How this PCN…improved care of asthma

Central Camden PCN is one of the six networks shortlisted for PCN of the year. Co-clinical director Dr Ammara Hughes shares the success of their asthma clinic pilot.

Central Camden PCN consists of nine diverse practices, covering more than 85,000 patients in the most deprived part of the London borough. Now in our fifth year, we have transformed our way of working to mobilise several services using our collective additional roles reimbursement scheme (ARRS) staff, demonstrating real value for the patients and the wider healthcare system.

Historically in the UK, asthma is undertreated and undiagnosed in the UK while many patients on biologics are initiated too late. Our PCN asthma multidisciplinary team (MDT) clinic was mobilised in January 2022 in collaboration with a University College London Hospitals (UCLH) respiratory consultant and PCN ARRS staff to create a diagnostic hub within primary care for the diagnosis of asthma and COPD. It provided an intermediate step before referral to secondary care for the management of asthma patients.

Our aim was threefold: establish a model of community care that incorporated spirometry alongside FeNO (Fractional Exhaled Nitric Oxide) measurements at baseline and on review post-treatment; provide management of asthma in line with national guidelines and sustainability agenda (NHS net zero plan); reduce emergency department (ED) admissions and improve quality of referrals into secondary care.

During the first 12 months of the asthma MDT clinic initiation, 282 adult patients were seen, of whom 158 were diagnosed with asthma. Only nine patients were referred to secondary care. Those referred onwards to a specialist asthma clinic avoid unnecessary waits to step up inhaled therapy as they are comprehensively assessed in a primary care setting. Recently, we have garnered international recognition for our asthma MDT clinic pilot with our poster presented at the American Thoracic Society Conference in Washington in May 2023.

Our team has worked hard to ensure our services are scalable. They are evaluated using a standardised framework to determine the impact on the wider healthcare system and improvements on patient care and outcomes.

Innovation

We collaborate strongly within our PCN and with external stakeholders, such as UCLH, TympaHealth, SurgEase, bioMérieux, and our local Health Innovation Network, UCLPartners (formally Academic Health Science Network), to mobilise and evaluate PCN services and technological innovations within a primary care setting.

As part of COVID recovery, our PCN has built relationships with UCLH consultants and managers, and has used a data-driven approach to identify ‘high volume low complexity’ elective procedures which could be undertaken in a primary care setting. Examples of this include our collaboration with UCLH ENT consultants and TympaHealth to develop primary care microsuction pathway, as well as our collaboration with UCLH colorectal consultants and SurgEase to develop a primary care rectal pathology service. Both services are delivered by the ARRS workforce and have been shown to reduce elective waits at UCLH and enhance patient experience by reducing outpatient visits and delivering care closer to home.

Based on respiratory-related admissions data we developed integrated asthma and COPD services delivered by our trained ARRS staff with support from an UCLH respiratory consultant and bioMérieux. The services have allowed a standardised diagnosis and management of chronic respiratory disease across the PCN and have shown a reduction in acute admissions, outpatient referrals and patient empowerment to self-manage. In addition, we have reduced unnecessary antibiotic prescribing and our carbon footprint by prescribing more ‘green’ inhalers.

Our multidisciplinary PCN anticipatory care team work closely with community providers such as Central and North West London (CNWL) NHS Foundation Trust to allow seamless stepdown from hospital care after an acute admission, to increase communication and improve efficiencies of system pathways. Our team accept appropriate referrals from practices and undertake proactive identification and intervention of: frail patients; adults living with multiple complex health conditions and/or disabilities; and those who are approaching the end of their life.

Prevention

By working with all teams involved in the patient’s care, we share and jointly produce personalised care plans in a patient-centred way. The overall aim is to improve patient outcomes and experiences of care by providing a holistic approach to care and a reduction in the number of contacts these patients have with various parts of the health and social care system.

We focus on prevention and wellbeing for our population and have established relationships within the community with some of our services being hosted at a local community centre, The St Pancras and Somers Town Living Centre, which serves the most deprived part of our borough. The centre provides cooking classes, yoga and a food bank while our PCN delivers an onsite nutritional therapy and physical activity programme, which staff can directly refer patients if they are registered at a Central Camden PCN practice.

By encouraging healthy eating and exercise in the form of group and one-to-one sessions, we support the local community to engage in other local activities and gain confidence and skills in other aspects of their lives. This approach has led to our PCN regularly participating in community-hosted events, such as health promotion activities and educational sessions designed to raise awareness of the importance of cancer screening and immunisations. We also provide vaccination and health check pop-ups in the community, which target hard-to-reach patient groups.

