%) were admitted, and this difference was not significant [oddsratio (OR) 0.84; 95% CI 0.58 to 1.23]. However, a subgroup analysisof the most severe cases (i.e. those children with a baseline clinicalscore of 13–15) showed a significant difference between the twogroups, with 27/76 (35.5%) children admitted from the budesonidegroup and 39/73 (53.4%) admitted from the placebo group [OR0.42; 95% CI 0.19 to 0.94]. Therefore, overall this was a negativestudy, but nebulised budesonide may possibly be effective in re-ducing hospital admission in children with more severe acuteasthma.

Smoke-free legislation is associated with reductions inpreterm births and hospital admissions for childhood asthmaBeen et al. Effect of smoke-free legislation on perinatal and child health:a systematic review and meta-analysis. Lancet 2014;383:1549-60.http://dx.doi.org/10.1016/S0140-6736(14)60082-9

This systematic review and meta-analysis has considerable societalimplications, and provides strong support for World Health Organ-ization (WHO) recommendations to create smoke-free environ-ments. The aim was to assess the effect of smoke-free legislationon perinatal and child health, specifically preterm births, low birth-weight, and hospital attendances for asthma. The authors searched14 online databases back to 1975 for published studies, the WHOClinical Trials Registry for unpublished studies, and screened refer-ence lists and contacted international experts to ensure that nostudy had been missed. Studies for inclusion had to have appropri-ate designs according to the Cochrane Effective Practice and Or-ganisation of Care, and had to contain data on associations betweensmoking bans in workplaces, public places, or both, and one ormore predefined perinatal or child health indicator. 11 studies wereincluded in the final analysis; all used an interrupted time-series de-sign and were published between 2008 and 2013. Five were NorthAmerican studies describing local bans and six were European stud-ies describing national bans. There were combined data on morethan 2.5 million births and nearly 250,000 asthma exacerbations.Meta-analysis of four studies showed that smoke-free legislationwas associated with reductions in preterm births [-10.4%; 95% CI -18.8% to -2.0%], and three studies showed reductions in hospitalattendances from asthma [-10.1%; 95% CI -15.2% to -5.0%]. Therewas no statistically significant association between smoke-free leg-islation and low birthweight [six studies, reduction of -1.7%; 95%CI -5.1% to 1.6%]. This study therefore provides convincing evi-dence of the benefits of smoke-free legislation.

Accuracy and discrimination of fixed FEV1/FVC ratio versuslower limit of normal (LLN) ratio for diagnosing COPDBhatt et al. Comparison of spirometric thresholds in diagnosingsmoking-related airflow obstruction. Thorax 2014;69:410-15.http://dx.doi.org/10.1136/thoraxjnl-2012-202810

Ever since the GOLD guidelines used a fixed FEV1/FVC ratio of<0.7 to define COPD, controversy has persisted over whether useof the lower limit of normal (LLN) for the FEV1/FVC ratio would bebetter. Given that the normal FEV1/FVC ratio reduces with age, thecriticism of the fixed 0.7 ratio is that it tends to overestimate theprevalence of COPD in the elderly but then underestimates the di-agnosis in younger (especially taller) patients. This important studyis a bit like a judicial review for the protagonists in the fixed ratioversus LLN debate. Using spirometric data from 7743 current and



former smokers aged 45–80 years with and without airflow obstruc-tion previously recruited into the large COPDGene study, the au-thors compared the accuracy and discrimination of the two COPDspirometric definitions using CT-defined emphysema and gas trap-ping as the disease ‘gold standard’. There was good agreement be-tween the two definitions [kappa = 0.85; 95% CI 0.83 to 0.86].However, in 7.3% of cases (i.e. 566/7743 subjects) there was dis-cordance between the two definitions; this discordant group con-sisted of two subsets – those with a fixed ratio-only diagnosis (thevast majority, n=548), and those with a LLN-only diagnosis (n=18).Fixed ratio-only patients were more likely to be older, male, to havea greater smoking history, and had a greater degree of CT-definedemphysema [4.1% vs. 1.2%; P=0.004] and gas trapping [19.8% vs.7.5%; P<0.001] than the LLN-only group. The fixed ratio-only groupalso had more emphysema, gas trapping, and bronchial wall thick-ening than the ‘at risk’ smokers without any evidence of airflow ob-struction [e.g. odds ratio for emphysema 1.12; 95% CI 1.09 to 1.15].Over the follow-up period, the fixed ratio-only group had more ex-acerbations than smoking controls. The authors conclude that, com-pared with the fixed 0.7 ratio, the use of the LLN FEV1/FVC ratiofails to identify a number of patients with significant pathology andmorbidity. So, in terms of a CT-defined diagnosis, perhaps the fixedratio proponents might have won the argument?

