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New exciting asthma project in Hull leads to both patient and environmental benefits

Written by: Harriet Smith - 1st November 2021

In this blog, our Programme Manager Harriet Smith, looks at the work in partnership with Hull University Teaching Hospitals NHS Trust to help asthma suffers improve their health and wellbeing.

Asthma is common in the UK, with approximately 5 million people suffering with the condition. In asthma, the airways in the lung become inflamed, leading to symptoms such as breathlessness, cough, chest tightness and wheeze. Although these symptoms can be mild for some, others find themselves having to take time off school or work and people are still dying from asthma each year in the UK. Although we have seen advances in treatment, health outcomes associated with asthma have stagnated, and as a country, we now have some of the worst outcomes in Europe.

Has asthma become ‘something you have to live with’? To endure?

When considering this, it is important to understand some basics about asthma treatment. The key to treating asthma is to control the airway inflammation using inhalers that contain a steroid. This kind of inhaler is often called a ‘preventer’ and needs to be taken every day. Many people with asthma also have a ‘blue’ inhaler that they use as a ‘reliever’. These inhalers relax the muscle around the airways in the lung, temporarily reducing symptoms. Unfortunately, these blue inhalers (known as SABAs) do not treat the inflammation, they only provide short term benefit. We know that people that need to use their SABA regularly are at higher risk of asthma attacks and that over-reliance on SABA and under-use of steroid containing inhalers is seen in people that die from their asthma.  Despite this, many asthma patients suffer in silence, using their SABA inhalers regularly to relieve their symptoms, without considering how their asthma can be better controlled.

There are some startling national statistics regarding our over-reliance on SABA inhalers:

  • Over 15 million SABA inhalers are prescribed every year in the UK.
  • 38% of SABA inhalers are prescribed for patients who are over-reliant on them (needing three or more SABA inhalers a year).
  • SABA over-reliance is associated with poorer health outcomes compared to those who are not, regardless of their asthma severity.

Regular SABA use is not only a sign that someone’s asthma may be uncontrolled and that they are at risk of asthma attack, it is also bad for the environment.

  • Blue inhalers account for 70% of the total carbon footprint of all inhalers in the UK.

So why have we come to rely on SABA, the blue inhalers that people have in their car, their handbag and bed side drawer? The drawer full of inhalers in the teachers’ desk (I am old enough to remember!).  Is there a need for a cultural shift?  A new perspective, where the norm is for an asthmatic to be symptom free with no asthma attacks?

Innovative solutions

There are around 20,000 people suffering from asthma in Hull, a region with some of the highest SABA inhaler use in the country.

In a bid to try and manage this and improve the health of asthma patients within the Hull region, Dr Michael Crooks (Respiratory Consultant and Senior Lecturer) and colleagues at Hull University Teaching Hospitals NHS Trust, Hull York Medical School and Hull CCG, started working in collaboration with a team at AstraZeneca. Together they worked with asthma clinicians and patients using experience-based co-design methodology to develop a programme to promote good quality asthma care through implementation of local asthma guidelines. At the same time, the team are undertaking a rigorous evaluation and generating real-world evidence to ensure that lessons are learned, and good practice shared.

What they came up with is a programme called SENTINEL to support and empower clinicians and patients to improve asthma care. This programme has the following five components: healthcare professional education, implementation of ‘gold standard’ prescribing practices, targeted reviews for asthma patients over-using SABA, patient education and support, and real-time data monitoring and reporting of asthma care metrics. The programme highlights the need to identify and to address over-reliance on SABA inhalers in order to improve asthma outcomes and reduce the environmental impact of asthma and its treatment.

One way that this is achieved is through the appropriate use of Maintenance and Reliever Therapy (MART), a different way of using combination inhalers in asthma to treat airway inflammation and relieve symptoms, without the need for SABA.

Maintenance and Reliever Therapy (MART)

MART refers to when the same inhaler is used as both a ‘preventer’ and a ‘reliever’. Inhalers used for MART contain both an inhaled steroid (to treat the airway inflammation) and a fast and long-acting bronchodilator called formoterol (to relax the muscle in the airway and relieve asthma symptoms).

The MART approach can help to improve asthma control and prevent asthma attacks. With MART, the blue reliever inhaler can be stopped.

Changing prescribing habits and ensuring that primary care clinicians have the time to review each asthma patient is a big ask. SENTINEL supports clinicians by equipping them with the knowledge and resources to identify and review asthma patients that are requiring their SABA frequently and to optimise their treatment in line with local and national guidelines.

Does SENTINEL help?

SENTINEL is already starting to produce some dramatic results. The first primary care network (PCN) to take part has achieved a significant reduction in prescribing of SABA inhalers. They have gone from being in the top 5% of PCNs in terms of SABA use, to being below the national average. An improvement that has been maintained ever since.

Data from the first three PCNs has shown a reduction in blue inhaler prescribing by nearly 9,000 units since starting the programme, equating to an offset of nearly 250,000 kg eCO2 emissions (this is equivalent to more than 300 transatlantic flights). This number continues to rise, month by month.

These results are in alignment both with the NHS Long Term Plan and with the Greener NHS strategy.

What next?

SENTINEL continues to be rolled out across Yorkshire and the Humber and the programme of evaluation and evidence generation continues. With the initial pilot showing such positive results, there is appetite to share SENTINEL more widely. Dr Crooks and colleagues at Hull University Teaching Hospitals NHS Trust and Hull York Medical School, along with AstraZeneca, have produced SENTINEL Plus.

SENTINEL Plus builds on the work undertaken in Hull with newly developed web-based support and education resources for both clinicians and patients.

If you are interested in more information, please contact: or to find out more about what support is available please visit