Kay Holt explains how simple strategies have helped transform asthma care across her PCT
There is a lot to be learnt in primary care through sharing experiences between practices and PCTs. If something works and can be applied to your practice or PCT then copy it. If you are considering implementing something new, then learn from the difficulties others have encountered.
The RAISE initiative launched by the National Respiratory Training Centre and the General Practice in Airways Group (GPIAG) aims to exploit this principle to reduce variations in the quality of asthma care and improve patients' quality of life (see box below).
At Wyre PCT, we decided to address failings in asthma care by joining with other PCOs through the RAISE initiative to share progress and reflect on experiences both positive and negative.
The five key outcomes that have been achieved in Wyre PCT as a result of our involvement in RAISE are listed below, together with practical tips.
Five key improvements
1. The asthma register
Unlike most chronic disease registers, the asthma register is changeable. A diagnosis of asthma, especially in childhood, does not mean you will have symptomatic asthma for ever.
Patients may dip in and out of the register through life. Moreover, a past diagnosis of asthma without objective lung function assessment could be wrong.
One way to deal with this problem is to have separate 'active' and 'inactive' asthma registers1. In Wyre, we have used the Read coded steps of the national asthma guidelines to determine this: step 0 is used for patients with no asthma symptoms or inhaler prescription in the previous 12 months; steps 1-5 become the active asthma register.
·Run a computer search of patients on the asthma register with no inhaler prescription and no asthma contact in the past 15 months. Code them as 'asthma step 0'.
·Have a system in place, through repeat prescription administration, to ensure that if a prescription is requested the patient is asked to make an appointment to have their asthma reviewed. At this review they can be put back on the active asthma register.
2. Asthma templates
Computerised templates are the only way to ensure consistent and correct data is entered during chronic disease management annual reviews. Orderly retrieval of data requires orderly entry to enable audit and appropriate recal · 2.
An asthma template needs to meet the following criteria:
·easily usable during a consultation, starting with assessment of symptoms, moving on to peak flow and inhaler technique and finishing with documentation of the advice offered,
such as self-management plans
·comprehensive but not too long
·documents all items needed for the quality and outcomes framework
·flexible enough to be used during telephone consultations.
·Look at templates already developed by other organisations and adapt these rather than starting from scratch. Have a template in place for a diagnostic asthma assessment as well as one for annual monitoring. A diagnostic template will ensure that a new diagnosis of asthma is accompanied by objective tests (peak flow or FEV1).
·Encourage all clinicians in the practice to use the template rather than documenting asthma symptoms in other ways.
Discourage any new diagnosis of asthma being documented without using the template. GPs could use Read code
terms such as 'breathlessness' or 'wheeze'
if asthma is suspected but not yet confirmed by tests.
3. Asthma questionnaires and telephone consultations
Patients with well-controlled asthma, experiencing very few symptoms, may not need to come into the practice for an appointment annually3.
As we move further towards symptom assessment based on the Royal College
of Physicians' 3 Questions, rather than
peak flow monitoring, asthma reviews that are not face-to-face become more of an option.
In Wyre, we have developed an asthma symptom questionnaire that is sent with all asthma check reminders and handed out with repeat prescriptions.
The questionnaire offers the patient the opportunity to request and book a telephone consultation as an alternative to attending the practice.
·Involve the administration and reception staff in the practice in plans to develop telephone consultations and/or questionnaires.
·Encourage GPs to hand out asthma symptom questionnaires to patients opportunistically if there is not enough time to do an asthma check. It may be possible to follow these with a nurse telephone consultation.
4. Hitting quality framework targets
The three strategies outlined above have helped practices in Wyre meet the quality framework indicators at the same time as improving the quality of care they provide to their asthma patients.
Documentation and administration seem to be the keys to success here. All letters and reminders need to be documented so that exemption codes can be used appropriately.
We have found that designating a small team within the practice comprising a GP, a nurse and an administrator promotes ownership and motivation.
However, it is crucial that we bear in mind the importance of quality beyond the nGMS contract.
There are several quality standards recommended by the BTS/SIGN guidelines that are not addressed by the new contract, such as management and follow-up of exacerbations.
·Nominate a small team to take responsibility for asthma Q&O.
·Plan an extra indicator to audit quality of care beyond that required by the nGMS contract, such as follow-up of exacerbations.
5. Transfer of information from secondary care
When asthma patients are seen in secondary care, either as a result of an admission or for a respiratory clinic appointment, information may be transferred to primary care via discharge slips or hospital letters. These are usually scanned into computer records with some Read codes entered by administration staff. If information were sent to primary care using agreed coded format, there would be a more consistent approach to data entry.
In Wyre we have worked in collaboration with the secondary care respiratory nurses to develop a form that can be completed in the hospital clinic/ward and faxed to the practice for the attention of the asthma nurse. Information on the form is coded using the Read codes in the Wyre asthma templates so it can easily be entered on to the practice records using existing templates.
·Identify interested respiratory nurses and practice nurses to explore ways of more effective data transfer.
·Try to raise awareness within the local respiratory department of the sort of data you need in discharge letters.
Kay Holt is respiratory co-ordinator for Wyre PCT and a nurse practitioner at Cleveleys group practice, Lancashire
RAISE Raising respiratory Awareness and Improving Standards through Education
Awareness and Improving
Standards through Education
The aims of RAISE are to:
·Raise awareness of asthma and of the current variation in standards of care and outcomes
·Raise standards of care through education, support and feedback
·Raise profiles of respiratory disease
·Use asthma as an exemplar for multi-agency, cross-professional working
·Raise the profile of primary care as main deliverer of care and innovation for asthma
1 Holt K (2003) Delivering a high-quality respiratory service in primary care: the groundwork. Airways Journal;1:131-4
2 Levy M (2003) Electronic patient records in the asthma consultation : coding and datasets. Airways Journal;1:85-7
3 Pinnock H (2003) It's good to talk but do I really need to see you? The potential of telephone consultations for providing routine asthma care. Primary Care Resp J. 12(3)79-80
GPs I Asthma Group www.gpiag.org
National Respiratory Training Centre www.nrtc.org.uk
British Thoracic Society www.brit-thoracic.org.uk
Primary care collaborative www.npdt.org
European Respiratory Society www.ersnet.org
Wyre PCT www.wyrepct.org.uk
Cleveleys Group Practice www.cleveleysgrouppractice.fslife.co.uk