Weight loss in obese patients with asthma improves asthmacontrol Dias-Junior et al. Effects of weight loss on asthma control in obesepatients with severe asthma. Eur Respir J 2014;43:1368-77.http://dx.doi.org/10.1183/09031936.00053413

In this open, randomised, controlled, 6-month, parallel-group study,patients with severe uncontrolled asthma and moderate obesity(body mass index >30 kg/m2) were randomised in a 2:1 ratio to anintensive weight loss programme (low calorie intake and use of sibu-tramine and orlistat) [n=22] or to usual care [n=11]. There was a 3-month run-in period during which patients demonstrated lack ofasthma control according to GINA criteria. The primary outcomewas asthma control according to the Asthma Control Questionnaire(ACQ). Secondary outcomes included the Asthma Control Test(ACT), lung function, the St George’s Respiratory Questionnaire(SGRQ), daily use of asthma medication, percentage of asthma-freedays, and asthma exacerbations. Of the 22 patients in the treatmentgroup, 12 achieved the weight loss goal of >10% of body weight.There was a statistically significant improvement (reduction) inmean ACQ score in the treatment group [mean±SE ACQ score3.02±0.19 at baseline, 2.25±0.28 at 6 months] versus the controlgroup [2.91±0.25 at baseline, 2.90±0.16 at 6 months; P=0.001]. Inparticular, the change in ACQ reached clinical significance (achange of > 0.5) in 11 of the 12 patients who lost >10% of their base-line weight. Forced vital capacity also increased significantly in thetreatment group [2.92±0.17L at baseline, 3.16±0.16L at 6 months]compared with the control group [2.55±0.11L at baseline,2.48±0.12L at 6 months; P=0.002]. There were no other statisticallysignificant changes in markers of airway inflammation or bronchialreactivity. The authors conclude that weight loss improves asthmacontrol in obese patients with severe asthma, but that this occursby means other than changes in airway inflammation.

Pharmacist-led multidisciplinary management of maternalasthmaLim et al. Multidisciplinary Approach to Management of MaternalAsthma (MAMMA): a randomised controlled trial. Chest2014;145:1046-54. http://dx.doi.org/10.1378/chest.13-2276

This is a small but interesting randomised controlled trial from twolarge Australian maternity hospitals which evaluated the effect of apharmacist-led intervention involving multidisciplinary care, edu-cation, and regular monitoring on improving asthma control in preg-nant women. Pregnant women <20 weeks gestation wererandomised to the intervention [n=29] or to usual care [n=29] andfollowed up through the rest of their pregnancy. The two primaryoutcomes were change in the Asthma Control Questionnaire (ACQ)score at 3 and 6 months, respectively. In the intervention group, themean±SD ACQ score decreased (i.e. improved) by 0.46±1.05 at 3months and by 0.89±0.98 at 6 months. In the control group, theACQ score reduced by 0.15±0.63 at 3 months and by 0.18±0.73at 6 months. The difference between the two groups, adjusting forbaseline scores, was -0.22 [95% CI -0.54 to 0.10] at 3 months and -0.60 [95% CI -0.85 to -0.36] at 6 months, and the 6-month differ-ence was both statistically [P<0.01] and clinically significant (i.e. adifference in ACQ score of >0.5). None of the pregnant women ineither group required hospital admission, oral corticosteroid treat-ment, or time off work during the trial. This is, of course, a very smalltrial, but these results seem encouraging. The authors conclude thatthis sort of intervention could be widely implemented in routineclinical practice, but larger trials will be required first.

Inhaled corticosteroid treatment for adult asthma increasesfive-fold over 18 yearsEkerljung et al. Five-fold increase in use of inhaled corticosteroids over18 years in the general adult population in West Sweden. Respir Med2014;108:685-93. http://dx.doi.org/10.1016/j.rmed.2014.02.016

In this study from West Sweden, the authors randomly selected pa-tients who had completed a population survey on respiratory symp-toms, and also recruited patients with known asthma; a total of 964patients with asthma were finally recruited. Data were collected in2010. The aim was to study the pattern of asthma medication useand its determinants, and to compare this with data from a previoussurvey in 1992. They categorised asthma patients into those with‘multi-symptom asthma’ and those with ‘other’ asthma (i.e. withfewer symptoms). In 2010, 11% of the population was using asthmamedication: 4.4% were using inhaled corticosteroids (ICS) togetherwith long-acting beta2-agonist (LABA) treatment; 3.3% were usingICS alone; and 3.2% were using short-acting beta2-agonists (SABA)only. Compared to 1992, use of asthma treatment had increased by54%, and the use of ICS had increased from 1.5% to 7.7% (i.e. agreater than five-fold increase). Patients with multi-symptomasthma were (not surprisingly) using asthma medication more fre-quently and at higher doses. It’s interesting to see the shift in pre-scribing patterns, and the doctors in West Sweden should becongratulated on the dramatic increase in ICS prescribing (and pa-tient use) over this 18-year period. The authors also highlight theneed to assess those patients with ‘multi-symptom asthma’ to seewhether they are being undertreated or are non-compliant.



AFFILIATION TO PCRS-UKOPEN TO ANY LOCALHEALTH PROFESSIONALGROUP

PCRS-UK introduced an affiliationprocess for local nurse groups someyears ago. The number of groups affili-ated to PCRS-UK has grown steadilyand we are delighted to have 52 localgroups now affiliated to the PCRS-UK.Many of these groups have evolvedover the years from small practice nurseforums to larger multi-disciplinarygroups. Aware of the myriad of differ-ent types of respiratory groups and net-works across the UK, from clinicalupdate groups to commissioning net-works, PCRS-UK is delighted to extendits affiliation process to any local healthprofessional group or network whosework is relevant to respiratory care inthe primary care community (see pages22 and 23).

