‘Hold on… you’re saying your GP called you to make an appointment... and you got to see a Paediatrician too?’
In the interest of full disclosure, this conversation was not actually overheard in a school playground. However, for the sake of telling you the fantastic story of the asthma-centred Hub day we ran at Paddington Green Health Centre, we hope you can use the power of imagination!
‘Please [insert parent’s name of choice], tell me more!’
‘Well, I was contacted by my GP practice and they told me that they were running a special asthma clinic, where a paediatrician from St Mary’s Hospital was coming out to the practice and reviewing asthmatic children together with the GP. They asked if I wanted to bring my son in for review.’
As many of you will know, 1 in 11 children in the UK suffer with asthma, which equates to roughly 3 children in every classroom. Many children grow out of their asthma, but some may not, and often will be affected by the condition for many years. Asthma also has the potential to be very dangerous and life-threatening so needs to be taken seriously. Just like any other chronic condition there is unfortunately no quick fix and this condition needs to be managed rather than treated. Key things to manage are: having a patient-specific asthma plan, use of regular preventative medication, frequent review by a healthcare professional and regular checking of inhaler technique.
‘That sounds great! But how do they know which kids need to be brought in?’
‘They told me that they could see on their online systems that he’d had quite a few prescriptions for his blue inhaler. We also had to take him to A&E last month for his breathing so maybe that’s what flagged up. Either way it’s great ‘cause I don’t think his breathing has ever really got back to its best and I was thinking of booking him in anyway!’
The ‘Asthma Radar’ is a sub-section of the Whole System Integrated Care (WSIC) Dashboard, and is a fantastic tool for looking at asthma care from a whole-population perspective. By applying various filters it is possible to highlight every child with asthma at a particular GP practice, and then triage them according to outcomes of interest. In order to identify children who might warrant review, these outcomes were: number of A&E attendances, number of exacerbations, number of risk factors and the number of salbutamol prescriptions received. The top 4-5 children on each triage list were then taken to the GP practice and the computer system was consulted together by a GP and a CC4C paediatrics trainee. By doing this and looking at the most recent asthma-related consultations/clinic letters it was easy to identify children who warranted a face-to-face review and they were invited in to clinic.
‘So what was the appointment like?’
‘Really good! We had the GP, the paediatrician and one of the paediatric junior doctors all together in one room. We got a 30-minute appointment slot and they really asked a lot of questions about my son’s asthma and how well controlled it was. They also watched him use his inhaler and went through different inhaler options that would suit him best. Another thing I found helpful was seeing this united front; so often the GP says one thing and then when you get to the hospital you hear something else from the paediatrician, so it was great to have both of them there together. Oh, and also, the paediatrician said that my GP can email them really easily with any further questions so it’s really reassuring to know those options are available.’
These longer appointment slots most definitely allowed sufficient time for a very thorough review. Despite all of these children having had asthma for many years, every single one had positive changes made to their management. There was also plenty of time for education about inhaler types and spacer usage. The paediatric trainee who attends the clinic has the opportunity to meet with one of the asthma specialist nurses in advance to get trained up in ‘all things inhalers’. This knowledge can be utilised and imparted during each clinical interaction on an individual child level, but can also be shared more broadly in the Hub MDTs that follow the clinic. Finally, and more practically
speaking, this clinic tried to alleviate some of the pressures that GPs are under by helping meet QOF outcomes for all children seen.
‘But your son’s had asthma for ages; surely you know most of this stuff already?’
‘Well you’d think! But it turns out we had actually been using the wrong spacer at home and also his inhaler technique wasn’t quite right for the inhaler that he was taking to school. So whilst I knew what medicine he needed to take and when, we both needed a bit of help on the little things like exactly how to take them!’
‘This all sounds great, but my issue is that it’s always so hard to get the kids out of school!’
‘But that was one of the best things – it was run at half term so it was super-easy! I overheard them saying that they were going to try and make it a regular thing during school holidays as well. It was also really nice being at my own GP practice. It was a comfortable environment for my son and simple to get to for me.’
Many GP practice nurses also have the capabilities to perform these reviews independently and have the luxury of 30-minute appointment slots. The idea born out of discussions that followed the clinic was to try to make this ‘business-as-usual’. The aim is for these clinics to continue every half term, run by the practice nurse in conjunction with a CC4C paediatrics trainee, as we feel this type of proactive approach has fantastic potential to improve asthma care in children.
Best practice suggests that children with asthma should have:
1. Good inhaler technique
2. An up-to-date asthma management plan
3. At least annual review
This asthma-centred Hub day ran in March 2019. 4 children were seen in the clinic and discussed at MDT afterwards. None of these children were due to be reviewed in the hospital or the GP practice in the immediate future and yet:
- 2/4 had sub-optimal inhaler technique
- 4/4 has sub-optimal devices and were prescribed more age-appropriate options
- 2/4 had no asthma plan and had one completed that day
- 1/4 had their official annual review completed that day
We felt that this was a hugely successful event and could be easily replicated at other GP practices to improve the care of their asthmatic populations. If it is something you’d like to replicate and you want more information about it please contact: firstname.lastname@example.org