In Focus: Be proactive in respiratory care

What should our priorities be for respiratory care in general practice? Aleksandra Gawlik-Lipinski shares her personal views with Nursing in Practice editor Carolyn Scott

Aleksandra Gawlik-Lipinski, a respiratory nurse specialist working in general practice in south London, believes respiratory care is ‘falling behind’ other specialties in the UK. Here, she tells Nursing in Practice that nurses need more support and better access to diagnostics if they are to help improve care for patients.

Where are we with respiratory care in general practice?

I think that, collectively, we are falling behind compared with other specialties. Training across the general practice team may not always be adequate – for GPs, nurses, physician associates, healthcare assistants or pharmacists. And from a nursing point of view, respiratory care is of course only a part of what nurses are dealing with.

We also know the levels of respiratory care provided vary too much from practice to practice, and from region to region, which is increasing health inequality in the UK. As it stands, we do not have the required standard level of respiratory care across the country.

Although organisations are good at providing guidelines and competencies – such as the Primary Care Respiratory Society (PCRS), Association of Respiratory Nurse Specialists (ARNS) and the British Thoracic Society (BTS) – training is often not readily available to clinicians and I think that is a big problem.

Workload in general practice is still high after the pandemic, and patients may not always be getting their annual reviews, or these are being done over the phone, which is not always appropriate. Patients also may not be reviewed on time after asthma or COPD exacerbations and we have problems with making timely diagnosis.

In my opinion, children – particularly young children – and young people, are often not properly diagnosed with asthma. I sometimes observe a hesitancy to diagnose a child with asthma, which can delay treatment. The child may only be given one inhaler – the reliever – rather than a reliever and a preventer.

That can lead to them having asthma attacks, resulting in emergency presentation or admission.

Another big problem with the paediatric population is the limited access to diagnostics in primary care, and the pandemic has played a big role in that. Before Covid, practice nurses were very much involved with spirometry, and then everything changed.

We do now have the new respiratory hubs, but the waiting times to be seen are very long. Locally where I practise, my patients are waiting four months or more for an appointment.

It’s all about the capacity and the funding that is not necessarily there for the NHS, but at the end of the day patients are suffering because they are not diagnosed in a timely manner because we don’t have ready access to the diagnostics.

With COPD, we’re typically waiting for a diagnosis before treatment will be initiated, resulting in a delay to treatment, which means the condition may deteriorate in the meantime.

Will additional funding for diagnostic centres help?

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The respiratory hubs are a good initiative, although I think we need more of them. What’s great is that the clinicians working there are performing quality-assured spirometry. They will be registered with the Association for Respiratory Technology and Physiology, which is really important because every now and then we do come across spirometry traces that may not have been performed in line with standards, or that have been misinterpreted. It’s a good thing that we are trying to achieve a high standard of care.

But we do also need more clinicians who are trained in quality-assured spirometry. As we lose nurses from general practice, or more plan retirement, we are at risk of losing more of those with experience in spirometry. Others may not be interested in going through the whole accreditation process; speaking from personal experience, it is a lengthy undertaking and of course it costs money.

What would you say has been achieved by nurses in general practice in respiratory care?

Nurses are doing a fantastic job. They’re educating patients about asthma and COPD so they can understand their condition – something that was lacking a lot in the past. Nurses often deal with complex asthma and COPD, creating self-management plans and providing emotional support to patients.

While nurses in general practice may not perceive themselves as respiratory nurse specialists, I think they should. They do have that level of expertise. I think nurse prescribing is also allowing for better access to care for patients – they can be seen by a nurse, who will help tailor care to their needs.

However, as we know, the level of training will vary from practice to practice, within practices, from city to city and from country to country in the UK. Training is something that should be more standardised.

Nurses’ approach is very different to the medical approach. We come from a different profession. Research shows that when a patient comes to see a nurse they feel they’re not rushed, they feel they are taken care of in a holistic way and that they are listened to. Nurses usually have slightly longer appointments, which is also a big benefit, and I do think patients value the caring approach that nurses bring.

