Analysis

Greater collaboration vital to treating asthma in the young

Asthma is now so common that in every classroom there will be, on average, at least two children who have the condition. But such familiarity seems to have bred complacency. In 2014 the National Review of Asthma Deaths: Why Asthma Still Kills warned not enough was being done to reduce unnecessary admissions and deaths. The findings were shocking, but perhaps not surprising.

Asthma is now so common that in every classroom there will be, on average, at least two children who have the condition. But such familiarity seems to have bred complacency. In 2014 the National Review of Asthma Deaths: Why Asthma Still Kills warned not enough was being done to reduce unnecessary admissions and deaths. The findings were shocking, but perhaps not surprising.

Many of the recommendations made – from patients needing personal action plans, to following up on emergency department visits – were well-rehearsed measures. But could we now have reached a turning point? The National Paediatric Asthma Collaborative (NPAC), an umbrella group of experts set up after the report was published to improve care, hopes so. 

UK asthma facts:
  • 1.1 million children have asthma
  • 25,000 emergency admissions a year
  • 19-fold variation in admission rates between local areas
  • 1,200 deaths from asthma in 2012 and 21 of these are in children aged under 14
  • There are preventable factors in nine out of ten deaths
  • Half of children have experienced an asthma attack in the previous year
  • Less than a quarter have a personalised asthma action plan

(National Paediatric Asthma Collaborative 2015)

 

Working together

Richard Iles, a respiratory and general paediatric consultant at the Evelina London Children’s Hospital and NPAC clinical lead, last year authored a document for the NPAC that called on those working in the field to capitalise on what has been set out by NHS England’s 2014 Five Year Forward View. Included in that strategy is a plan to get GP practices working together in federations which, he believes, should lead to wider access to community-based asthma specialists – many of whom are nurses. Similarly, a push to get hospital specialists out into the community running clinics should also have significant benefits.

‘It’s clear we’re not doing as well as we should be. I think over the past five years we have had something like 16 national documents setting out good quality care.’ Dr Iles says the solutions often lie in doing the ‘simple things’ well. These include making sure patients are using inhalers properly, getting regular reviews and adhering to medication.

The work of the NPAC has been influenced by the success Finland has had in reforming asthma services. The country introduced a National Asthma Programme in the mid 1990s.

Unmitigated success

Subsequently, asthma lead doctors and nurses were appointed in each local area and supported closely by hospital specialists. The emphasis was on improving self-management, educating patients and ensuring those who needed it got speedy referrals. It was an unmitigated success: the time spent in hospital by asthma patients had fallen by more than 50% by 2003.

Dr Iles says that, while there are similar examples of good care in England, it is all too often ‘operating in isolation’.

‘The challenge for all of us now is to make sure we grasp the opportunity to bring everything together,’ he says. ‘And the encouraging thing with the Five Year Forward View is that we have the impetus.’

At risk

He believes getting it right will mean identifying those children who are most at risk, although he acknowledges they are ‘all too easy to miss’ because of the sheer numbers with the condition. University Hospitals of Leicester respiratory nurse consultant Jane Scullion agrees: ‘We need to make sure we learn from what works, particularly in terms of reaching those patients who are not using their inhalers properly. Too many are relying on relievers rather than preventers.’

Ms Scullion believes there is a big onus on the clinical lead role in primary care. ‘Many nurses are fulfilling that role and providing an excellent service. But they do not always get the support they need in terms of access to training, while the demands on their time can be too much.’

Sara Nelson, a nurse who leads on children’s asthma for the Healthy London Partnership, a collaboration between the 32 clinical commissioning groups in the capital and NHS London, says school nurses can play a ‘critical’ role.

‘They cannot be in all the schools all the time, but what they can do is help educate school staff. We are not so good at recognising when children may be at risk. If children are struggling in PE or missing school because of asthma, we need to know so they can get the help they may need.’

Word of warning

But she also has a word of warning over the push to get hospital specialists in the community. ‘We do need it, but it’s important the clinics are run in partnership with local GPs and nurses,’ she says. ‘There’s no point in them working in isolation because then those working in the community do not get the experience of these complex cases and may become deskilled.’

In her role at the Healthy London Partnership, which exists to improve care in the capital, Ms Nelson is at the forefront of ensuring the health service gets it right. She has helped develop a set of standards for asthma care for children, which include many of the recommendations in the National Review of Asthma Deaths.

London is also looking to innovate in other ways. For example, a project was run last summer involving pharmacists talking to young asthma patients and their parents about how they were managing their condition – 10,000 families were helped in total – while medical students have gone into schools to offer advice.

Ms Nelson says one of the reasons NHS bosses have focused on asthma is that it could act as a blueprint for a whole host of long-term diseases.

‘Asthma care and its commissioning cuts across local authorities and primary, secondary and tertiary care. If we can get it right for asthma, we can get it right for a lot of conditions.’

 

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