Are we nearing a turning point in children’s asthma services?
Asthma has become so common in the UK that there are, on average, at least two children with the condition in every classroom. Moreover, the familiarity of the condition may have bred complacency. The Royal College of Physicians (
Asthma has become so common in the UK that there are, on average, at least two children with the condition in every classroom. Moreover, the familiarity of the condition may have bred complacency. The Royal College of Physicians (2014) National Review of Asthma Deaths warned that not enough was being done to reduce unnecessary admissions and deaths. The findings of the report were shocking, but perhaps unsurprising.
Many of the recommendations it makes, from personal action plans to follow-up visits to emergency department, had been made before. But according to the National Paediatric Asthma Collaborative (NPAC), an umbrella group of experts set up after the report was published, we may now have reached a turning point.
Respiratory and general paediatric consultant at the Evelina London Children’s Hospital Richard Iles, who is NPAC clinical lead, last year authored a document for the NPAC in which he calls on staff working in the field of asthma care to capitalise on recommendations in NHS England’s (2014) Five Year Forward View.
One of these recommendations is that GPs should work in federations, which Dr Iles believes can ensure people with asthma have wider access to community based specialists, including nurses. Similarly, more hospital specialists should run clinics in communities.
‘We are not doing as well as we should. Over the past five years we have had 16 national documents setting out good quality care,’ Dr Iles says, adding that solutions often involve simple forms of care, such as making sure patients use inhalers properly, get regular reviews and adhere to medication.
The work of the NPAC has been influenced by the success of Finland in reforming asthma services. In the mid-1990s, the country introduced a national asthma programme, which has reduced the amount of time asthma patients spend in hospital. Key to its success is ensuring that primary care doctors and nurses are supported by experts, including local asthma leads and hospital specialists.
How Finland transformed its asthma services
Finland’s National Asthma Programme was launched in 1994. It focused first on adults and then children. Over the years, asthma lead doctors and nurses were appointed in each local area and supported by hospital specialists. Their job was to work closely with primary care professionals, including pharmacists.
The programme involved improving self-management, educating patients and ensuring those that 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, they tend to operate in isolation. ‘The challenge for all of us is to make sure we grasp the opportunity to bring everything together,’ he says. ‘The encouraging thing about the Five Year Forward View is that we have the impetus.’
He believes that the right sort of asthma care will involve identifying children who are most at risk, although he acknowledges that, because so many have the condition, they are easy to miss.
University Hospitals of Leicester respiratory nurse consultant Jane Scullion agrees: ‘The fact that asthma is so common can make us complacent. There is an assumption that people don’t die from it, but sadly that is not true.
‘But I don’t want to be too downbeat. We are good at berating ourselves, but we are getting better. We just need to learn from what works, particularly when trying to reach patients who are not using their inhalers properly. Too many rely on relievers rather than preventers.’
Ms Scullion says that improving asthma services is partly the responsibility of clinical leads in primary care. ‘Many nurses fulfil this role and provide an excellent service,’ she says. ‘But they do not always get the training they need, while the demands on their time can be too much.’
NHS England quality improvement manager Julia Charnock, who has been involved with drawing up asthma standards for Greater Manchester, Lancashire and South Cumbria, says the rest of the primary care workforce have a role too, and it is inevitable that practice nurses will carry out some asthma reviews.
‘Children need more reviews more frequently than adults, so it will often fall to practice nurses to ensure that they are carried out as part of their regular contact with children. Nurses must make sure that all children’s and young people’s diagnoses are in line with British Thoracic Society guidelines, that asthma action plans are reviewed and updated, and that inhaler techniques are checked at every contact. It is also important that these nurses provide children, young people and their families with self-management education and support.’
Ms Charnock believes that expertise is available through wider professional networks, and could be deployed in the most needy cases. ‘Where there are concerns about a child, or if a case is particularly complex, practice nurses need the support of asthma leads or must refer the patients concerned to secondary care services,’ she says.
Former Royal College of Nursing Practice Nurses’ Association chair Tina Bishop believes that this vision is achievable if practice nurses get the right support.
Training and support
‘They can cope only if they have the right training and support, and time to spend with patients. Evidence shows that, if they have enough time, they can help patients with long-term conditions. The problem is that general practice is under a lot of pressure,’ she says.
School nurses have a role in asthma care too, and School and Public Health Nurses Association professional officer Sharon White says that her colleagues already play a vital role.
‘School nurses identify children who have not been diagnosed or whose asthma is being poorly managed during health assessments and drop-in clinics at schools,’ she says, adding that school nurses experience workload pressures.
Sara Nelson, who is a nurse lead for children’s asthma at the Healthy London Partnership, a collaboration of NHS London and the capital’s 32 clinical commissioning groups, says that part of the school nurse’s role should involve raising awareness of asthma in schools.
Educate school staff
‘School nurses cannot be in all schools all the time, but they can help to educate school staff. If children are struggling in physical education or missing school because of asthma, we need to know so they can get the help they need.’
This should be part of a wider proactive approach to managing asthma in the community, she says. In her role at the Healthy London Partnership, which was set up to improve care in the capital, Ms Nelson has helped to develop a set of standards for asthma care for children. In the process of being implemented, these standards include many of the things recommended by the National Review of Asthma Deaths.
Asthma care in London is developing in other ways. For example, last summer a project in which pharmacists talked to young asthma patients and their parents about how they were managing their condition was run in the capital and helped 10,000 families. Meanwhile, medical students visit schools to offer advice.
Ms Nelson has a word of warning about encouraging hospital specialists to work in the community, however. ‘We need it, but it is important that the clinics are run in partnership with local GPs and nurses,’ she says. ‘There is no point in hospital specialists working in isolation because, if they do, those working in the community will not experience complex cases and may become de-skilled.’
She says that one of the reasons NHS managers in London focus on asthma care is that their solution could become the blueprint for the management of other long-term diseases.
‘Asthma care and its commissioning cuts across local authorities and primary, secondary and tertiary care,’ she says. ‘If we can get it right for asthma, we can get it right for a lot of conditions.’
UK asthma facts
- 1.1 million children have asthma
- There are 25,000 emergency admissions a year
- There is a 19-fold variation in admission rates between local areas
- In 2012, there were 1,200 deaths from asthma, of which 21 involved children aged under 14 years
- Nine out of ten of these 1,200 deaths involved preventable factors
- Half of children with asthma experience an attack each year
- Less than one quarter of children have personalised asthma action plans
(National Paediatric Asthma Collaborative 2015)
Nick Evans is a freelance health writer
National Paediatric Asthma Collaborative (2015) 5YFV Proposal. NHS England, London.
NHS England (2014) Five Year Forward View.
Royal College of Physicians (2014) National Review of Asthma Deaths: Why Asthma Still Kills.