Learning from real world examples of spread and scale is a great way to increase our understanding and inform our thinking about this challenging topic. I met with Joe Sladen (@SladenJoe) from Wessex AHSN to hear about their reflections of leading the spread of the national FeNO programme through the lens of the NHSE Leading the Spread and Adoption of Innovation and Improvement: A Practical Guide. Video of our chat is here, the case study with further details here.
What is FeNO testing and why is it important?
FeNO tests measure the level of Nitric Oxide in an exhaled breath providing an indication of inflammation in the airway. A test takes around 10 seconds to do, is not invasive, and gives an immediate result – you can watch a video about FeNO testing here. Alongside a detailed clinical history and other tests, FeNO is used to support the diagnosis and management of asthma.
Historically, FeNO testing has been widely used in secondary and tertiary care however there is limited adoption in primary care. FeNO testing is a large-scale adoption opportunity for the NHS to improve asthma management and contribute to the respiratory goals outlined in the NHS Long Term Plan.
Improving asthma outcomes is important. Around 5.4 million people have a diagnosis of asthma in the UK of which 1.1 million are children and 4.3 million are adults (Asthma UK – Severe Asthma Report, 2018). There is evidence of under and over diagnosis of asthma in adults and increased risk of inappropriately prescribed medication, producing a significant opportunity to improve accurate asthma diagnosis which more widespread use of FeNO testing can contribute to.
FeNO testing and the 7 interconnected principles for spread and adoption
Wessex AHSN is one of 15 Academic Health Science Networks in England, commissioned by NHS England to support the systematic adoption of (proven) innovation. Wessex AHSN leads the national FeNO programme, working with all 15 AHSNs to enable the wide-spread adoption of FeNO testing in primary care.
Joe and team compared the approach taken with the FeNO programme to the 7 interconnected principles in the Spread and Adoption Guide to help further the understanding of spread and adoption and to demonstrate the value the Guide brings to those working to help adopt and spread innovation. Full details in the case study here and summarised below.
Complexity – although a FeNO test is simple the clinical pathway is complex as is the context of primary care. Added to this was the complexity at a national level with many related and concurrent initiatives and the programme occurring during the COVID pandemic. Being aware of the complexity was important. The team aimed to gather and understand the views of as many stakeholders as possible during the programme scoping and set up phase to assess the context complexity.
‘we were essentially looking to deliver a large scale respiratory change programme during a respiratory pandemic’
Leadership – Joe explained that a devolved enabling leadership style facilitated all AHSNs to work to a collective national ambition, while supporting the implementation of FeNO testing in their local geography in their own way.
‘We’ve been descriptive not prescriptive in our leadership approach’
‘We have built a collective ambition around a set of simple programme priorities and goals. We’ve seen engagement and ambition at all scales; from individual GP practices all the way through to Integrated Care Systems that have used the resources created and disseminated by the FeNO programme to implement FeNO in the best way for their local population’.
The Individual – at the core of the programme team are two fantastic public partners (Emma and Louise) who advocate FeNO in very practical terms. Living with severe asthma, they hold the programme to account and retain its patient focus making it clear what FeNO means to them and how it has positively impacted their lives.
Benefit and Adopter focus – NICE recommends the use of FeNO testing in the diagnosis of asthma and evidence demonstrates FeNO testing can improve patient management when used with other assessment and decision methods.
Fundamental to the approach taken was the focus on the adopters – respiratory nurses, general practitioners, and primary care (respiratory) commissioners. This list was expanded to include operational, managerial colleagues, as well as patients. Materials to support implementation for all these audiences is freely available in the FeNO implementation toolkit here.
Networks – At a national level, the connected network of AHSNs across England is core to the way the adoption and spread of innovation was supported. Quarterly FeNO Learning Collaboratives connected people using FeNO, implementing FeNO and considering FeNO testing. The Collaborative agendas focus on the adopters and the individuals joining the Collaborative to encourage them to share experiences and learning, network with others, and generate traction and enthusiasm.
Learning – is embedded across three levels:
- National Learning Collaboratives which support clinical teams (regardless of clinical setting) who use FeNO (above)
- AHSN Network community of practice which supports AHSNs directly linked with the implementation teams on the ground
- National Programme Group chaired by Wessex AHSN, which takes a national overview of the programme, its goals and successes
Learning is shared across these groups and more widely with the FeNO programme’s sister programme which is working to improve access to biological therapies for people with severe asthma. This relationship has proved hugely beneficial as both programmes learn from each other to further improve.
Reflections on using the Guide
Joe explained that although they have attempted to describe separately, how each of the 7 principles have been used as part of this programme, the reality is – as described in the Guide – a set of ‘7 interconnected principles’ and that they certainly experienced the interconnected aspects of the principles in their programme approach.
Two key reflections are the importance of:
Adopters – the team are strong advocates for the need to focus on the adopters, the individual people who are adopting FeNO, and the team have held this principle at the core of the programme.
Networks – to share best practice, learning, build communities and support the movement have been one of the greatest successes, and should be at the forefront of the minds of anyone planning an innovation implementation programme.
FeNO testing – the future and more information
The FeNO programme is gathering pace with a rapidly growing number of users across England who are ‘thinking FeNO’ early.
The national FeNO programme has developed a suite of resources, including two training modules with free open access for all NHS staff via the Health Education England e-Learning for Health platform here.
It also runs quarterly FeNO Collaboratives at which all are welcome. Please contact Wessex AHSN at enquiries@wessexahsn and browse the programme resources at www.wessexahsn.org.uk/feno for further details.
Interested in more information?
More information is available on the Leading the Spread and Adoption of Innovation and Improvement: A Practical Guide in the blog here and on the 7 spread and adoption principles and system convening, including blogs and videos, on the NHS Horizons website.
This case study describes the approach Wessex Academic Health Science Network (Wessex AHSN) has taken to supporting large scale adoption of FeNO testing across England through the lens of the Practical Guide.
We hope to see more teams using the Guide to inform their innovation adoption projects in the future, resulting in innovations being adopted faster, and used more sustainably.