Neighbourhood Respiratory Model: Improving Access and Proactive Care
Implementation
Over a 24-month period, we established a pharmacist-led one-stop respiratory clinic across Dudley primary care networks, initially piloting practices with the worst respiratory outcomes. The model was led by a single specialist respiratory pharmacist supported by a satellite multidisciplinary team (MDT) with the Difficult Asthma Centre to identify patients with severe asthma eligible for asthma biologics.
Key actions included:
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Targeted case-finding using prescribing data and risk stratification to identify undiagnosed or misdiagnosed patients.
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Comprehensive diagnostic assessments, including quality-assured spirometry and FeNO testing.
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Holistic review and management of high-risk groups including patients with learning disabilities, mental health issues, substance use, or care home residency.
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Optimisation of inhaler technique and medication regimens, discontinuation of inappropriate treatments, and proactive management of comorbidities.
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Integration with local secondary care services for rapid access to advanced therapies.
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Engagement with patients and carers to co-design the service and improve communication.
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Continuous evaluation using patient-reported outcomes, service activity data, and qualitative feedback.
NICE guidance underpinned all interventions, informing diagnosis, treatment optimisation, and self-management support strategies. Cross-sector collaboration and iterative feedback loops addressed implementation challenges, including referral criteria refinement and workflow adjustments. Funding was provided by the trust, using existing practice infrastructure and targeting groups that use healthcare the most to ensure impact and sustainability.
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