Well run practices are seizing the opportunities offered by the new contract to optimise the care they offer asthma patients, says Dr Peter Saul


Practices are now well into the second year of the new GP contract and it is a good time to take stock of what has been achieved and identify areas for further work in the future.

Asthma is an important part of the clinical domain in the quality and outcomes framework (QOF), ranking fourth in terms of points available – 72 – after coronary heart disease, hypertension and diabetes.1 Economic necessity has encouraged practices to concentrate on achieving the clinical indicators (Table 1, below), but most clinicians will also be using the opportunity that this affords to evaluate more closely and improve the care that patients with asthma are offered.

The importance placed on effective diagnosis and management of the condition reflects its high prevalence and its potential adverse effects on lifestyle. According to the Health Survey for England 1996, 12% of adults and 21% of children have asthma diagnosed by a doctor.2 There can be few other chronic conditions better supported than asthma by clinical guidelines and evidence,3 and these aids are readily available to help GPs identify and manage patients effectively. Consequently, there is great potential for practices to achieve high scores, and challenging questions need to be asked in cases of poor performance.

In some primary care organisations there have been remarkable achievements in respect of QOF scores in general, and in asthma in particular. For example, of the 36 practices in South Warwickshire PCT, 26 have scored a maximum 72 points, and the average PCT score is just under 71.4

Such a high score would probably have been more difficult to achieve in areas with greater social deprivation, where there is more pressure on resources and practice populations are less stable.

Our practice, too, has been fortunate in achieving a high score for the asthma indicators. A key element in this has been a partner who, as well as being highly IT literate, is very familiar with the requirements of nGMS and the way that software tracks information for the targets.

In addition, we have used computer templates that allow us easily to identify and record the essential data, and all the clinicians have a clear understanding that we share the responsibility for accurate data recording.

Table 1: Clinical indicators for asthma

Disease/indicator no

Clinical indicator


Maximum threshold


Asthma 1

The practice can produce a register of patients with asthma excluding patients with asthma who have been prescribed no asthma-related drugs in the past 12 months



Initial management

Asthma 2

The percentage of patients age 8 years and over diagnosed as having asthma from 1 April 2003 where the diagnosis has been confirmed by spirometry or peak flow measurement



Ongoing management

Asthma 3

The percentage of patients with asthma between the ages of 14 and 19 years in whom smoking status has been recorded in the previous 15 months



Asthma 4

The percentage of patients age 20 years and over with asthma whose notes record smoking status in the past 15 months, except those who have never smoked where smoking status should be recorded at least once



Asthma 5

The percentage of patients with asthma who smoke, and whose notes contain a record that smoking cessation advice has been offered within the past 15 months



Asthma 6

The percentage of patients with asthma who have had an asthma review within the past 15 months



Asthma 7

The percentage of patients with asthma aged 16 years and over who have had influenza immunisation in the preceding 1 September to 31 March



Patient register — Asthma 1

Superficially, establishing an accurate register seems to be a fairly simple procedure. Most practices will have looked at previously recorded diagnoses and run searches for bronchodilator and inhaled steroid drugs to identify patients. However, we found that this threw up a number of queries. For example, for how long is a diagnosis valid?

We found some patients who were diagnosed with asthma a decade ago. Many, particularly those diagnosed as children, had been symptom-free for five years or more and were no longer receiving treatment.We took the view that these patients were not currently suffering from asthma and should not be included on the register. This situation demands a fairly pragmatic approach. Some patients will experience a recurrence of symptoms in later life, while in others, sophisticated testing such as bronchial provocation or exercise tests may show spirometric evidence of asthma. However, we did not test patients who were clinically free of symptoms.

Another issue was how to distinguish asthma from COPD.Patients in whom it was not possible to differentiate based on recorded history were invited to attend for a nurse check up and spirometry.Diagnostic criteria contained in the British guideline on the management of asthma and the NICE COPD guideline were then used to distinguish between the two diagnoses.3,5

Our practice prevalence was 7.2%,which may be an underestimate given the published figure of 10% for Wales.6 However, practices seem to have a wide spread of prevalence even within the same area. Figures from St Helens PCT show that prevalence varies between 2.8% and 10.1%.7

Unless there are exceptional factors, perhaps any practice with a prevalence lower than 8% (including ours) should re-examine its criteria for including patients on the register.

Confirmation of diagnosis — Asthma 2

This clinical indicator relates to patients aged 8 years and over diagnosed with asthma after 1 April 2003. Its purpose is to help address some of the uncertainty regarding diagnosis.

Airway reversibility is one of the key diagnostic criteria and serves to distinguish asthma from COPD. Spirometry, a relatively novel diagnostic procedure in primary care, may help make this distinction but it often requires postprovocation tests.