NEW PCRS-UK QUALITY IMPROVEMENT TOOLS NOWAVAILABLE

Read about the new EQUIP improve-ment modules and supportingpractice improvement worksheets onpage 24. Visit http://www.pcrs-uk.org/resource-types-improvement-tools (make sure you are logged in firstas these are member-only access) todownload and use the tools.

STRONG PCRS-UK REPRESENTATION IN THE NATIONAL REVIEW OFASTHMA DEATHS

PCRS-UK was well represented at thelaunch of the report from the NationalReview of Asthma Deaths (NRAD),

with Professor Mike Thomas presentingon 'What the NRAD report means forprimary care'. Mike and Dr KevinGruffydd-Jones have representedPCRS-UK on the NRAD Steering Groupthroughout the confidential enquiry andwe were delighted when PCRS-UK wasasked to contribute a section to the re-port summarising the key findings andrecommendations for primary care.Many PCRS-UK members contributedto the panels which reviewed the clini-cal information on each case and cometo a view on whether there were factorsinvolved in each death that could havebeen avoided. All reviewers are ac-knowledged and thanked in the report.The key findings and implications forprimary care are reviewed extensivelyin this edition of Primary Care Respira-tory Update (see pages 9 and 13).

NEW STREAMLINED PCRS-UKMEMBERSHIP SCHEME

The PCRS-UK premium, e-connect,and practice membership schemeswere rationalised into a single individualmembership scheme on 1 June 2014,with a single membership fee of £59. Allexisting members have been notified ofthe change and all have been trans-ferred to the new scheme for theremainder of their current membershipperiod at no additional cost to them.

The practice and e-connect schemeswere introduced 3 years ago in anattempt to reach out to a far widergroup of practices and primary carehealth professionals responsible for res-piratory care. The introduction of theseschemes coincided with a decision torestrict PCRS-UK resources to mem-bers only. One of the main selling pointsof the e-connect and practice schemeswas access to a wealth of primary carerespiratory resources, whilst the pre-mium scheme continued to include, in

addition, a free hard copy of the PCRJ,discounts on registration to the PCRS-UK national conference and access tothe Respiratory Leaders Programme.Whilst the premium scheme continuedto thrive, uptake of the new e-connectand practice schemes, despite exten-sive promotion, has been very poor andthe costs of running them cannot bejustified.

OPEN ACCESS TO AWEALTH OF PCRS-UKRESOURCES

Experience with the e-connect andpractice schemes has shown that pri-mary care health professionals, at leastin the current NHS climate, are not will-ing to pay for educational tools andresources and expect them to be freelyavailable via the internet.

The PCRS-UK Education Committee ar-gued in February that the main driverfor joining a society such as PCRS-UK isa sense of community and belonging,alongside a shared concern for profes-sional accountability and development.Access to higher added-value tools andresources such as the new PCRS-UKimprovement tools is seen as attractivefor anyone with a lead role in respiratorymedicine, but routine information of thetype freely available from multipleopen-access sources is not a strong rea-son to join.

A decision has therefore been made bythe PCRS-UK Executive and Trustees toprovide open access to all the PCRS-UKmain clinical resources such as our opin-ion sheet series and quick guides, toensure they are more widely used. Ournew quality improvement tools andresources for respiratory professionaldevelopment will remain member only.

PCRS-UK News Round-Up



Our strategy ‘Delivering excellence locally’ focuses oncontinuing to build on our network of passionate and en-thusiastic PCRS-UK national and regional leads, localchampions and local group leaders who, supported byPCRS-UK (see box), are inspired to drive excellence inrespiratory care in their own locality. Our vision is to de-velop respiratory networks and leaders across the UKwho will link up, share experiences, knowledge, resourcesand help drive implementation of quality respiratory serv-ices to ensure patients receive optimal care.

The national and regional leads have already been busythis year contacting local people with influence and res-piratory champions, setting up network meetings in theirlocality, and promoting the PCRS-UK resources availableto support clinicians working to improve respiratory care.We are hoping that you will have met or had contact fromyour local PCRS-UK lead; if not, why not contact them andfind out what plans they have. You can also share any ex-citing respiratory projects or local initiatives in which youare involved and get their support (contact details athttp://www.pcrs-uk.org/pcrs-uk-regional-leads).

We are delighted that more than 50 members are alreadysigned up as PCRS-UK local champions, but we are keento partner with more of you so that we can give you thesupport you need to take the lead, motivate and inspirebest practice in your locality. If you want to develop a localnetwork in your area, work with like-minded colleaguesand be better equipped with the knowledge and tools tobecome more empowered to take the lead, then get in-volved today and sign up to be a PCRS-UK champion.

If you would like to join us as a local champion and benefitfrom PCRS-UK support to influence and improve respira-tory care in your area, please contact [email protected] become a part of our inspiring community!

Delivering Excellence Locally

A round-up of the activities of PCRS-UK regional leads, champions and affiliated groups from aroundthe UK plus the latest PCRS-UK developments to equip you to improve respiratory care locally.

