Breathing new life into asthma care

Half of the one million children in the UK with asthma will have an asthma attack every year, with about 25,000 requiring hospital admission. This article looks at how initiatives such as creating networks of GP practices and placing hospital specialists in the community could improve the care of children with asthma.

There are more than one million children with asthma in the UK, and each year half of them will experience an asthma attack. In 25,000 cases, the incident will require admission to hospital.

The Royal College of Physicians’ 2014 report, Why Asthma Still Kills: The National Review of Asthma Deaths, warned that not enough was being done to reduce unnecessary admissions and deaths. It also advised that improving care would help children to manage their condition.

So what is the answer? Over the years, there have been many national documents and pieces of guidance on asthma care, most of which offer the same advice: make sure patients use inhalers properly, receive regular reviews and adhere to medication; and ensure that visits to emergency departments are followed up.

Nurses should encourage children to self-manage their asthma

Picture credit: Alamy

But after years of slow progress, the 2014 publication of NHS England’s Five-Year Forward View has led to some momentum starting to develop.

The National Paediatric Asthma Collaborative, an umbrella group of experts, produced a report on how asthma care could benefit from federations of GP practices and getting hospital specialists out into the community – both of which are part of NHS England’s vision.

The theory is that by creating networks of GP practices, the availability of clinical asthma leads (roles usually filled by GPs or senior nurses) will be improved, as will access to secondary care asthma expertise. This would mirror what has been done in Finland, the country seen as the gold standard for transforming asthma care.

Finland introduced a National Asthma Programme in 1994. Over the following decade, asthma lead doctors and nurses were appointed in each local area, supported by hospital specialists. The emphasis was on improving self-management, educating patients and ensuring timely referrals. The initiative was a success: the time patients with asthma spent in hospital fell by more than 50% by 2003.

University Hospitals of Leicester NHS Trust respiratory nurse consultant Jane Scullion says better identification of children most at risk of an asthma attack will improve services in the UK.

‘The fact asthma is so common can make us complacent,’ she says. ‘The assumption is that people don’t die from it. Sadly that is not true.

‘However, I don’t want to be too downbeat. We’re good at berating ourselves, but we’re getting better. We just need to make sure we learn from what works, particularly in terms of reaching patients who are not using their inhalers properly. Too many people are relying on relievers rather than preventers.’

Ms Scullion believes the onus will be on the clinical lead in primary care: ‘Many nurses are fulfilling that role and providing an excellent service. But they don’t always get access to training, and the demands on their time can be too much.’

So how can the rest of the primary care workforce help? NHS England quality improvement manager Julia Charnock, who has helped to draw up asthma standards for Greater Manchester, Lancashire and South Cumbria, says it is inevitable that practice nurses will carry out some of the children’s asthma reviews.

‘Children need more frequent reviews than adults so it will often fall to practice nurses to ensure that happens as part of their regular contact with this patient group,’ she says. ‘Diagnosis of children and young people must be in line with British Thoracic Society guidelines, and these patients need their asthma action plans reviewed and updated, and inhaler techniques checked at every contact.

Diagnose people in accordance with British Thoracic Society guidance

Perform a structured review at least twice a year

Provide training and assessment in inhaler technique before starting a new treatment

Create a written personalised action plan

Provide a follow-up within two working days for children who need hospital or out-of-hours care for acute exacerbation of asthma

Provide secondary care follow-up after two or more emergency department attendances, or after every hospital admission due to asthma

Offer children with difficult asthma an assessment by a multidisciplinary difficult asthma service

Develop a system to ensure those who fail to attend an appointment are followed up promptly

Source: British Thoracic Society and NICE

‘It is also important that nurses give children, young people and their families self-management education and support.’

Ms Charnock believes the expertise available through the wider networks could then be deployed on the neediest cases.

‘Where there are concerns about a child, or if the case is particularly complex, the practice nurse will need the support of the asthma lead or referral into secondary care services,’ she says.

Primary care adviser and past chair of the RCN Practice Nurses’ Association Tina Bishop believes this vision is achievable: ‘Practice nurses are able to cope but only if they have the right training and support, and have time to spend with patients.

‘If we get that, the evidence shows that practice nurses do well at helping patients with long-term conditions. However, the problem is that general practice is under a lot of pressure at the moment.’

And what of school nurses? School and Public Health Nurses Association professional officer Sharon White says her colleagues already play a vital role: ‘During health assessments and drop-in clinics, school nurses identify children who have not been diagnosed or whose asthma is poorly managed.’

However, she says workload pressures can be a barrier to providing an effective service.

Sara Nelson, a nurse who leads on children’s asthma for the Healthy London Partnership, a collaboration between NHS England and the 32 clinical commissioning groups in the capital, says school nurses should raise awareness about asthma.

‘They can help educate school staff,’ she says. ‘If children are struggling in PE or missing school because of asthma, we need to know so they can receive help.’

Ms Nelson warns against the push to get hospital specialists working in the community: ‘We need it, but it’s important that clinics are run in partnership with local GPs and nurses. There’s no point in specialists working in isolation in the community because then they won’t get experience of complex cases and may become deskilled.’

She says there is an added incentive to improve asthma care: ‘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 many conditions’.

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