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A new respiratory model for primary care

Portsdown Group Practice is a group of 6 GP surgeries across the wider Portsmouth area with a patient catchment size of 44,000, allowing it to be registered as its own Primary care network (PCN).

With an increasing register of patients with respiratory disease and a shortage of appropriately-skilled respiratory nurses, the practice team decided to develop an alternative approach to deliver care.


Primary care is incentivised to deliver routine care for long-term conditions by the Quality Outcome Framework (QOF). It’s not particularly well-suited to respiratory conditions such as asthma. It encourages a one-size-fits-all approach on an annual cycle, at a time and location convenient to the GP surgery.

Asthma is a condition characterised by its variability and its impact on individuals varies tremendously.

Applying the same assessment and review to every person with asthma poses a number of problems. It may:

  • be inconvenient to patients with good disease control and minimise the importance of a review
  • not allow enough time for patients with poor disease control
  • miss periods of poor control, again sending a message that poor disease control is acceptable


There will be a process to enable the team to identify high-risk patients throughout the calendar year. The process would address poor control when it's identified and create a more valuable use of the clinician’s and patient’s time.

It would also help to change the culture of acceptance of poor asthma control where patients and clinicians accept overuse of reliever medication and asthma exacerbations.

An initial telephone or video assessment would enable the clinician to engage with the patient, identify patient needs and highlight the need for a more detailed assessment where appropriate.

Solution and impact

The new system uses risk stratification in order to respond to patient needs while enabling the practice to achieve its QOF targets.

The practice collated routinely-collected patient data that can act as signals of poor asthma control.

This included:

  • the Royal College of Physicians (RCP) '3 questions' for asthma
  • reliever inhaler prescriptions
  • oral steroid prescriptions
  • unscheduled care events

All GP surgeries have access to this data, although the quality of the data varies.

The team, who are skilled in searching the GP IT systems, ran weekly searches. Using this data, the respiratory team analysed the results to identify those patients at highest risk of future asthma attacks.

The team then contacted the patient by telephone and did a detailed assessment of the patient’s asthma. This review was completed, where appropriate, in a face-to-face appointment at a time and venue that suited the patient.

The clinical team was given the flexibility to allocate an appointment length according to the needs of the patient. Some appointments would only need to be 10 minutes and others as long as 60 minutes.

This approach streamlines the use of team resources, allows personalisation of the clinical review according to need and makes every contact more relevant for people with asthma.

By being more responsive to patients’ needs and their pattern of disease, Portsdown hopes to improve the quality and safety of care above current QOF requirements.


A GP IT system and a skilled data-handling team who can:

  • accurately and consistently input searchable Read Codes (unscheduled care events, hospital letters, patient symptom scores)
  • accurately produce searches to identify unscheduled care events, prescriptions and symptom scores


Use of risk stratification and data collection to respond to patient needs in GP practices so that the most at-risk patients are seen as priority.


Clinical settings.

Key learning points

  • Investment in data skills is crucial for primary care.
  • Treat people with long-term conditions as individuals and not all the same.
  • Prioritisation of high-risk patients can allow more meaningful engagement with patients in terms of health needs, patient experience and patient understanding.

Initial telephone/video reviews can:

  • identify patient needs
  • encourage better engagement, reducing Did Not Attends (DNAs)
  • allow planning for a more detailed reviews if appropriate

Key figures

Care outcomes in 2016 and 2019
Outcomes 2016 2019
Respiratory slot type DNA 508 8
Asthma QOF exception 82 43
Asthma prevalence 2,534 2,942
Asthma QOF points 45/45 45/45

Given the change in approach has been functioning for less than 12 months, a comprehensive evaluation of the service is yet to be completed.

Despite this, initial results suggest an improvement in patient attendances, improved care to disengaged patients and improved revenue for the PCN through maximising QOF outputs.

Prior to the service being introduced:

  • there were 508 DNAs for respiratory-only appointments in 2016
  • DNAs cost the practice approximately £18,5000
  • DNAs were demoralising for the respiratory team and led to patients not receiving the care that they needed to stay well

Since the introduction of the new service:

  • there was a 98% reduction in DNAs for respiratory-only appointments (from 508 in 2016, down to 8 after the service was introduced)
  • asthma prevalence has increased by 14%, meaning more patients have been identified who were not typically engaging with the primary care system
  • total revenue from QOF has been increasing for the practice

In conclusion, the change to asthma management within Portsdown has largely occurred without the need for upfront investment, a barrier commonly experienced for new digital projects in healthcare.

Key contact

Dr Andy Whittamore, GP and Clinical Lead, Asthma UK+BLF