June Roberts, Steve Holmes, Co-Chairs PCRS-UKRegional Development, Sara Askew, PCRS-UK Development Director

PCRS-UK: Equipping you to improve respiratory care

Whether you are a clinical commissioning (or Managed Clinical Net-work) lead concerned to address respiratory care across a group ofpractices (e.g. CCG, health board) or a practice lead keen to improverespiratory care within your own practice, PCRS-UK offers a compre-hensive programme of support (available by joining PCRS-UK):

The EQUIP improvement modules guide you through looking at howyou are doing, helping you with data sources, search and audit toolsand providing links to a range of PCRS-UK tools and resources.

PCRS-UK Practice Improvement Worksheets helps you/yourpractice address key areas identified from improvement through step-by-step workflow sheets (or disease management algorithms), sup-ported by quick guides, opinions sheets, PGDs, protocols and checklists. These resources, available through the PCRS-UK website, providesuccinct guidance and information designed specifically for primarycare health professionals.

The PCRS-UK Quality Award - recognising quality care in practice,is available for practices providing a high standard of respiratory care(who may, for example, have worked through the EQUIP modules andassociated practice improvement worksheets) to apply for and achieveformal recognition of the quality of care they are providing.

Through the PCRS-UK affiliated local groups’ programme, we can sup-port you to create and implement a respiratory interest group or network(with access to PCRS-UK regional leads/champions). Local groups/net-works help to galvanise and support change and provide on-going sup-port/education for primary care health professionals locally.

Respiratory clinical leadership development and support is availablethrough the PCRS-UK Respiratory Leaders Programme. The PCRS-UK Respiratory Leaders Programme offers national/regional trainingworkshops and on-going support to enable primary care health pro-fessionals to take the lead, motivate and inspire best practice withintheir locality.



Join the Respiratory Leaders Programme and we’ll support you totake the lead, motivate and inspire best practice within your sphereof influence whether it be in a practice, neighbourhood, CCG orHealth Board role. The leadership scheme enables any health pro-fessional working with primary care to take the next step. Plus, it’sFREE to get involved if you’re a PCRS-UK member. The programmeincludes two knowledge, networking and skills workshops per year.They are facilitated by GPs and nurses working within community,integrated and primary care settings today who bring their own ex-periences and skills to support you to develop in an informal, safeand inspirational environment.

In 2014 we are running two linked workshops which will focus onsetting up a project (Workshop 1) and then implementing the proj-ect (Workshop 2). The dates for the second meeting are 14/15thNovember 2014; to book your place please log on to the PCRS-UKwebsite and visit http://www.pcrs-uk.org/respiratory-leaders-events.

At the first workshop in July we heard from experts about how toset up a project with real-world examples from people like you whohave done it. The delegates worked on creating one of our four ex-ample projects in a team with fellow delegates supported by facili-

tators and experts. In our second workshop we will be exploringthe successful implementation of projects. So, whether your nextstep is organising an educational event or creating a financial casefor a service redesign project, the Respiratory Leaders team and fac-ulty will give you the confidence to scope your project, find anagreed aim and develop your strategy. We also look forward toeveryone sharing ideas and plans so we can signpost delegates toappropriate resources to make it work.

After the event, our past delegates have kept in touch and used thefaculty and other delegates to get continued support. We also offeran online ‘ask the expert’ facility where you can pose a questionabout service delivery to our expert panel of clinicians who will giveyou advice on a possible solution or advice on where to find outmore to help you.

Since 2007 we have held a mentorship programme once a year forrising stars at a national or international conference. Many of today’srespiratory leaders within CCGs, Health Boards and at regional levelhave come through this programme and can now support you todo the same.

We look forward to meeting you whatever your background andwhatever your role in influencing improvement in primary care.

Unlock, explore and achieve your leadership potential with theRespiratory Leaders Programme

Noel Baxter, Chair PCRS-UK, Respiratory Leaders Team,Sara Askew, PCRS-UK Development Director

Set up (or join) a local respiratory group and make a real difference in respiratory care in your area

Sara Askew, PCRS-UK Development Director, Carol Stonham, PCRS-UK Nurse Lead

As a practice nurse with responsibility for improving respiratory carefor patients can be a little daunting, especially when you’re jugglingworkloads and trying to keep up to speed with the latest developments.

A local group is the ideal way to bring practice nurses (and otherrespiratory clinicians in your area) together. It provides a forum tohelp you and your colleagues develop your clinical skills and knowl-

edge, share best practice with peers, and benefit from a local net-work of support.

Coordinating a group or network takes time, but it is also very reward-ing and, if you share responsibility with colleagues, it can be good funas well as a great experience. It will raise your own profile locally andhelp you to make links with other healthcare professionals who might



“After attending the PCRS-UK Respiratory LeadersWorkshop in June 2013, we felt inspired anddecided to set up a respiratory network in Leeds forpractice nurses. At the time there was not a formalnetwork for sharing ideas, best practice and sup-port. Practice nursing can be quite an isolated role,and we felt this was needed. We had previouslyresearched the quality of respiratory care in Leeds using the Atlas of Variation(http://www.rightcare.nhs.uk/index.php/atlas/respiratorydisease/) and identifiedthe need for nurse education in order to reduce variation and improve quality of carefor respiratory patients.

The primary aim of the Leeds Respiratory Network is to improve quality of care andreduce variation in respiratory care across Leeds.

