How to avoid pitfalls of new discrimination law
Dr Keith Holgate believes practice nurses can play a key role in raising expectations of asthma treatment he explains why
My practice has run an asthma clinic since 1990, although its format has evolved over time as the regulations and guidelines have changed. The 1990 GP contract led to significant developments in asthma care by shifting the focus from secondary to primary care. Of particular importance has been the development of GP-run asthma clinics and in my opinion the most important change in primary care asthma management has been the corresponding expansion in the role of the practice nurse.
I cannot now imagine how we ever managed without them and this view is endorsed by studies that demonstrate how the use of nurse-run asthma clinics can reduce morbidity, improve inhaler technique and increase the use of inhaled steroids and salmeterol (see table 1).
The BTS/SIGN asthma guidelines state that routine clinical review of asthma patients is associated with a better clinical outcome, and that the outcome is similar whether a practice nurse or GP conducts the review. But the guidelines add: 'Observational evidence suggests practice nurses with a diploma in asthma care may achieve better outcomes.'
Running a successful asthma clinic
Although not all practices organise their asthma care into clinics, those that do may well gain more quality points under the new GMS contract. In my six-partner practice we have made each doctor responsible for one or two clinical domains within the quality and outcomes framework to maximise the benefits it offers. I am responsible for asthma care.
My practice has never run totally 'nurse-led' clinics as I feel the asthma nurse and GP should work in partnership with agreed priorities and standardised treatment regimens. If GPs only ever see the complicated cases they may never have the opportunity to see the well-controlled asthmatic who has no symptoms from whom much can be learnt about 'what works'! I therefore have slots each week where I try to see all types of asthmatics. The downside of this arrangement is that my partners say they never see asthma anymore!
We have found several factors important in establishing a successful asthma clinic:
·Staffing levels Are a doctor, nurse and administrator all available to staff the clinic?
·Timing and location Is there time and space to run the clinic effectively? If not, how might things be rearranged?
·Expertise Do the doctor and nurse have sufficient interest in asthma to regularly update their skills? Ideally the asthma nurse should have gained some extra diploma in asthma care such as a qualification from the National Asthma and Respiratory Training Centre.
·Monitoring and recording Do you have an asthma register? Although time-consuming to set up, this will provide the foundation for establishing an effective call and recall system.
Achieving best practice
·There is evidence that patients' expectations in asthma are different from those of the health care professionals looking after them. The AIR study2 concluded that health care professionals need to put more emphasis on what matters to patients. One way of doing this is by phrasing questions carefully for example, instead of asking 'How is your asthma?' consider asking 'Has your asthma stopped you from doing anything recently?'. By asking questions in this way we can gain a more accurate assessment of asthma control.
Good communication and understanding of patients' needs are essential and generally nurses are much better placed to carry out these assessments than GPs as they tend to have more time to spend with patients. The asthma nurse might even conduct regular asthma reviews by telephone, followed up by annual face-to-face consultations.
·Concordance with treatment should be assessed. Is the patient taking the right treatment in the right dose at the right time and can they use the device prescribed? It is important to establish each patient's understanding of the disease and of how their medication works. Patients who have an active role in their asthma management are four-and-a-half times more likely to use controller medication everyday than those who were not involved in the treatment decisions with their health care professionals3. Self-management plans should be written down. These can be as simple or as complicated as the patient wants and should reflect the patient's needs.
·Peak flow diaries are useful and we suggest to patients that they measure peak flows for about one week prior to their clinic visit, although a clinic measurement will also need to be included as part of an asthma review under the new contract.
·An asthma protocol and treatment regimens should be agreed by the whole practice and based on current guidelines such as BTS/SIGN guidelines4. They should not be influenced by financial considerations of the PCO (I have spoken to asthma nurses who have been told to prescribe only metered-dose inhalers, a practice contrary to NICE guidelines5).
·I think the concept of 'total control' as described in the recent GOAL (Gaining Optimal Asthma Contol) study6 is achievable with many patients (see table 2). A few years ago I would have accepted that an asthmatic who used reliever medication occasionally and suffered infrequent symptoms was well-controlled, but now I feel we can realistically set our sights higher.
