Dr Tonia Myers, a GP and clinical director for children, writes about the simple measures to avoid preventable deaths
Too many children still die from asthma in the UK each year. Learning from the National Review of Asthma Deaths (2014) identifies common themes;
- Multiple A&E attendances without appropriate follow up
- Frequent unmonitored prescriptions for reliever bronchodilator inhalers without a request for an inhaled steroid preventer
- No evidence of use of a spacer devices
- No teaching and reviewing of inhaler techniques
- No evidence of the existence of a Personalised Asthma Action Plan (PAAP)
With many of these deaths preventable, we need to work hard to ensure all children, young people and parents are supported to manage their asthma effectively. This can be achieved by having simple measures in places such as an asthma plan (PAAP), good inhaler technique and an annual review.
GPs need to keep up to date with NICE guidance about childhood asthma and remember to keep child health care as a high priority on their Personal Development Plans (PDP). As a GP appraiser I know that GPs often focus on adult chronic disease management for their professional development and forget about paediatrics other than statutory safeguarding training. Regrettably, although 25% of our GP consultations are about children, more than 50% of GPs have never had an opportunity to do formal postgraduate training in paediatrics. Clinical Commission Group (CCG) education sessions and online resources such as ‘spotting the sick child’ are a good way to start rectifying and any gaps in this important area.
Emergency Department (ED) discharges need to be reviewed in a timely manner to ensure that children are appropriately coded for asthma on the clinical record. GPs need to ensure these children and young people have attended appropriate follow ups and have an annual asthma review.
It is important to flag for review any patients that have been prescribed more than two courses of oral steroids in a year. These patients need to be made an appointment in a specialist asthma clinic as this is a risk factor of poor overall control.
We must diligently monitor repeat prescriptions of reliever inhalers and always check the child or young persons record rather than just signing prescriptions for asthma drugs. Frequent prescriptions of reliever inhalers should trigger a recall, particularly if the child is not taking or complying with their preventer. We also need to check whether a spacer has been prescribed. How many courses of steroids has the child had in the previous year? Are they on an inappropriately high dose of inhaled steroid? And of course, has the child got a Personalised Asthma Action Plan (PAAP)?
Practices should also ensure that reception staff are trained to understand the seriousness of childhood asthma and know never to turn a family away.
GPs and practice nurses should invite children for annual reviews and do this opportunistically when they present. We should use annual review template checklists, such as the one built into our GP IT systems, as an aide memoire to standardise care;
- Checking inhaler technique
- Capturing peak flow (starting aged five years)
- Recording triggers such as allergens and exercise
- Checking they’ve had their flu jab
Not all doctors and practice nurses are competent in drawing up a good PAAP. With the advent of specialist practice nurses, some GPs (myself included) have become relatively de-skilled in managing long term conditions such as diabetes and asthma. My default after managing an acute exacerbation has been to advise families to see our excellent practice asthma nurse for a follow up and an annual review. However, there is always the risk with doing this that they will not attend.
We recently ran a GP education session in Waltham Forest with our local specialist asthma paediatrician using case studies to demonstrate how to write a good plan. This was definitely a Doctors Educational Need (DEN) for me personally and was positively received by our other GPs. We have previously run inhaler technique sessions for primary care health professionals in conjunction with our community asthma nurse and our excellent CCG medicines optimisation team.
Using the Healthy London Partnership Asthma Toolkit and ‘simple measures improve lives’ messaging from their recent AskAboutAsthma campaign, we can all do our bit and ‘ask’ each child, young person and parent about their asthma. These steps will help ensure their asthma is managed and consequently will help prevent further attacks;
- Have an asthma management plan. The plan helps identify the right colour inhaler and dosage and the time to seek emergency help
- Be able to use an inhaler effectively
- Have an annual asthma review
The campaign is aimed to inspire individuals and NHS organisations to sign up to an asthma pledge. My pledge to support children and young people is to;
- Check the Personalised Asthma Action Plan (PAAP) in every child and young person who presents with asthma
Please join me in making an asthma pledge.
About the author
Dr Tonia Myers FRCGP is a GP & clinical director for children, Waltham Forest CCG and GP rep for Healthy London Partnership’s Children and Young People Clinical Leadership Group.