Setting up the network was not too difficult; PCRS-UK offered lots of help, advice,support and encouragement. The practice nurses informed us they really appreciatethe network as it is easy to keep practice up to date and is also a chance to meet andexchange ideas with other nurses. Setting up the network has opened up a wealth ofopportunities for us personally and we would recommend nurses in other areas totake the lead and set up a local network without waiting to be asked.

We aim to hold four meetings a year, where guest speakers are invited to pass on theirknowledge and skills to practice nurses in Leeds. We have developed a mailing list,twitter, Facebook community page and blog with regular updates of new guidance,evidence-based practices and resources to improve respiratory care. We are currentlyplanning the first Leeds respiratory event with PCRS-UK which is due to take place inOctober 2014.

Since forming our network we have built relationships with other healthcare profes-sionals including school nurses, public health, pharmacists, speech and language ther-apists, secondary care consultants and nurses, and also the community respiratoryteam. We hope to bridge the gap between primary and secondary care, therebyimproving quality outcomes for patients. Our vision is to inspire others working inprimary care to take the lead and invest in strategies to improve quality of care in theirarea.”

Melissa and Sarah, Leeds Respiratory Network leads

otherwise continue to function in their own boxes without any interaction. Setting up andrunning a local group is also a real career development opportunity for you. Read on to hearthe enthusiastic story from Melissa and Sarah on setting up their respiratory network in Leedsand learn how easy and inspiring the experience was!

If you are interested in setting up a

local respiratory group or network

then PCRS-UK is here to support you.

Our start-up pack of resources and

tools contains lots of useful materials

(many of which are just as useful for

running your 10th meeting as your

first) and provides template examples

of event schedules, invitations, cost-

ing grids, feedback forms and much

more.

Affiliate your group to PCRS-UK. Af-

filiation is free and offers enhanced

credibility to the group. We allocate

free membership to leads of PCRS-UK

affiliated groups and provide access to

a wealth of resources to help you in

running the group as well as some ad-

ministrative support. We provide a

map of PCRS-UK affiliated groups on

the website helping to promote them

and we are delighted we have 52

groups listed, but hope we can grow

even more! Check out the locality of

the groups at https://www.pcrs-uk.org/

civicrm/google-mapping?reset=1

We offer a free annual meeting for the

leaders of local groups to help make

all your meetings a success, and our

next exciting group leaders meeting is

Thursday 25 September 2014 (prior to

the PCRS-UK annual conference).

Agenda and details will follow very

shortly, so watch the website for de-

tails. Click here to read feedback

about our fantastic event in 2013

http://www.pcrs-uk.org/nurse-events



For many years there have been respiratory guidelines and strate-gies, standards and frameworks, all aimed at improving clinical prac-tice across the whole patient pathway and across the whole NHS.These are laudable, have been written using the best minds and thebest criteria available, and set out clearly what our patients need inorder to ensure that they have the best care, most effective symp-tom control, and most optimistic long-term future possible.1,2,3,4,5

And yet, in recent times there have been a series of publicationsand reports highlighting what many describe as sub-optimal carefor patients across both asthma and COPD in the UK.6,7,8

Bridging the gap between our knowledge of what works and ourability to put it into clinical practice is a challenge. Busy cliniciansdon’t always know what is in the relevant guideline,9 and QualityOutcome Framework targets10 may not reflect the most effectiveclinical interventions that come from the core documents. Compet-ing clinical and managerial commitments in an ever more demand-ing environment mean that we need to have simple tools at ourdisposal that we can use effectively to address our most pressingproblems.

To this end (and to support grass roots general practitioners, prac-tice nurses and practice managers), the PCRS-UK has developed aseries of Practice Improvement Tools. These simply written toolshighlight specific problem areas in practice (see Box).

They provide simple step-by-step advice on how to address eachproblem, implement better practice, and measure success.

In NHS Grampian we have been closely involved in the develop-ment of the PCRS UK Practice Improvement Tools, having identifiedthrough our Managed Clinical Network a list of clinical prioritiesbroadly matching the tools we have now developed.

• A simple audit of 30 patients admitted to secondary care withexacerbations of COPD highlighted the following commonthemes that we believed were important factors in the break-down of post-discharge care and consequent re-admission to

hospital. The themes were identified by reviewing the patients’primary care records and assessing the COPD care receivedduring the preceding 12 months. We found that:

• 60% (18/30) had not been to pulmonary rehabilitationclasses

• 90% (27/30) had no record of a self-management plan

• 63% (19/30) had at least one previous admission for COPD

• 27% of the 19 patients with a previous admission had nofollow-up appointment post-discharge

• None of the 30 patients had any record of an objective as-sessment of COPD control (e.g. COPD assessment test(CAT) score)

PCRS-UK Quality Improvement Programmes: Equipping you to deliver excellence locally

NEW … PCRS-UK Practice Improvement WorksheetsIain Small, Morag Reilly

PCRS-UK Practice Improvement Worksheetsavailable: see http://www.pcrs-uk.org/resource-types-improvement-tools (make sure you are logged in first as theseare member-only access)

• Identifying undiagnosed COPD

• Accurate diagnosis of COPD

• Identifying high impact COPD

• Stepping down triple therapy in COPD

• Post-acute COPD care bundle

• Assessing patients with advanced COPD

• Management of advanced COPD

• Diagnosis of asthma in children

• Reviewing high dose ICS in asthma

• Post-acute care bundle in asthma



In the community healthcare partnership with the highest COPDadmission and re-admission profile, we have developed a‘Post Acute Discharge Review’ employing the practiceimprovement worksheet post-acute COPD care bundle(http://www.pcrs-uk.org/system/files/Resources/Improvement-t o o l s / Po s t a c u t eCOPDca r ebundle_Final.pdf) as illustrated.This pilot will test three importantissues:

• Do the Improvement Toolswork?

