How to achieve high-quality, low-carbon asthma care

Pressurised metered dose inhalers (pMDIs) use propellants, which are powerful greenhouse gases, to deliver medicines. These inhalers account for 13% of the direct carbon footprint of the NHS.

Meanwhile, outcomes for asthma in the UK are among the worst in Europe. How can we improve asthma care and reduce its carbon footprint?

Dr Aarti Bansal is a GP in Sheffield and founder of the primary care sustainability network, Greener Practice. I spoke to Aarti about the development of a quality improvement toolkit for asthma care.

How did you arrive at your focus on asthma?

I started out from the environmental perspective. I was aware inhalers are a carbon hotspot for the NHS and that change was needed, so my initial question was, ‘how do we make this change safely and effectively?’

I wanted to understand and integrate the concepts of high-quality care and low-carbon care. And it is a win-win-win scenario! The things we want to do to improve the environmental sustainability of asthma care are the same things we would do to improve patient health and public health, even if there wasn’t a climate crisis.

I am very motivated by ‘how’ – taking an idea of what we need to do and thinking through how we are actually going to implement it. That’s a thread that runs through everything I’ve done.

Why is the carbon footprint of asthma care so high?

The high carbon footprint comes from the fact that, in the UK, 70% of the inhalers we prescribe are metered dose inhalers. There is no clinical reason for this. We are outliers compared to other European countries where metered dose inhalers account for less than half of inhalers prescribed.  

There are two ways of tackling this high carbon footprint. The first is to reduce the number of these inhalers and the second is switching to clinically effective lower carbon inhalers.

In asthma, there’s a robust case for reducing the number of inhalers because most are being used for ‘rescue’ treatment, sometimes called ‘relievers’. These inhalers, often blue, are being used for symptom control, but if asthma is well controlled, then people don’t have symptoms.

Asthma is an illness causing inflammation in the lining of the airways. The treatment is a preventer inhaler, often prescribed to be used daily, to reduce the swelling in the lining of the airways. People with well controlled asthma rarely have symptoms and only rarely need to use their rescue treatment. If they are using separate preventer and rescue inhalers, this equates to needing only one or two rescue inhalers a year.

Unfortunately in the UK, approximately half of all asthma patients do not have well controlled asthma and have ended up relying on three or more reliever inhalers a year to control symptoms they don’t need to be living with. Many are using six or more rescue inhalers, which is associated with a higher risk of asthma attacks. If we reduced reliance on rescue inhalers, by improving asthma control, the inhaler carbon footprint would be reduced by two-thirds.

What will changing inhalers mean for people with asthma?

We know most patients would be interested in a more environmentally friendly inhaler, However, for most people, the reason to switch will be because it works better for them.

The higher carbon inhalers can be tricky to use well. I’ve been a doctor for 25 years and I can count on one hand the number of times I’ve seen someone using a metered dose inhaler correctly. People tend to take a quick and a deep breath, instead of a slow and steady breath in with a spacer device. This results in the medicine hitting the back of the throat, not reaching the airways.

For most people, using a lower carbon dry powder inhaler, which requires a quick and deep breath in, will mean their medicine gets to the right place.

The other issue with metered dose inhalers is that many don’t tell you how many puffs you have left. Most of the lower carbon, dry powder inhalers have dose counters and that is really helpful.

Some people, such as those with severe asthma or young children, may be better off on metered dose inhalers, which should be used with spacer devices.

What parts of practice need to change?

I’m very motivated by making sure the default thing is the right thing. We’re so stretched in healthcare, the last thing you need is to have to work against the system to provide good care.

It’s important to have a conversation in your practice about how to do this better. We undertook a mapping exercise to look at when people with asthma access care. That was important for us in understanding that this is a whole team issue, and an issue of systems.

People with asthma symptoms will see someone for immediate care, often a doctor or a nurse practitioner. They also contact us when they need an inhaler and a receptionist will take that call. What does the receptionist need to know in that scenario?

People with asthma may also access emergency services and should be reviewed afterwards in general practice. What does the coding team need to know to code a letter from A&E as an asthma attack and send it to a clinician to organise an appointment?

The annual asthma review is an opportunity to make sure patients are receiving the right medicine and that it is getting to the right place. We want people to understand that asthma is an inflammatory condition and we can use airways diagrams and visuals to make that point. Having that short explanation is a lightbulb moment for many patients.

Are people on the best treatment for them? Would they, for instance, be better off with a combination inhaler that contains both preventer and rescue treatment? Is the inhaler device the right fit for them?

There are other things that are important for patients to know about, around air pollution, breathing techniques and self-care. We can talk to patients about moving to a lower carbon inhaler, but it’s better to give them the information beforehand so they can ask questions at the review. We created information leaflets and text messages that the admin team can send to patients.

The asthma toolkit contains all the resources we created for general practices. It also has lots of simple quality improvement projects. Some of the projects can be done in ten minutes, others are more like an audit.

For me, this has all been about integrating an environmental issue with what’s best for the patient. As a health professional, many of the long-term conditions we encounter are so complex that it can feel difficult to make a difference. With asthma, it is entirely within our gift as health professionals to improve care.

Visit the Greener Practice website to explore the asthma toolkit.