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Breathing new life into asthma care nationally

Ireland has one of the highest rates of asthma prevalence in the world, with nearly half a million Irish adults and children living with the chronic condition.

The HSE National Asthma Programme, under the stewardship of Consultant Respiratory Physician Prof Pat Manning, aims to help each individual with asthma to improve symptoms and ensure their asthma is controlled.

The Programme has had a number of achievements since its inception, most notably the introduction of an Asthma Cycle of Care for the under-sixes in 2015 at an annual cost to the State of €67 million.

But many objectives remain and in some targeted areas for improvement, such as spirometry testing, advancements have been slow.

Furthermore, the Asthma Model of Care, due to be launched last year, has yet to be published.

Prof Manning explained that the Model of Care was developed initially in 2010/2011. He noted that many aspects of the model are contained in the Asthma Cycle of Care.

“It details how physicians, nurses and healthcare professionals can work together with patients in terms of clinical decision-making that is appropriate to their circumstance,” Prof Manning told the Medical Independent (MI). 

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Prof Pat Manning

However, its publication is on hold following the start of negotiations between GPs and Government on a new GP contract, Prof Manning stated.

Prof Manning noted that the ICGP refused to review the Model of Care following the withdrawal of GP leads from clinical care programmes some years ago.

“We’re updating it now in view of the fact that things have moved on in terms of integrated care,” he added.

Care package

Over 90 per cent of GPs have signed-up to the Asthma Cycle of Care to date and further positive developments for asthmatics are hoped once the contract has been agreed, Prof Manning asserted.

A care package for asthma, as it is one of the country’s biggest chronic diseases in terms of numbers affected, is expected to be included in the new GP contract under ‘chronic disease care’.

In the meantime, Prof Manning is trying to develop primary care support services for asthma.

“We have a number of specialist nurses linked-in with COPD [chronic obstructive pulmonary disease] and asthma as integrated respiratory nurses. There are about nine of them in 12 CHO [Community Healthcare Organisation] areas at the moment,” Prof Manning outlined.

“Some are in post a year and some are just settling in and three of these nine posts are [in the process of] being filled at the moment. Essentially, what they’re doing is bringing specialist respiratory nurse expertise. They are funded by primary care, so they spend a great deal of their time in primary care and link-in with the specialist service in the local hospital.”

Bigger picture

There is also a specialist group of physiotherapists who are providing pulmonary rehab for COPD patients linked with nurses at primary care level.

These developments are all part of the bigger picture in healthcare, which is aiming to take people out of hospital and into primary and community care.

The National Asthma Programme is attempting to model itself on the National Diabetes Programme with less hospital-based nurses and more in the community, Prof Manning explained. “We’ve a way to go yet, but it’s a start,” he added. 

Prof Manning also wants to upskill practice nurses in asthma care. In this vein, the online E-Learning Asthma Education Programme for healthcare professionals is currently being updated.

The resource is run in conjunction with the Asthma Society of Ireland and contains a practical workshop and paediatric component. Work on updating the programme is due to be complete by the end of the year.

In addition to the e-learning programme, a number of guidelines around asthma, including emergency asthma, emergency paediatric asthma and asthma control in general practice, have been developed.

National Clinical Effectiveness Committee (NCEC) guidelines on the Management of an Acute Asthma Attack in Adults were launched in late November 2015.

The Asthma Control in General Practice guidelines are due to be updated in conjunction with the ICGP this year.

“Now we have to ensure the guidelines are implemented with a view to getting down admissions and speeding-up the management of asthma,” Prof Manning stated.

He would also like to see, on an annual basis, all asthma patients being managed in primary care under a specific cycle of care management. However, resources are required to deliver this objective.

However, its publication is on hold following the start of negotiations between GPs and Government on a new GP contract, Prof Manning stated 

Resources

Despite a resurgence following the economic downturn, budgets remain tight within the HSE and it are an uphill battle to secure funds in all service areas.

For instance, Prof Manning would like to see spirometry testing in the community expanded, as what is in place currently is “only a drop in the ocean” and needs to be developed further.  “It’s a matter of funding,” he said.

The specialist nurses that have been employed have the training to complete spirometry testing but it is hoped that more practice nurses, once the new contract is agreed, will be equipped to perform testing.

Currently, spirometry testing is very haphazard, with some GPs providing the service and others not. Yet it is a very useful test for asthma sufferers to undergo, Prof Manning underlined. 

“It’s very important for the assessment of asthma, but also for COPD as well,” he said.

Self-management

Meanwhile, work on updating the Self-Management Plan for asthma patients is underway. The plan helps people with asthma to manage their symptoms and overall condition with a view to reducing attacks.

“What we want for each patient, when they have an annual review, is a guided self-management plan and that’s a plan they have that focuses on themselves and their asthma. We’re working on updating that at the moment. We do have one in place but we want to make it a little more friendly, based on the information we’ve got back from patients using it. It is widely used,” Prof Manning said.

Another area that requires further development is severe asthma care. As part of this, the development of a National Severe Asthma Network is underway.

The Severe Asthma Sub-Group of the Programme’s Clinical Advisory Group is currently devising ways to enhance services for around 400-to-500 Irish patients with severe asthma.

“It’s an unusual type of asthma but difficult to manage. They are often on very high doses of steroids and are uncontrolled and have to come into hospital quite a bit,” Prof Manning explained.

“There is treatment for them. At the moment there’s a drug called Xolair, an expensive biologic therapy. It’s available primarily in public hospitals but it’s not available everywhere and it’s limited. So we’re working with Mr Michael Barry to ensure patients get access to this type of drug,” he said.

There are two new drugs coming into the market, developed by GSK and Teva, that could also help to reduce the severity of symptoms in severe asthma, one of which has been refused by the HSE based on price, it is understood.

The Severe Asthma Sub-Group is trying to establish a network to identify patients who could benefit from high-cost therapies with a view to bringing this information to the HSE’s Medicines Management Programme in order to secure a ring-fenced budget.

“At the moment, it’s coming out of the hospital budget and we’re competing with everything. These drugs are very effective in terms of keeping people well,” Prof Manning said.

The plan is to have centres around the country with assessment protocols in place to provide access to the drugs for the majority of patients with severe asthma.

The aim is to reduce asthma hospital admissions (currently around 25,000 a year) and improve patients’ quality of life.

But resources are a concern for the HSE, as a single patient taking this type of drug could cost the State up to €24,000 annually.

Deaths audit

Meanwhile, plans to launch an asthma registry and to undertake an audit of asthma deaths in Ireland have also encountered delays due to cost pressures.

A submission to the HSE to undertake an audit of asthma deaths was made by the programme, modelled on the Royal College of Physicians’ National Review of Asthma Deaths in the UK.

“It was going to be quite expensive, so it wasn’t approved because of that. They’ve asked us to go back to the drawing board and have a look at things. So we’re looking at doing a truncated version, a more abbreviated one,” Prof Manning said.

“I think it’s important because the numbers seem to be increasing again. The numbers were down to one a week and they’ve now gone up a little bit higher in the last couple of years, but those figures haven’t been fully validated. There used to be about 40 or 50 and now they’re up at around 70 a year. If it’s rising, that’s a concern and we do need to find out why that is.”

Prof Manning declined to reveal the proposed cost of the initial audit submission, but said it was in the territory of “hundreds of thousands of euro”. A new submission is due to be finalised by the end of the year.

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