All our PCN services fit with the strategic priorities of our local ICB and NHSE’s Core20plus5 approach to reduce healthcare inequalities, long elective waiting lists and unplanned admissions, and our local integrated care board (ICB) has approached us with regard to the wider spread and adoption of our services and innovations. 

Partnership working

Our PCN ARRS staff are upskilled and trained to deliver high-impact, low-cost services in primary care. We have partnered with our local secondary care provider and organisations who have developed innovative technological solutions to mobilise at-scale services across the PCN in a primary care setting.

Our services support system resilience through saved secondary consultant and GP practice appointments, and increased workforce satisfaction. Patient/carer benefits include improved access to services and care provided closer to home, reduced appointment waiting times, and reduced health inequalities. Patient/carer feedback has been positive with all services receiving above 80% for service recommendation.

UCLPartners are supporting the PCN with service evaluations and data analysis of both patient and wider healthcare system benefits. The PCN-led microsuction pathway has been shown to be two-thirds cheaper than the acute-led version, with referral to treatment time reduced from 12 months to three weeks. Since the programme started in September 2022, 294 patients have attended a microsuction appointment and referrals to secondary care have fallen by 40%.

Outcomes

Just over half of patients (51%) seen in the asthma clinic received a confirmed diagnosis of asthma, 14% received a new diagnosis of asthma and 35% received a new diagnosis that was not asthma, i.e. allergic rhinitis. Hosting this clinic in a primary care setting has benefited our patients hugely, with appointments offered within a month of referral and 87% of patients said they had a positive overall experience of the service.

Our COPD exacerbation service ran from December 2022 to March 2023 to support COPD patients experiencing exacerbation symptoms and reduce unnecessary antibiotic prescribing. Over four months, 77 patients were swabbed at home, with 21 patients positive for influenza and other respiratory viruses. Only two COPD patients were prescribed antibiotics and exacerbation symptoms were found to be reduced after two follow-up telephone consultations.

The nutritional therapy programme has been running for more than three years and has had 506 referrals since the service commenced. Our nutritionists support patients who are experiencing issues with weight gain, weight loss, IBS, raised HbA1c and other gut-related conditions and complaints.

Feedback has shown patients appreciate and benefit from the personalised care they receive from our nutritionists. The monthly sessions allow them space to understand what works for them and their specific problems. Data analysis has shown a significant reduction in patients’ primary and secondary symptoms, a reduction in BMI and three-quarters reaching all three of their personalised goals.

Sixty-nine patients have completed the physical activity programme to date, with results showing significant physical and mental benefits for all patients. A Bengali-speaking physician associate assists the personal trainer on this project to collect patient outcome measurements on their first and final session. This includes BMI, BP, waist circumference and pulse rate. Nearly all (98%) patients said they would continue to exercise after they completed the programme, which highlights that we are embedding long-term behavioural changes rather than a short-term intervention.

Early evaluation from our rectal pathology service has shown a 90% reduction in referrals to secondary care and a 92% reduction in waiting list time.

Future

The NHS Long Term Plan highlighted cardiovascular disease (CVD) as the largest area where the NHS can save significant numbers of lives over the next 10 years.

To reduce instances of CVD in the PCN and support the Core20plus5 approach, a lipid optimisation clinic has been launched in collaboration with a UCLH diabetes and lipid metabolism consultant. PCN ARRS pharmacists are being educated on the lipid optimisation pathway for secondary prevention in primary care and have begun initiating patients on the new inclisiran treatment to lower cholesterol.

The PCN has also started collaborating with UCLPartners, Google and Huma on a blood pressure optimisation programme to improve the identification and management of patients with hypertension and support patients to maximise the benefits of remote monitoring. We will be running a pilot programme that aims to raise awareness around hypertension and empower patients to self-manage their condition through lifestyle goals and drug adherence.

Recently, the PCN has invested in three point-of-care testing (POCT) machines to enable more efficient and quicker diagnosis of diseases and conditions, and to improve chronic disease management. POCT provides test results within minutes, which helps support clinicians with the creation of patient management plans and improves patient experience by reducing the number of appointments they have to attend.

Early evaluation suggests POCT is cost-effective for the wider healthcare system as fewer patient appointments are required and patient compliance with management plans is improved. The next step will be to roll out a POCT machine in each of our nine practices.

Dr Ammara Hughes is co-clinical director of Central Camden PCN.

The General Practice Awards are run by Cogora, the publisher of Pulse PCN. These awards highlight innovation in primary care across the UK. This article is part of a series on the shortlisted PCNs.