• Can they be embedded intoroutine clinical practice?

• Does the evidence from a pilotimprovement site encouragebroader uptake of the toolkit?

We hope to be able to report back to this journal in due course withthe results of this implementation project.

If you would like to be involved in reviewing these new tools, logon to the PCRS-UK website to access these member-only tools athttp://www.pcrs-uk.org/resource-types-improvement-tools (makesure you are logged in first as these are member-only access). You

can vote on its usefulness and tell us what you think of the tools byemailing us at [email protected]. Don’t forget to tell us about anyother improvement worksheets you think would be valuable to youin your practice.

References1. British Thoracic Society/Scottish Intercollegiate Guideline Network. British Guide-

line for the Management of Asthma. BTS/SIGN, 2012. Available fromhttps://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-guideline-on-the-management-of-asthma (Accessed 5 June 2014)

2. National Institute for Health and Care Excellence. Quality Standard for Asthma.NICE, 2013. Available from http://publications.nice.org.uk/quality-standard-for-asthma-qs25 (Accessed 5 June 2014)

3. National Clinical Guideline Centre. CG 101: Management of chronic obstructivepulmonary disease in adults in primary and secondary care. NICE, 2010. Availablefrom http://guidance.nice.org.uk/CG101 (Accessed 5 June 2014)

4. Health Improvement Scotland. COPD Standards for Scotland. HIS 2010. Availablefrom http://www.healthcareimprovementscotland.org/our_work/long_term_conditions/copd_implementation/copd_clinical_standards.aspx (Accessed 5June 2014)

5. Department of Health, Social Services and Public Safety. A healthier future: astrategic framework for respiratory conditions. Available from http://www.dhssp-sni.gov.uk/sqsd-service_frameworks_respiratory (Accessed 5 June 2014)

6. Asthma UK. Compare your care. Asthma UK, 2013. Available fromhttp://www.asthma.org.uk/compareyourcare (Accessed 5 June 2014)

7. Royal College of Physicians (RCP). National Review of Asthma Deaths (NRAD).RCP, 2014. Available from http://www.rcplondon.ac.uk/projects/national-re-view-asthma-deaths (Accessed 5 June 2014)

8. Sharif R, Cuevas C R, Wang Y, Arora M, Sharma G. Guideline adherence in man-agement of stable COPD. Respir Med 2013;107:1046-52.

9. Pinnock H, Holmes S, Levy ML, McArthur R, Small I. Knowledge of asthma guide-lines: results of a UK General Practice Airways Group (GPIAG) web-based 'Testyour Knowledge' quiz. Prim Care Respir J 2010;19(2):180-4.http://dx.doi.org/10.4104/pcrj.2009.00052

10. Primary Care Respiratory Society UK. QOF Respiratory Summary. PCRS-UK.Available from http://www.pcrs-uk.org/current-copd-and-asthma-qof-targetshttp://www.pcrs-uk.org/current-copd-and-asthma-qof-targets

NEW… Effecting Quality in Practice (EQUIP)Anne Smith, CE, PCRS-UK Tricia Bryant, PCRS-UK Operations Director and Project Lead, EQUIP

Respiratory conditions such as asthma and COPD are common andhave a significant impact on patients, their families and the localhealth economy. Yet management of these conditions is amenableto improvement that can lead to reductions in:

• Mortality

• Hospital admissions and unscheduled care activity

• Inappropriate drug prescribing

We also know that there is substantial variation across clinical com-munities in these variables and, for many practices, there is scopefor improvement. However, the increasing demands on primarycare make it increasingly difficult to find time to dedicate to devis-ing and implementing programmes of improvement.

A group of PCRS-UK leading members – Iain Small, Iain Small, Res-piratory Lead, NHS Grampian; Stephen Gaduzo, GPwSI, Stockport;Dr Noel Baxter, Respiratory Champion NHS Southwark; Ms June

A simple, modular tool to help practices, Clinical Com-missioning Groups, Health Boards and other primarycare-based groups deliver high value, patient-centred,respiratory care

Equipping you to:

• Tackle smoking cessation

• Achieve early and accurate diagnosis

• Reduce inappropriate pharmacotherapy prescribing

• Reduce hospital admissions

Effecting Quality

in Practice

Authors: Iain Small, Aberdeen; Morag Reilly, Aberdeen; June Roberts, Cheshire

Editor: Dr Iain Small

© Primary Care Respiratory Society UKThe Primary Care Respiratory Society is a registered charity (Charity No: 1098117) and a company limited by guarantee registered in England (Company No: 4298947). VAT Registration Number: 866 1543 09. Registered Offices: PCRS-UK, Unit 2, Warwick House, Kingsbury Road, Curdworth, Sutton Coldfield, B76 9EETelephone: +44 (0)1675 477600 Facsimile: +44 (0) 121 336 1914 Email: [email protected] Official Publication: Primary Care Respiratory Medicinehttp://www.nature.com/npjpcrm/

The Primary Care Respiratory Society UK (PCRS-UK) is grateful toAstraZeneca UK Ltd, Boehringer Ingelheim Ltd/Pfizer Ltd, ChiesiLtd, GlaxoSmithKline, MSD UK, Napp Pharmaceuticals and Teva UK Ltd for the provision of educational grants to establishthe development of the PCRS-UK Quality Improvement Programmes and its resources. The PCRS-UK wishes to acknowledge he ongoing support of AstraZeneca UK Ltd,Boehringer Ingelheim Ltd, Chiesi Ltd and GlaxoSmithKline in thecontinued development of this programme in 2014.

