Working Harder and Smarter

Members of the asthma management team - a general practitioner (Dr H. John Fardy), respiratory physician (Assoc. Prof. Charles Mitchell), pharmacist (Irvine Newton) and asthma educator (Robyn Paton) - have put together their collective thought for this article

Working harder and for longer hours seems to be a general trend within the Australian workforce and healthcare professionals are no exception. As a result, GPs are seeing more patients per day. This fact has made it difficult for GPs to spend the time which is necessary when managing patients with chronic diseases such as asthma.

Generally, GPs are handling the pressure very well. However, there is still a need for further assistance in terms of education for both practitioners and their patients. It is also important that whenever patients come into contact with healthcare professionals we all speak the same language. The NAC's work in establishing a language for asthma, with terms such as 'preventers' and 'relievers' as accepted terminology, has been useful in helping healthcare professionals give consistent messages to patients.

Increased workloads in healthcare in general, and the evolution of a more collaborative team approach have probably been the two biggest changes in the role of medical professionals in asthma management over the past ten years.

General practitioners - developments and initiatives

The creation of the NAC's General Practitioners' Asthma Group (GPAG) in the early 1990s, thanks largely to the efforts of Dr Ian Charlton, has provided an excellent forum in which asthma can be discussed from a GPs perspective. This has ensured that the voice of GPs is heard and acknowledged across a broad range of policies, educational initiatives and information materials.

Particularly heartening is the fact that the GPAG now has Asthma Liaison Officers in 90 of the 120 Divisions of General Practice across Australia. They have an important role in acting as a conduit for asthma information to GPs in their division.

In recognition of this role - which provides feedback from GPs as well as 'cascading' GPAG information - the NAC will be holding the first Asthma Liaison Officers' national conference in early 1999. One of the key areas of focus will be on further developing the Asthma Liaison Officers' 'peer group leader' role.

Another initiative which holds exciting prospects for GPs is the introduction of the 3+ Plan. This has been developed in response to work by the GPAG which identified that asthma patients present in surgery in one of two ways: (i) in an emergency situation, or (ii) with their asthma tagged onto the end of a list of things', e.g., Pap smear, suspicious mole on the back, etc. The 3+ Plan introduces a 'contract for care' between GPs and asthma patients which plans for regular reviews of a patient's asthma symptoms and treatment over a four to five month period.

Pharmacists - the first line of contact

It is now recognised that pharmacists play an increasingly important role as the first line of contact with patients. Pharmacists are easily accessible - patients can walk in at no cost and ask for advice - and many pharmacists are now encouraging people to seek more information. Consequently, leaflet stands are a common feature in most pharmacies today.

It is generally accepted that patients need several training sessions on how to use their inhalers and pharmacists play a valuable role in meeting these educational requirements. Similarly, pharmacists are uniquely placed to be able to provide an additional check in terms of monitoring a patient's total medication regimen (e.g. aspirin usage) and referring people to GPs when indicated.

There is no doubt that GPs and pharmacists are working better together, but where the system falls down is in patient follow-through with pharmacists' recommendations. It would be good to see some work done in assessing ways to 'close the gap'.

Asthma educators - a new team member

Ten years ago, many GPs did not see a role for asthma educators, but they are now generally accepted as part of the asthma management team. Indeed, as the problem of adherence receives more attention, education is becoming increasingly important.

The role of education in improving the management of asthma was recently examined as part of the evidence-based review of the Six-Step Asthma Management Plan. The findings reinforced the view that education is vital in asthma management and that it is no longer possible to accept the handing over of a leaflet at the end of the patient consultation as adequate education.

Studies show that patients need to receive about three hours of education, over six weeks, to be able to use their asthma medication properly. This is obviously too big a demand on a GP's time and the asthma educator is well positioned to take on this role.

However, while it would be good to see more GPs referring patients to asthma educators, we need to recognise that not everyone has access to them. As with other specialised services, unfortunately there are inequalities of distribution in our system.

Respiratory specialists - the interchange of ideas

While the relationship between GPs and specialists is well established, there has been quite a significant change in the last five or so years with both groups of practitioners now working together more effectively.

The phrase which is often used is 'continuum of care'. With a chronic disease like asthma, the majority of patients are best looked after by their GP, with occasional referral to a specialist if they have particular problems. In this fashion, GPs are more than comfortable referring patients for specialist attention when necessary. However, in many cases, GPs will manage a patient through a particular scenario by contacting the specialist for advice and then administering treatment within the general practice setting.

While access to specialists for critically ill people is not a problem, the issue of general access for non-emergency cases does apply. Waiting times for specialists can often be several weeks and it is in these cases that the direct contact between GP and specialist offers the most benefit.

Even after specialist attention, most thoracic physicians are happy to refer patients back to their GPs for ongoing management. It is only on occasion, with complex or severe cases that a joint management strategy, involving both a GP and a specialist, may be implemented.

Asthma clinic nurses - a specialist service

The concept of asthma clinics run by nurses in general practice works well in the UK, but to date they have only been introduced in Australia in a limited way. They are most appropriate as a specialist service in surgeries where there are already a number of patients with asthma. The question of cost is the biggest issue facing GPs considering establishing an asthma clinic.

Organisations - facilitating success

The principal asthma organisations - the NAC, Asthma Australia through the seven Asthma Foundations - provide an excellent service for healthcare professionals and patients alike who often contact them to obtain advice or resources.

The NAC has been a driving force behind collaborative efforts in managing asthma. By accepting responsibility for facilitating discussion across the professional groups (GPs, pharmacists, thoracic physicians and asthma educators), and the Asthma Foundations, an environment has been created where a common terminology and best practice guidelines now define the process of asthma management.

In summary, the team approach to managing asthma more effectively is already happening, with the result that health outcomes for people with asthma have improved. Even so, the role of different health professionals in the overall management process will continue to evolve as new challenges and opportunities present themselves.

Content Updated July, 2001