How Lewisham’s journey towards providing better asthma care for children and young people was achieved…
One single aspect lies at the heart of our journey in Lewisham; partnership. In Lewisham strong partnership and professional commitment by clinicians, commissioners, public health and service users has been key for us setting our goal of improving health outcomes for children and young people living with asthma. Our vision was to achieve a new paediatric asthma pathway, a reduction in paediatric asthma admissions and an improvement in asthma care across community, primary and secondary care.
Our journey starting point was to get a broad overview of how care to children with asthma in Lewisham compared to other children in London and how we compared to other statistical neighbours on prevention and protective factors. We set about doing this by using the ‘National Guidelines for Management of Asthma’.
One of the first areas we focused on was improving support and awareness around breastfeeding. We did a lot of work to promote breastfeeding including health visiting in universal settings; breastfeeding cafes and activity based workshops in children centres.
We also looked at exacerbating factors for asthma, particularly smoking exposure and pollution. We did a large amount of engagement with local business and the wider community. Our local strategy on air population and expenditure commitments were approved by the Mayor.
In regards self-care and care management of asthma we knew this part of the journey would mean entering the realms of clinical quality improvement (CQUIN). But CQUIN only incentivises part of the system and not the whole. Achieving a whole system by in was approached by engaging with stakeholders and interested parties.
As the planning for the CQUIN started to take shape the winds of change blew favourably in our direction. Working collaboratively with Our Healthier South East London (OHSEL) we developed a vision for what our asthma care outcomes should look like which coincided with the London Asthma Standards being published. Through our first CQUIN we set ourselves the objectives to achieve;
- An analysis of the movement of children and young people with asthma that could be shifted from hospital into the community
- Develop a series of events with stakeholders and service users to ensure the local approach to pathway redesign meets the needs of children and young people but also reflects the strategic and partnership priorities for community services
- Test pathways and develop proposals for shadowing the use of an outcome based indicative tariff
We started by trying to understand how it feels for a child with asthma or their parent, carer presenting to A&E. What do they value most when they are seen, treated and discharged? How does it feel for a GP, practice nurse or community pharmacist when they see a child with asthma and what are the support and management needs of children and young people living with asthma?
Our varied but consistent lines of enquiry took us to very different conclusions on what the gaps in our service provision for users and clinicians were. Once we had established how to best determine what a new model would cost and considered how this could give value for money. We applied for one more CQUIN.
We have jumped through a fair number of hoops but we are rather pleased with some of our successes. These include:
- A new outcomes framework for asthma to inform evaluation of a pilot for a new community service
- A new tariff for the service has been developed that will be piloted in the second year following the results of the evaluation
- A whole system-led asthma pathway agreed in line with the London Asthma Standards
- We undertook a training needs analysis of our local primary care, community and community pharmacy workforce to develop a training programme for GPs, practice nurses and pharmacists in collaboration with Healthy London Partnership
- Education session with GP’s
- A new children and young people’s asthma template which has been uploaded onto our local GP practice IT system
- A prevalence finder tool will be used to help us identify children whose management plans and care have not been reviewed
- Secured funding for a new children’s community nursing asthma service from our local acute trust. This has been commissioned and will be piloted in October
- A small number of GP practices and adjacent community pharmacies will participate in the new asthma pathway
- Strengthening of our out-of-hospital offer with our local trust, primary care and local community pharmacy committee
- A new Asthma Steering Group with a wide representation of clinicians has been formed to oversee some of development work post CQUIN
- In a snap shot, that’s how Lewisham’s journey towards providing better asthma care for children and young people developed. They key to achieving our goal was working with and engaging with our patients, stakeholders and partners.
Co- Authors: Dr Angelika Razzaque, GP Lead for CYP and Asthma for Lewisham CCG and Victor Ferreira, CYP Joint Commissioning Lewisham CCG and London Borough of Lewisham