Where I work, we are very multidisciplinary team – we have nurses providing some respiratory care and myself with a special interest. We also have lots of pharmacists and several GPs with an interest in respiratory care. We are constantly working to enhance our respiratory care as a team, with various quality-improvement projects running in the background.

The latest project is to identify patients with severe asthma in our practice to make sure they are coded accordingly and are under the care of a respiratory physician, and secondary care if required. Patients with severe asthma are on six-monthly rather than yearly reviews. They are well educated on the early signs of exacerbation – they know they need to call the GP practice, and they will be seen by the duty doctor or by me to ensure we prevent escalation, prevent unnecessary hospital admission and prevent damage to their lungs.

We know for example that COPD patients who have exacerbations are much more likely to experience cardiovascular events post-exacerbation. They may have a stroke or heart attack as a result of that, the lung damage during each exacerbation is usually irreversible and lung volumes will reduce in such patients.

What should GPNs have in their sights right now?

Be proactive and take our education into our own hands. The level of education clinicians receive in general practice does need to be standardised. That may be largely out of our control but there are free training and resources available from the PCRS, ARNS, BTS and other organisations that are supporting primary care in respiratory disease. There is also a free course for nurses that is not widely known about, available on elearning for healthcare (see Resources). As discussed above, GPNs should have proper access to diagnostics so they can refer patients to diagnostic services as required.
All asthma patients need asthma management plans to reduce the risk of life-threatening exacerbations. We also need to emphasise to patients the importance of avoiding triggers. This is discussed during consultations, but perhaps we don’t talk enough about the impact of air pollution, which contributes to many premature deaths. Comorbidity is another thing to consider. In the future, we need to develop a holistic management plan that includes all a patient’s medical conditions and considers all the treatments and advice, which might contradict each other.
Challenge perceptions around asthma. What patients might call ‘mild asthma’ doesn’t exist – asthma still kills. It is often underplayed and it’s seriousness not acknowledged. So we should never be prescribing salbutamol only.
Remember non-pharmacological treatments. This is important for patients with COPD and breathlessness. Shortness of breath in COPD might often be linked with levels of anxiety. Professor Morag Farquhar and her team at the University of East Anglia have created a useful online resource to support breathlessness (see Resources).
Check patients are receiving the follow-up they need. If we do suspect asthma, we should record them as suspected asthma or suspected COPD. We should contact patients so that they don’t vanish off the radar, ensuring the diagnostics have been done and that they have been referred if needed. However, we do need to remember that with asthma, the diagnostic tests are only supporting the clinical diagnosis. For a diagnosis of COPD, we typically want to see obstruction on spirometry, so it is important that we follow the proper diagnostic process in patients with respiratory symptoms. Make sure you have audited patients who have very high use of salbutamol.
Consider using a template message to inform patients about trigger control. This is a useful option if you use a messaging system. Speak to each patient about the triggers they have and then signpost them to information on prevention and control.
Check that systems are in place to follow up patients after exacerbations. Was the exacerbation managed at home or were they seen in A&E? Ensure they are next being reviewed by a clinician who is trained to do so and can adjust their medication if necessary and monitor them. Again, we know people are highly vulnerable in the period after an exacerbation.
Address inequalities. We have something of a national postcode lottery for respiratory care. The inhalers on some local formularies may not have been updated for a few years even when there may be newer products on the market. Someone in one area might get an inhaler that has better evidence than an older inhaler. I believe this should be regulated more centrally, rather than locally because it is contributing to health inequalities across the country.

Aleksandra Gawlik-Lipinski is an advanced nurse and paramedic practitioner, an independent prescriber and a respiratory nurse specialist working in general practice at Herne Hill Group Practice in south London. She is vice-chair of the research and education subcommittee of the ARNS and co-chair of the BTS nurse special advisory group, and is currently undertaking a PhD focusing on mortality in childhood asthma.

Resources