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Welsh respiratory care plan focuses on community nurses in bid to reduce variation

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Funding for the delivery of respiratory care is set to be “rebalanced” in Wales away from hospitals and towards specialist nurses working in the community, according to a plan to reduce variation.

An updated plan to improve respiratory health in Wales was published on Friday, setting out the Welsh government’s “vision” for services and the “actions” the NHS would take in response.

“It is likely this will result in a rebalancing of resources towards supporting specialist nurses in the community”

Simon Barry

It said the plan was focused on delivering care that “best impacts” on patient experience and outcome, including improving smoking cessation services and standardising prescribing.

In particular, the Respiratory Health Delivery Plan 2018-20 warned of the “inappropriate variation” in care for a range of conditions, including asthma and chronic obstructive pulmonary disease.

“This document follows the standard themes of other deliver plans, but it differs significantly because the focus has been on reducing variation and sharing best practice,” it stated.

Such variations highlighted by the document included concerns about the widespread differences across the country in the number of specialist nurses for a range of conditions.

The plan was developed by many experts and specialists, including nurses, in a series of workstreams under the umbrella guidance of the country’s Respiratory Health Implementation Group.

“Highlighting variation is the crucial lever to gain support for such changes”

Simon Barry

In his introduction to the plan, Dr Simon Barry, the group’s clinical lead, said: “By engaging a large proportion of the respiratory community in this process, we believe that there will be ownership of the problems and a desire to change and improve.

“This will not always be a comfortable process, but we are confident that this will result in value-based care with a rebalancing of the healthcare funding to where it is most needed, helping to fund community COPD and asthma nurses in order to reduce admissions, for example,” he said.

Reiterating this point, Dr Barry said implementation of the plan was likely to see resources moving to “supporting specialist nurses working in the community to deliver respiratory care and reduce hospital admissions and unnecessary cost”.

“Highlighting variation is the crucial lever to gain support for such changes,” he also stated in his summary of the plan.

He added: “We want to create educational resources and guidelines for patient pathways across the spectrum of respiratory medicine, and crucially we want to enthuse primary care physicians and practice nurses to engage and influence the respiratory delivery plan.”

According to the plan, during 2015, around 15% of adults in Wales were being treated for a respiratory condition and respiratory diseases caused more than 16% of all deaths in Wales.

Dr Barry noted that respiratory health “remains a real burden to the NHS in Wales”. As well as one in 12 people having a respiratory illness, Wales also has the highest prevalence of asthma in Europe and respiratory disease “consumes” £400m a year, he said.

Under the its actions on asthma, the plan called on health boards to nominate a lead physician for asthma with a dedicated secondary care asthma clinic, supported by an asthma specialist nurse.

It highlighted that, at present, access to specialist nurses was a “particular concern that needs urgently addressing”.

Only Aneurin Bevan University Health Board in South Wales currently has a “dedicated specialist asthma nurse”, the report highlighted. It noted that the specialist asthma nurse at Aneurin Bevan had a coded weekly list of asthma admissions that were seen in her asthma clinic.

All patients were provided with an asthma action plan, general asthma advice and have their inhaler technique checked. Their allergy and immunity status was also reviewed and the specialist asthma nurse undertook an antenatal clinic for all pregnant women with asthma under consultant-led care.

Betsi Cadwaladr University Health Board

‘Real time’ monitoring of HCAIs in Welsh hospitals

Vaughan Gething

Likewise, the plan revealed a “significant variation” in the nursing workforce dedicated to tuberculosis across different health boards.

“Whilst the number of active TB cases remains small, much of the work of TB nurses involves important public health measures such as contact tracing, screening and vaccinating at risk populations,” it noted.

“In addition, TB nurses are frequently involved in screening patients from rheumatology, gastroenterology and dermatology who are due to start biologic therapy,” it also highlighted.

The report identified a need to ensure there was sufficient dedicated specialist nurse time allocated to TB management, including contact tracing and outbreak management in each health board.

Boards should also support the implementation of an All-Wales senior nurse role for TB to provide clinical leadership required, it stated.

In addition, the report called for boards to ensure all patients with interstitial lung diseases (ILD) to have “ready access” to ILD clinical nurse specialist support.

It noted that ILD was a diverse group of conditions – including idiopathic pulmonary fibrosis, sarcoidosis, hypersensitivity pneumonitis and connective tissue disease-associated lung disease – that comprised 10% of the secondary care respiratory workload.

“These are serious conditions that may be progressive and ultimately fatal,” it said. “Timely access to specialist care, diagnostics and appropriate support during the course of the illness is crucial.”

Meanwhile, the plan highlighted a need to address “inappropriate variation and support” for the implementation of specialist oxygen nurses.

There was also a need to develop standard operating procedures for pleural disease interventions performed by advanced nurse practitioners, it said.

“This plan will support health boards to provide more consistent services across Wales”

Vaughan Gething

It highlighted that the condition could “occasionally” be managed through ambulatory pathways and with support of specialist nurses trained in the management of pleural disease.

Forms of pneumothorax and occasionally recurrent malignant pleural effusions were examples, it said, of effective management in the community where patients were supported by trained nurses.

Lastly, it cited “wide variation” in the availability of specialist respiratory nurses or physiotherapists to support patients with domiciliary non-invasive ventilation (NIV).

In 2017, only Betsi Cadwaladr University Health Board and Cardiff and Vale University Health Board had three or more whole-time equivalent (WTE) nurses to support domicillary NIV.

In contrast, Aneurin Bevan Health Board and Cwm Taf Health Board had less than one WTE nurse for NIV and Powys Teaching Health Board had none at all.

Health secretary Vaughan Gething published the plan after a visit to Prince Charles Hospital in Merthyr Tydfil to meet the Royal College of Nursing’s Welsh “nurse of the year” for 2017.

Louise Walby has worked as a respiratory nurse facilitator in a part of the Welsh valleys with one of the worst mortality figures in Britain for chronic lung disease.

She was recognised for her work in improving the patient experience and management of COPD, and her work is now being used as an example of best practice across Wales.

Mr Gething said: “I was delighted to speak to Louise again, following her great achievement at the RCN Awards last year.

“Improving the respiratory health of the people of Wales is a major challenge for healthcare services,” he said. “With this plan, we hope to improve the quality of life for many patients with acute or chronic respiratory diseases.

“This plan will support health boards to provide more consistent services across Wales and to deliver services reaching national standards of care for respiratory disease,” said Mr Gething.

Joseph Carter, the British Lung Foundation’s head of Wales, said: “We now need health boards to respond positively and deliver the plan locally to improve the lives of their citizens.” 

Royal College of Nursing in Wales

Respiratory nurse named Welsh ‘nurse of the year’

Pictured: Jason Mohammad, master of ceremony, Vaughan Gething, cabinet secretary for health and social care, Louise Walby, RCN in Wales Nurse of the Year 2017, Andrea Byrne, master of ceremony

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