If we want different outcomes, we need to understand the system - the processes, people and how they interact with each other.  This is important in identifying where you need to focus your improvement work.

Suggested actions - understanding systems

Health boards

• Is this a clinical priority for the health board? If not, why not?
• Does the board have an identified clinical lead for this?

Managed Clinical Network (MCN) and Respiratory Specialists in secondary care

• Are the MCN and respiratory specialists aware of the guidelines and ready to lead by example in implementing these?
• Does the MCN link with local groups of people with respiratory conditions and can these be developed locally?

Clusters and Cluster Quality Leads (CQLs)

• Have the CQLs and clusters reviewed the recently published cluster reports?
• Are the clusters willing to work together to share experience and learning and work together to focus implementation on this area?

GP Practices and Primary Care Team

• Is there a clinical lead within the practice for Respiratory? Is this the sole practitioner managing these people? 
• How does the practice direct/support clinicians involved in respiratory care to ensure competence and confidence? What training is offered to keep practitioners up to date? Consider the level of training for standard, advanced or expert respiratory care. See PCRS recommendations.
• How is the practice managing and risk stratifying care and service to those most in need, for example the vulnerable, house bound or those with poorly controlled symptoms?
• Has the practice considered using a variety of consultation methods, e.g. group consultations, digital?

Communicate with key stakeholders  

Engage with special interest groups of people living with respiratory conditions, wider MDT, community link workers/third sector groups to understand the current situation.

Use your data to help you understand where to focus your improvement work (including person outcome data as well as prescribing data).

Suggested actions - understanding systems

Dashboard - National therapeutic indicators data visualisation - Public Health Scotlandhttps://publichealthscotland.scot/publications/national-therapeutic-indicators-data-visualisation/

National therapeutic indicators available include:

• Poor Asthma Control: Number of people prescribed 3 or more short- acting beta2-agonists (SABA) per annum
• Poor Asthma Control : Number of people prescribed 6 or more short- acting beta2-agonists (SABA) per annum
• Poor Asthma Control: Number of people prescribed 12 or more short-acting beta2-agonists (SABA) per annum
• High dose corticosteroid inhalers as a percentage of all corticosteroid inhalers items (using 2019 SIGN/BTS classification of high dose)
• Prescribing of SABA only (in absence of other inhalers)
• CO2 Emissions (kg) per 1000 patients on list size (including targets)
• Proportion of pMDIs versus all inhalers (dry powder and soft mist inhalers) in BNF Chapter 
• Proportion of people receiving reliever and preventer inhalers in (BNF Chapter 3) as different pMDI / DPI devices
• Number of people prescribed inhaler that could be prescribed as combination inhaler in the same calendar quarter as a proportion of people prescribed any inhaler

How does this compare with others – board, cluster, practice and individual levels? Use the data to compare and understand areas of excellence to share and where to improve.

NTIs are available at https://scotland.shinyapps.io/nhs-prescribing-nti/

A new dashboard view is also available at https://scotland.shinyapps.io/nti-dashboard-view/

• Scottish Therapeutic Utility (STU) in GP practices linking prescribing data with GP system read codes, values, etc.
• Information and download instructions for practices
• STU installation

Process map – a QI tool to help you understand your system and key processes which may need to be improved.

Review data on your own IT systems

• GP systems : Are drug dictionaries up to date? Are formulary choices highlighted? Are prescribing synonyms up to date? How are ScriptSwitch messages for clinicians used? Number of asthma and COPD reviews taking place, self-management plans issued, What are your DNA rates? What are your smoking cessation rates?
• Hospital prescribing systems – highlight new formulary choices and update dispensary stock systems.

• Air pollution dashboard
• Smoking prevalence: Scottish Health Survey data
• Vaccination uptake
• Pulmonary rehabilitation
• Health and Care experience data
• Patient satisfaction surveys (internal data)