The recent Asthma UK Annual Asthma Survey threw up some stark realities for the NHS in how it cares for people with asthma. At a time when NHS services are increasingly stretched and being encouraged to look at new care models, this survey highlights that complacency still exists around the significance of asthma symptoms and we need to re-think how we support people with such a variable long-term condition.
Asthma is not ‘just’ asthma. It affects 5.4m people in the UK. Three people die from asthma each day. Two out of these three deaths are preventable with better care, and self-care. Current NHS systems do not accommodate the variable nature of the condition.
Some 82% of people surveyed reported symptoms suggesting poorly controlled asthma - despite more people attending asthma reviews and being shown inhaler technique. Not only does this translate into significant impact upon work, school and the lives of people with asthma but it also increases the risk of people experiencing a life-threatening asthma attack and being hospitalised.
Asthma UK is calling for people with asthma to pay more attention to their asthma symptoms and to have a written asthma action plan so that they know what actions to take when they are symptomatic. Having symptoms or using a reliever inhaler three or more times per week suggests poorly controlled asthma.
The report also asked about follow up after a hospital or out-of-hours attendance. The NICE Quality Standards for asthma suggest that everyone should be reviewed within 48 hours of discharge from hospital. This is an opportunity to assess recovery from the exacerbation, prevent readmission but also to optimise treatment in order to prevent further loss of control of asthma symptoms and exacerbations.
The survey found that only 27% of people who attended hospital or an out-of-hours service had a follow-up appointment within two working days. There could be a number of reasons for this. Patients typically present to A&E where staff may or may not be aware of asthma guidelines beyond immediate treatment.
Patients may or may not be getting explicit instructions to seek follow up and GPs may or may not be alerted in a timely manner of the attendance or acting upon that information. Key to this lack of follow up is again complacency. Because emergency medications for asthma work so effectively at relieving symptoms there is an assumption from patients and clinicians that the patient is better. This doesn’t address underlying chronic inflammation and future risk.
Commissioners and clinicians can do more. NHS organisations, including those in primary care, need to consider pathways for people with uncontrolled asthma who present to the GP surgery, walk-in centre, out-of-hours, A&E or who are admitted to hospital. These pathways should concentrate on effective communication.
GP follow up
Firstly, to the patient – explicit (written) instructions on what they should do next, follow up, when to seek further support, what medicines to take and how to take them correctly. Secondly to other members of the team – whether that be the usual GP/practice nurse or specialist where that is relevant – timely and clear communication about what treatment was required and what actions have been requested of the patient/primary care team.
The British Thoracic Society has produced an Asthma Care Bundle which can have a big impact in all urgent care settings. This can be implemented more widely and its use monitored.
Unlike other long-term conditions, asthma has seen few benefits from QOF. Fixed-term annual reviews do not accommodate the variable and unpredictable nature of asthma. Seeing patients once a year, when they are stable, likely compounds the complacency that symptoms come and go and are easily treated with salbutamol. As primary care continues to evolve and as QOF slowly dissipates we need to develop the capacity and structures to manage people with asthma according to need – responding to symptoms, reliever over-reliance and exacerbations as an opportunity to confirm diagnosis, assess and manage triggers, and optimise treatment.
As we examine our services and try to cope with workforce and funding challenges, and as new ways of working emerge, we need to change how we approach asthma so that the NHS and its patients address symptoms and risk more effectively. This report highlights inadequacies across the system. We can all start by equipping people with asthma with the information and education they need to stay well.