GP partner and PCN clinical director Dr David Coleman offers advice on the steps nurses can take to help vulnerable patients in the community stay well this winter
With Covid-19 an ongoing concern, the current pressures on the NHS and the added stresses of a cost-of-living crisis mean this winter will present a challenge greater than most of us have encountered in our careers to date.
It goes without saying that patients who are elderly, frail or have a chronic illness will be particularly vulnerable. We must also be mindful of the pressure on carers and the challenges facing young families.
There is no magic bullet to improve patient care across the board, but there are ways to make a positive impact. Here are ten top tips to help community nurses care for our most vulnerable patients this winter.
1: Actively screen for mental health problems
Screening for mental health issues at chronic disease reviews will be particularly important. Rising prices, particularly food and energy bills, mean patients are under unprecedented pressure. Financial stressors are a mental health risk factor, as is chronic disease, so in patients facing both, active screening and careful responses to mental health-related cues will be crucial.
Admitting a mental health issue can be taboo for many patients, so we will need to be alert to body language and demeanour to identify patients who may need our support. Gentle, conversational questioning may reveal hidden issues. If your area offers counselling services specifically for patients with long-term conditions, make use of these. Social prescribers can also help with practical support for issues such as bills, benefits and debt management, and should be open to receiving referrals from across the primary care team.
2: Promote the Covid-19 booster and flu vaccination campaigns
While the national conversation has largely moved on from Covid-19, the disease continues to take lives and create morbidity at a significant level. Patients may grow weary of the Covid vaccine when they receive an invite for their fourth or fifth dose, but it remains important that they attend and boost their vaccine-induced immunity.
This year, Australia has recorded higher case numbers at the peak of flu season than its five-year average,1 so we must not overlook the risk of a troublesome flu season here. Co-administration of Covid and flu vaccines can help maximise vaccine uptake; while vaccination should not be delayed because of lack of supply of either, it makes sense to do all we can to protect patients as soon as possible and to familiarise ourselves with the updated vaccines and protocols. The JCVI statement2 and the Green Book3 explain the eligible cohorts and available Covid vaccines (see Box 1, below, for a summary).
3: Focus on housebound patients and the socially isolated
The housebound are among the most vulnerable people we care for. In our practices, we are prioritising these patients for Covid and flu jabs, and tying in chronic disease reviews where possible. It is tempting to focus on efficiency, but the home setting can provide an array of sensory cues, from clutter, to trip hazards, to unopened medications. It is worth taking the time to explore these sensitively – a pile of unopened inhalers may explain those stubborn COPD symptoms!
4: Prioritise poorly controlled asthmatics
My practice uses a patient’s birthday month to guide their chronic disease review date. This makes sense on the whole, but I like to see some flexibility for patients vulnerable to winter respiratory illnesses. A search to identify patients with a low Asthma Control Test score at their last review can work as a proxy list of those who may benefit from a further review. Text messages can be used to ask patients to complete another questionnaire prior to winter. Going through the responses will yield a handy list of patients to follow up more closely as those winter bugs begin to circulate.
A similar exercise looking at exacerbation frequency, prednisolone prescriptions or hospital admissions for your COPD patients is also worthwhile.
5: Support type 1 diabetes patients to access continuous glucose monitoring
There is strong evidence that continuous glucose monitoring (CGM) improves both quality of life and glycaemic control for patients with type 1 diabetes.4 In August a new monitor, Dexcom One, was made available on NHS prescription. This differs from previous flash monitors, where the user had to scan the sensor with their smartphone; instead, it delivers real-time readings continuously. There is uncertainty about whether these devices are funded, but national guidance5 is clear that CGM or flash glucose monitoring should be available on the NHS to anyone with type 1 diabetes.
6: Optimise blood pressure and lipid management
Through necessity, general practice has largely prioritised Covid vaccination over chronic disease management for the past two years. As we restart our monitoring programmes, we are consequently picking up signs of suboptimal control of cardiovascular risk factors like elevated HbA1c, increased weight and raised blood pressure (BP) and lipids. Cardiovascular disease remains the leading global cause of death, with hypertension the number one risk factor. Nurses in primary care have a key role in identifying raised BP readings and taking a holistic approach to management.
To address raised lipids, it is worth a refresh on the current targets and processes for lipid-lowering therapy. NICE advises that statin treatment should achieve a greater than 40% reduction in the non-high-density lipoprotein (non-HDL) cholesterol level from baseline.6 If this is not achieved after three months, discuss with the patient their treatment adherence, timing of dose, diet and lifestyle. If baseline cholesterol is unknown, as is often the case with secondary prevention, follow the Joint British Societies recommendation7 to treat to a non-HDL target of below 2.5mmol/L (low-density lipoprotein cholesterol below 1.8mmol/L).
