Purpose and context

This guide will build on what already works well in respiratory prescribing and encourage further quality improvement within NHS Scotland. It highlights key respiratory prescribing indicators, and it is hoped that clinicians will reflect on their current practice in prioritised areas. It should be read in conjunction with clinical guidance such as SIGN or NICE - it is not intended to replace them. The guidance has four main sections on Asthma, COPD, Bronchiectasis and Interstitial Lung Disease focusing on Idiopathic Pulmonary Fibrosis.

Environmental considerations for respiratory prescribing are introduced and explored. NHS Scotland has committed to be a ‘net-zero’ greenhouse gas emissions organisation by 2040¹ with more patients interested in their own carbon footprint.

We refer to ‘patients’ throughout, and recognise that different terminology is often used in official documentation. We recognise that patients are people who are managing different medical conditions, including respiratory disease.

• This guidance is for all health care professionals involved in respiratory care and prescribing decisions in both primary and secondary care including doctors, nurses, pharmacists, pharmacy technicians, physiotherapists and occupational therapists.
• It is available on this app for ease of access and as an additional support for patients and clinicians.
• If clinicians can reflect on their own practice it will help to reduce unwanted variation of prescribing across Scotland.³

• Respiratory conditions are a major contributor to ill health, disability, and premature death – the most common conditions being asthma and COPD.⁴   Scottish health Survey reported average incidence of asthma as 16% and COPD as 4%. ⁵
• The World Health Organisation has identified chronic respiratory disease as a non-communicable disease (NCD) along with diabetes, cancers and cardiovascular disease. NCDs are responsible for 71% of global death annually. ⁶
• The impact of respiratory conditions can vary depending on many factors. There is often a high co-morbidity of heart disease, hypertension and diabetes in individuals with respiratory conditions, which will also have to be addressed during a prescribing review. Optimising pharmacological treatment of these conditions is vital to help control symptoms and increase the quality of life for our patients.
• The guidance promotes Realistic Medicine using the holistic 7 Steps polypharmacy approach to medicine reviews that includes shared decision making, a personalised approach to care, reducing harm and waste and addressing unwarranted variation. ^{7 8}

The chart below highlights spend of respiratory prescribing in Primary Care in 21/22 by inhaler type.

• The total annual spend in 2021/22 was approx. £112.9 M. This represents 10.1 % of the Scottish Primary Care prescribing spend and is £11.9 M less than the total prescribed in 2015/16.
• Prescribing costs of Short Acting Beta Agonist inhalers (SABA) has reduced by 15% in the same time period.
• At the same time, there has been an increase in use of long-acting combination bronchodilator inhalers (LABA/LAMA) and triple combination inhalers (ICS/LABA/LAMA) as they are now more widely available and are more cost effective compared to single ingredient inhaler use.

• Clinicians involved in respiratory care will have access to and utilise this guidance. With its promotion and focus on quality prescribing, this should result in improvements in patient care and treatment of respiratory conditions.
• The 7 Steps medication review process promotes a shared decision-making approach to medicine reviews with patients. This places the individual at the centre of the review to ensure prescribing is effective and appropriate for them.
• Patients will be encouraged to self-manage their condition where appropriate and be asked ‘what matters to you?’ ⁹ to support a holistic approach to care of the individual in line with polypharmacy guidance.⁸

• Optimising therapy through shared decision-making will lead to improved patient care.
• Ensuring appropriate and effective use of pharmacological therapy for respiratory conditions will provide the opportunity for better patient outcomes and should therefore reduce health care utilisation and hospital admissions due to respiratory disease.
• There is an increase in volume of prescriptions dispensed and cost of medicines year on year. Appropriate review of respiratory prescribing should reduce volume of prescriptions, ensuring cost effectiveness and safety.

General prescribing information for health boards

This section contains some top-level prescribing information comparing NHS Boards. The graph below highlights the cost per treated patient which has increased by £2.00 in NHS Scotland between 2019/20 and 2021/22. 

Respiratory costs per treated patient

Generic prescribing  

National and local guidance promotes branded prescribing of all inhalers excluding salbutamol inhalers.

The graph below shows prescribing of generic inhalers across health boards, showing improvements across all boards.

Proportion of generically prescribed inhalers as a proportion of all inhaler (excluding salbutamol)

The numerical data for NTI graphs can also be viewed here.

The most up to date national therapeutic indicator data is available here.