Correct at date of revision: April 2014.

Sponsorship details correct at time of publication

Post-acute COPD care bundle

Practice Improvement Worksheets, DRAFT version 01,Date of Expiry 10 September 2014

This series of practice improvement worksheets are prepared in DRAFT format, for members to use withintheir practice as part of a PILOT test. Feedback is soughtfrom users of these tools based on effectiveness, accuracy, completeness, usefulness and outcomes.

Please submit your feedback direct to [email protected]

The COPD discharge care bundle is a short list of evidence-basedpractices which should be implemented prior to discharge for allpatients who have been admitted with AECOPD. It is based on areview of national guidelines and other relevant literature, expertopinion and consultation with patients. The bundle is beingadopted in various hospitals across the UK and could also be usedin practice to follow on from an unscheduled episode of COPDcare This practice improvement worksheet covers the 5 key areas of review.

Delivering excellence locally…

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�� Improved care planning

�� Better anticipatory care

�� Management in line with national guidance

�� Reducing the impact ofunscheduled care in the practice

PCRS-UK Resources:

� PCRS-UK Opinion sheets - Social and lifestyle impact of COPD, Hospital at home, Exacerbations of COPD, COPD self-management and self care, Smoking cessation, Pulmonary rehabilitation, Inhaler devices, Practical self-management

� PCRS-UKQuick Guide to the diagnosis and management of COPD in primary care

� PCRS-UKCOPD assessment and review protocol

� PCRS-UKCOPD checklist

Other Resources:

� BLF Patient information COPD

� NHS Shared decision-making programme (COPD)

� National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 101. Management of COPD in adults. http://guidance.nice.org.uk/CG101

� IMPRESS value pyramidGOLD – Global strategy for the diagnosis, management and prevention of COPD

PCRS-UK Practice Improvement Worksheets

Equipping you to improve respiratory care



Roberts, Respiratory Clinical Lead Advancing Quality Alliance –have therefore harnessed their substantial expertise to produce theEQUIP programme, offering commissioners and clinicians practicaltools and know-how to improve local outcomes.

EQUIP is a simple modular tool for practices, Clinical Commission-ing Groups, Health Boards and other groups working in primarycare respiratory medicine. It provides a structured, systematic wayof reviewing the respiratory care being delivered and identifiesways in which the standards of care can be optimised within a prac-tice or across multiple practices in a given locality.

The five modules (see box) take the interventions most likely to leadto improvement based on the National Institute for Health and CareExcellence (NICE), Asthma and COPD Quality Standards, the De-partment of Health Outcomes Strategy for COPD and Asthma, theIMPRESS guide to the relative value of COPD interventions, theBTS/SIGN guideline for the management of asthma and SevenSteps to High Quality COPD Care/DREAM. Each module is astand-alone tool and participants can select those most appropriateto their needs.

Each module identifies the interventions most likely to lead to im-provement and provides suggestions on and links to:

• Data sources - to help you to understand how the data for yourpractice/group of practices compare with national data

• Audit and search tools - with suggested search criteria to helppractices identify key groups of high-risk/high-cost patients

• PCRS-UK resources - including our new concise easy-to-followpractice improvement worksheets (see page 24), quick guides,opinion sheets, nurse protocols and other tools to support thepractice team

• Other evidence-based guidance – other resources from ap-propriate credible organisations

The report of the national review of asthma deaths (NRAD 2014) spurred me and my commissioning colleagues on to ensurethat the critical components of good asthma care happen every time for every patient. For example, in the households of childrenwho died there was a 36% prevalence of smoking. One of the EQUIP modules can help practices to identify both smoking prevalencein asthma registers and whether evidence based treatment has been provided. The links from EQUIP to PCRS-UK resources will helpour GPs and practice nurses to feel confident in diagnosing asthma and providing a structured review. There is also an opportunity todo an asthma audit and see how our practices compare with others across the UK. Noel Baxter, London

Modules Available

• Prevention and treatment

• Prevalence, early and accurate diagnosis

• Structured review and optimal care

• Admissions and unscheduled care

• End of life care

“

”

PCRS-UK Quality Award – Get recognised for the difference youmake in respiratory care

The Primary Care Respiratory Society UK Quality Award, developedin conjunction with the British Thoracic Society, Royal College ofGeneral Practitioners, Association of Respiratory Nurse Specialists,Asthma UK, British Lung Foundation, Education for Heath and Res-piratory Education UK, sets out the standards that best define highquality respiratory care in primary care, providing:

• Recognition of practices providing a high standard of respira-tory care – serving as a quality assurance mark not only for pa-tients, but also commissioning groups and the wider NHS.