Asthma clinics are an important tool in the effective management of asthma in general practice and the role of the practice nurse is crucial in achieving best practice. Advances in asthma care in recent years have led to an achievable aim of 'total control', which is more likely to be achieved if patients are actively involved in decision-making about their care.
The GOAL study key findings6
·Patients with uncontrolled asthma were stratified according to prior medication and randomised to salmeterol/fluticasone propionate combination or fluticasone alone. Treatment was stepped up every
12 weeks until total control or maximum dose reached with a one-year double-blind treatment period.
·Key finding was that total control of asthma (equating to remission) is achievable and should be a goal for all patients. Among patients previously taking low-dose inhaled steroids, the cumulative proportion who achieved total control after one year's use of salmeterol and fluticasone was 44 per cent compared with 28 per cent among the group on fluticasone alone.
Total control was defined by: no daily symptoms; no rescue ?-agonist; no exacerbations; no night-time waking; no emergency visits; no days with am PEF <80% predicted;="" no="" treatment-related="" side-effects="" enforcing="" change="" of="" asthma="">80%>
References 1 Dickinson J et al. Reducing asthma morbidity in the community: the effect of a targeted nurse-run asthma clinic in an English general practice, Respiratory Medicine 1997 91,634-640
1 Dickinson J et al. Reducing asthma morbidity in the community: the effect of a targeted nurse-run asthma clinic in an English general practice, Respiratory Medicine 1997 91,634-640
2 Price D et al. The AIR study: asthma in real life. Asthma journal 1999 4:74-78
3 Chambers CV et al. Health beliefs and compliance with inhaled corticosteroids by asthmatic patients in primary care practices.Respiratory Medicine 1999:93:88-94
4 British Thoracic Society/Scottish Intercollegiate Guidelines Network. British guidelines on the management of asthma (www.brit-thoracic.org.uk/docs/asthmafull.pdf)
5 2002/02 NICE Guidance on inhalers for older children with chronic asthma (www.nice.org.uk/pdf/Niceinhalers_ldC38GUIDA.pdf)
6 Boushey H,Bateman E,Bousquet J et al.Abstract presented at World Asthma Meeting.
Bangkok. February 2004
Keith Holgate is a GP in Barry, South Glamorgan he was an investigator in the GOAL study
Patient group directions
Delegating asthma treatment to nurses
Dr Nicholas Norwell, medicolegal adviser at the Medical Defence Union, offers advice on using patient group directions
When delegating any service a GP must be satisfied the nurse providing the treatment or care has the right level of competency and specific training to carry it out. It is also advisable to ensure training is regularly reviewed and updated.
The GMC says GPs must pass on enough information about the patient and the treatment needed. The GP will still be responsible for overall management.
Nurses who have not had specialised prescribing training can care for a particular group of patients, such as asthmatics, under patient group directions (PGDs). If the nurse is supplying and administering named medicines to a particular group of patients, a PGD is legally required under the Medicines Act 2000.
Each PGD is in essence a statement of which condition can be treated with what medication by whom. A PGD needs to be drawn up by doctors, nurses and pharmacists who will implement it and it must be signed by a senior doctor and senior pharmacist, both of whom should have been involved in developing it.
A PGD should be authorised by the relevant primary care organisation and should contain:
·The name of the business to which it applies (eg the practice name)
·The date the direction comes into force and when it expires
·The description of the medicine to which it applies
·The class of health professional involved (eg registered nurse)
·The clinical condition or situation to which the direction applies
·A description of patients excluded from the treatment under the direction
·A description of when further advice should be sought and referral
·Details of the appropriate dosage, the maximum total dosage, quantity, pharmaceutical form and strength, route and frequency of administration, and minimum and maximum period over which the medicines should be administered
·Relevant warnings, including potential adverse reactions
·Details of any necessary follow-up action
·Signature of doctor or pharmacist and appropriate health organisation.
(c) copyright MDU 2004