7: Be especially vigilant when reviewing dementia patients
Every patient interaction is an opportunity to review and reflect on a patient’s care. Discussions about future wishes and preferences often occur in practice nurse-led chronic disease reviews, and our practice welcomes input and prompts from all team members regarding our dementia patients. Often nurses have known these patients for years and recognise subtle changes or signs of strain on the family and carers. Things can change quickly and keeping advanced care plans and ReSPECT forms up to date can help avoid traumatising inappropriate hospital admissions.
8: Update your knowledge of local long Covid pathways
It is highly likely you have encountered patients suffering the after-effects of Covid infection. For some, this is an unpleasant inconvenience lasting four to six weeks but for others it has created life-changing morbidity. Different localities have different pathways and referral criteria for long Covid services so it is worth familiarising yourself with yours. In Doncaster, we have to complete a range of blood tests, an ECG, a chest X-ray and a questionnaire. If there is a query about long Covid at a chronic disease review, it may be worth expanding the blood request to include all of the necessary items so as to streamline the patient’s journey. The NHS website Your Covid Recovery features useful resources, including patient information leaflets.8
9: Promote weight-management services
Frail and elderly patients are not the only ones who can be vulnerable. A morbidly obese 50-year-old person with diabetes, for example, is also highly vulnerable. Not only are they at increased risk of stroke and cardiovascular disease, they are also far more likely to experience severe Covid if they become infected.
We shouldn’t underestimate the potential for a sensitively delivered brief intervention regarding obesity. The BWeL Study9 showed brief interventions are effective for weight loss but that clinicians rarely use them.10 The study website includes some useful resources. If you don’t have a local obesity referral pathway, another option is to signpost eligible obese patients to the NHS Digital Weight Management service.11 It offers a 12-week online behavioural and lifestyle-based programme, which may help motivated patients get the ball rolling.
10: Don’t neglect your own self-care
It goes without saying that your health and welfare is of paramount importance. Take your breaks, leave on time, limit exposure to social media (consider a time limit for social media apps), talk about things that are causing stress, within your team and with the wider practice, and don’t be afraid to suggest changes to your working patterns. We will all face immense pressure this winter and we need to look out for each other so we can do our best for our patients.
Box 1: Seasonal flu and Covid booster campaign summary
Eligible Patients
- Care home residents and staff (older adults’ care settings)
- Frontline health and social care workers
- Adults aged 50 years and over
- People aged five to 49 years in a clinical risk group
- People aged five to 49 years who are household contacts of people with immunosuppression
- People aged 16 to 49 years who are carers
Covid vaccines: adults aged 18 years and above
- Moderna mRNA (Spikevax) Bivalent
- Moderna mRNA (Spikevax) Original
- Pfizer-BioNTech mRNA (Comirnaty) bivalent Original/Omicron*
- Pfizer-BioNTech mRNA (Comirnaty) Original*
- Novavax Matrix-M can be used in exceptional circumstances for adults if no other product is available
* Ages 12 and above
Covid vaccines: children aged five to 17 years
- Pfizer-BioNTech mRNA (Comirnaty) 30mcg for ages 12-17; 10mcg for ages five to 11
Source: JCVI statement on the Covid-19 booster vaccination programme for autumn 2022: update 3 September 2022. Link
Dr David Coleman is a GP partner and co-clinical director at Doncaster South PCN, South Yorkshire
References
- Australian Government. Department of Health and Aged Care. Australian Influenza Surveillance Report No 7 – fortnight ending 03 July 2022. Link
- UK Government. Department of Health and Social Care. JCVI statement on the Covid-19 booster vaccination programme for autumn 2022. Update 3 September 2022. Link
- UK Health Security Agency. The Green Book. Chapter 14a: Covid-19. Link
- Lin R et al. Continuous glucose monitoring: A review of the evidence in type 1 and 2 diabetes mellitus. Diabet Med 2021 May;38(5):e14528.
- NICE. Type 1 diabetes in adults: diagnosis and management. London: NICE, 2022. Link
- NICE. Cardiovascular risk assessment and reduction including lipid modification. London: NICE, 2016. Link
- NHS England. Summary of national guidance for lipid management for primary and secondary prevention of cardiovascular disease. NHS England, 2021. Link
- NHS England. Your Covid Recovery. Link
- University of Oxford. Nuffield Department of Primary Care Health Sciences. BWeL: Brief intervention on weight loss trial. University of Oxford, 2022. Link
- Aveyard P et al. Screening and brief intervention for obesity in primary care: a parallel, two-arm, randomised trial. Lancet 2016;388:2492-500. Link
- NHS England. The NHS Digital weight management programme. Link
