Needs-led innovation: the power to meet local ambitions with national programmes to improve asthma pathways.   

Logan Ryan, ICHP Senior Innovation Manager, discusses how marrying local ambition to national drive can lead to brilliant innovation.

In London it is estimated 600,000 people suffer from Asthma. Some areas of North West London (NWL) have the highest levels of air pollution in the country, yet some of the lowest volume of diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Asthma. The case for earlier and more accurate diagnosis, as well as the right treatment, is clear. 

As the Academic Health Science Network (AHSN) for NWL, we’ve been working with NHS England, the AHSN Network, the Accelerated Access Collaborative (AAC), partners across the NWL health and care system and healthcare innovators to support changes to Asthma pathways that improve diagnosis and management of respiratory conditions and therefore improve patient outcomes.  

We want all patients to have the right care, in the right place, at the right time. Through embedding FeNO (Fractional Exhaled Nitric Oxide) testing in primary care and increasing access to Asthma Biologics through the design and testing of improved severe asthma pathways, we are confident that our patients will benefit, and our systems will develop. Where local ambition meets national drive like this, amazing innovation happens. 

Pathway not product 
To deliver and embed real needs-led innovation, our role shouldn’t be to try and shoehorn in a product to a pathway but rather to take a more holistic view – what is working here, would it help to implement a new product and what part of the national mechanism can we use to our advantage?  

In the case of FeNO testing, the benefits were clear. FeNO testing is a simple, non-invasive test to measure the amount of nitric oxide in an exhaled breath – a biomarker for airway inflammation – and can improve patient care by contributing to a faster and more effective asthma diagnosis when used alongside a detailed clinical history and other tests. As FeNO testing was identified as a Rapid Uptake Product supported by the AAC and The AHSN Network, ICBs (Integrated Care Boards) were able to apply to the Pathway Transformation Fund (PTF) to facilitate system enablement and improvement.  
Alongside NWL Integrated Care Board, Imperial College Healthcare NHS Trust and Circassia (one of two approved suppliers for the programme), ICHP were able to secure funding to supply devices and mouthpieces to 5 of the developing Respiratory Diagnostic Hublets (RDHs). The RDHs provide spirometry and FeNO testing to patients from across their boroughs, with the intention of increasing access to quality-assured asthma and COPD diagnoses, providing additional capacity in system to support primary care colleagues in achieving a differential diagnosis, and improving the identification of “hidden” asthma and COPD patients to ensure they receive appropriate management before avoidable exacerbations take place.  
By utilising the PTF, NWL was able to be truly innovative and pilot an entirely new pathway for asthma and COPD diagnosis, with a reduction of the financial risk. Removing that risk allowed space for innovation – to try things, demonstrate the benefit to patients, and make the case for transformation by promoting system enablement and getting all partners ready for change.  
As a result of the catalyst which the national programme and the “pathway not product” thinking provided, NWL ICS was able generate business intelligence to support the call for more sustainable funding of the FeNO offer in the RDH model, as both the product and the pathway worked for our population. NWL now has 16 RDHs across our 8 boroughs, each providing FeNO testing, ensuring 1,576 patients had received a FeNO test (figures to end of Jan 2023), exceeding our PTF target by over 100%. 

Ownership across the patch 
Collaboration is key to delivering and sustaining change. Our focus for improving Asthma pathways and outcomes has been focused on collaboration at national, regional and local level across healthcare systems. And, of course, London is an inherently nomadic population – moving across the city is the norm. As such, it is essential that any improvements in London pathways do not inadvertently embed inequity due to variation across systems. Championing the sharing our learnings and experiences alongside our sister London AHSNs (UCLP and HIN), particularly around RDHs, with colleagues and ICBs across London (via the London Respiratory Clinical Network) ensured that colleagues from across the regional could provide expert check-and-challenge for our approaches, that wheels were not being re-invented, and most importantly that variation across the capital with regards the RDH model is limited. This means we’re ensuring that patients and the public can access the same services across boroughs, and we’re not building inequity into the system.  

Engaging national programmes to deliver local change  
National drive aligning with what local systems need is where brilliant innovation happens. Funding from the centre can support the unblocking of pathway issues where additional headspace and resource are needed, can remove financial risk and make a clear case for transformation. Where the two align, it’s a perfect union. In the case of the asthma innovations identified by the AAC, this couldn’t have been truer. National teams heard and responded to the priorities of systems, and in return, systems committed to testing innovation, and learning as they went.  
Another AAC Rapid Uptake Products (RUP) programme that allowed us to take the opportunity to marry national drive and local ambition was the implementation of Biologic therapies for patients with severe Asthma (nationally led by the Oxford AHSN). Asthma Biologics work in a targeted way, by disrupting pathways causing airways inflammation, helping to manage symptoms and reduce exacerbations in those patients for whom traditional asthma treatments such as SABA inhalers and oral corticosteroids are not as effective. These therapies can transform patients’ lives by reducing long-term side effects of other treatments, such as steroids, and reduce the number of life-threatening asthma attacks.  
It is also fair to assume that optimising a severe asthma pathway would bring system benefits both to our clinical workforce and our health economy, with improve patient management reducing need associated with exacerbation within the system and therefore supporting with capacity efficiencies. While the full impact of this programme is still being finalised nationally, in NWL 1260 patients (as of March 2023) have begun receiving life-changing Asthma biologics treatment, with some of these patients being empowered to be able to self-administer their medication at home if appropriate. This is approximately a 20% increase across the year. 

As the innovation arm for NWL ICS, we aim to take the learnings from the impact of the national programmes and align them with proposed improvement projects that focus on local need and ambition in all our work. Working collaboratively with NWL and South East London ICSs, we’ve launched the London Asthma Decision Support Tool, one of NHS England’s pathfinder projects. Gaining a picture of asthma outcomes across ICS borders means that never-before possible system-level analysis can be performed and fed back to clinicians at a Primary Care Network (PCN) level, so relevant hyper-local interventions can contribute to London-wide improvements in asthma care. 

This kind of needs-led innovation is powerful, and it really works.  

Have a question about our work in this area? Get in touch.