• A developmental framework that can be used at practice, local-ity and national level to promote, support and reward qualityrespiratory care in the primary care setting.



NEW improved Award, Modular Format

There are nine modules and associated standards covering clinical, organisationaland practice team topics. Each module comprises specific standards which practicesapplying for the award will be required to demonstrate that they have achieved usingwell recognised forms of analysis including audit, case studies, significant eventanalyses, protocols, and surveys.

The award offers practices a valuable developmental experience, whilst being rela-tively straightforward to complete. Practices can elect to undertake single modulesas part of a learning framework, or undertake the full Award.

PCRS-UK can support you throughout the Award process. If you would like to talkto someone about participating in the Award or speak to someone who has alreadyparticipated in the Award, contact us at [email protected] or telephone Tricia directat 01675 477603.

Visit our website for more information and to view the standards http://www.pcrs-uk.org/quality-award-standards and related evidence required to achieve theAward. Visit our Getting Started pages http://www.pcrs-uk.org/getting-started-you-apply to help you get started towards achieving the Award.

Standards Booklet

Recognising Quality Respiratory Care in Practice

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www.pcrs-uk.org

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SPECIAL OFFER – FREE Participation in the Award for practices applying in 2014

Duration of Award now extended to five years



Reaping the benefits from the PCRS-UK Quality Award

Collating the evidence you need to demonstrate the quality of care you are providing and apply for the Quality Award is alot of work. Here are some comments from three individuals who were involved in working towards the Quality Award,giving a flavour of how the Award has helped and supported them in their practice in addition to successfully achieving theAward as a practice team.

The PCRS-UK Quality Award has allowed us to understand better the impact of, and the

need for us to plan and co-ordinate our health promotion services, particularly around

smoking. The fact that we have achieved the Award has been highlighted as an example

of high quality asthma care by NHS Grampian in their response to a parliamentary

question, which was picked up by the local press.

We have a great nursing team in the practice, but doing the PCRS-UK Award allowed

them to reflect on and seek to develop the skills they needed in order to fill some

identified gaps.Iain Small, Peterhead Health Centre

Quality Award Participant 2011

We started from the premise that we are doing a good job and agreed that we would like to see if that is

the case, so demonstrating this was a core objective. This helped to get the whole practice team on board.

We shared the work in bite-sized chunks, looking at who was best suited to different tasks, then we set

time frames and reviewed regularly, which really helped us to stay on track.

We had a file on the shared drive with sub-folders: one for evidence in progress (i.e. unfinished) and one

for evidence for the submission (where completed documents were put). Being systematic with this, using

the evidence number as the title of the evidence, really helped. Using the shared drive meant that every-

one who was contributing could find the information in one place.

Deirdre Siddaway, Chesterfield Drive Practice, Ipswich

Quality Award Participant 2013

Several changes to processes of care have come about as a result of undertaking the

Award, and these will be sustained. These include a new system for monitoring and

following up all patients with COPD or asthma who are experiencing exacerbations of

symptoms, and changes have been implemented to practice templates and documents

that allow much easier construction of self-management plans.

Anne Rodman, Rushall Medical Centre, Walsall

Quality Award participant 2013

www.nature.com/npjpcrm

npj Primary Care Respiratory Medicine is an online-only open access journal published in partnership with the Primary Care Respiratory Society UK and the International Primary Care Respiratory Group.

Formerly published as the Primary Care Respiratory Journal (PCRJ), npj Primary Care Respiratory Medicine builds upon its tradition of publishing internationally-relevant open research that is essential to the future of primary care management of respiratory and respiratory-related allergic diseases.

Papers published by the journal represent important

of primary care and respiratory medicine.

Open for submissions devoted to the management of respiratory diseases in primary care

EDITORS-IN-CHIEF

Professor Aziz SheikhProfessor of Primary Care Research and Development, Allergy and Respiratory Research Group, Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK

Dr. Paul Stephenson The Christmas Maltings and Clements Practice, Haverhill, Suffolk, UK

Honorary Clinical Research Fellow, Allergy and Respiratory Research Group, Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK

FREQUENCY OF PUBLICATION

Continuous, new content published weekly

IMPACT FACTOR2.19*

All content is indexed within PubMed/Medline

*2012 Journal Citation Report (Thomson Reuters, 2013), formerly published under Primary Care Respiratory Journal

Part of the Nature Partner Journals series.

Respiratory

Ideas from the Laboratory of Life

Like riding a bike.

Without the awkward

learning how to do it part.At Teva Respiratory, we like bikes. We especially like the fact that learning how to ride a bike once is

learning it forever. We think that principle should apply to inhaler devices, because too often patients

have to be trained and trained again. And even then they forget. But there is one thing we don’t like

about bikes: the fact that they’re tricky to learn in the fi rst place. For us, that would never do.

Approval code: UK/RESP/14/0008.Date of preparation: March 2014.Teva UK Limited, Ridings Point, Whistler Drive, Castleford, West Yorkshire, WF10 5HX.

AROU

ND-T

HE-CLOCK COPD SYMPTOM CONTROL

1,2

Around-the-clock COPD symptom control1,2

with morning and evening administration.3

Significant and sustained bronchodilation from the first dose.1,2

EKLIRA has been approved by the EMA, but is not yet commercialised in all European countries.

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