A more practical approach, and one used by many practices in line with the British Guideline,3 is to supply the patient with a peak flow meter and instructions on how to use it. If the patient, or carer, plots daily measurements, variability can be easily demonstrated.

Data published by Mendip PCT show that practices achieved almost universally high scores for Asthma 2,8 mirroring our own experience. Using the practical measures outlined above, this indicator should easily yield a high number of points.

Smoking — Asthma 3, 4 and 5

Asthma 3 and 4 relate to identifying smokers and monitoring their smoking status at intervals of no more than 15 months. Asthma 5 rewards practices for providing smoking cessation advice.The British Guideline offers good evidence for the rationale of seeking smoking status in young people, but evidence to implicate smoking in worsening asthma control in older people is less clear.3

Surprisingly, the Mendip PCT data indicate a more patchy achievement of high scores here.7 In particular, the data are worst for the 14-19 year olds (Asthma 3).We need to put aside our reluctance to ask young people about smoking status, and ask them – ideally when their parents are not present.

Achieving these indicators is mainly down to recording basic information accurately in the computer record. Using templates appropriately and ensuring that clinicians are trained in their use are the key issues.

Many patients will be receiving repeat prescriptions. Contacts for repeat precriptions may be used to gather information needed by the practice, such as smoking status. Good relations with local pharmacists can facilitate this.

Perhaps the revised QOF will challenge GPs to enquire about the smoking status of parents of children with asthma. A mother who smokes quadruples the chance of her child developing a wheezing illness.3

Asthma review — Asthma 6

"Proactive routine clinical review of people with asthma is associated with favourable clinical outcome including reduced school or work absence, a reduced exacerbation rate and improved symptom control.”3 This is the reason behind this indicator, and why it carries most points.

The Mendip data show that this indicator and Asthma 7 were the hardest to achieve, and that experience mirrors our own. It can be difficult to persuade generally well, young and middle-aged individuals to attend for routine review in an asthma clinic.

To encourage those who will not attend, two approaches can be used. The first is opportunistic review, when they visit the practice for another purpose (this is most effective when there is a computer ‘flag’ to show that a review is due); unfortunately, while it achieves the points it may be clinically less effective.

Telephone consultations are the other way to reach such individuals. Much of the information needed can be gathered without face-to-face contact; the exception is a check on inhaler technique, and here again the pharmacist’s help can be useful.

Essential elements of the asthma check are listed in Box 1 (below).

Box 1: Essential elements of the asthma check
    • RCP’s three questions8

In the last week (or month)

    • Have you had difficulty sleeping because of your symptoms (including cough)?
    • Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)?
    • Has your asthma interfered with your usual activities (e.g. housework, work/school etc)?
  • Review of medication or other treatment
  • Review or development of personal asthma action plan

Influenza immunisation — Asthma 7

Influenza immunisation is another area that practices seem to find challenging. The main issue here involves persuading patients to attend for immunisation – many asthma patients do not see their condition as serious and do not feel they need to have a flu vaccination. The annual review should provide an opportunity to encourage these individuals.

Some thought may also need to be given to the timing of vaccination clinics, as many asthma patients will be busy during the working day.

This indicator is restricted to patients aged 16 years and over. This seems illogical and is not evidence-based, so I hope that it will be revised to include younger children.

Exception reporting

An important element enabling practices to achieve high scores is effective exception reporting. This allows patients to be excluded, including those who refuse review or treatment and those for whom review is inappropriate because of other medical conditions,frailty or age.

This provision of exception reporting in the QOF may in part explain the wide range in prevalence reported and in points scored by practices.For example, for the 14 practices providing the Mendip data for this domain, exception reporting is between 2% and 10% with an average of 6%. A five-fold difference may be difficult to support on more rigorous review.


The current year should see practices consolidating their work in this field and addressing areas where they have performed less well. Practices that have scored highly must not rest on their laurels but should be looking at their disease prevalence and comparing it with local and national averages. Are they correctly identifying all patients?

Compare, too, the level of exception reporting – could more asthma patients be persuaded to participate in the process? Think, too, about ways in which care could be further enhanced.After all, the clinical indicators are just milestones in a much longer journey to improved care.


  1. Investing in General Practice:The New General Medical Services Contract. www.bma.org.uk.
  2. Department of Health. Health Survey for England 1996. London:TSO, 1998
  3. The British Thoracic Society and Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma.Thorax 2003; 58(Suppl I).
  4. South Warwickshire PCT.General Practice Achievement against the Quality and Outcomes Framework. www.swarkpct.nhs.uk/qof/default.htm
  5. National Institute for Clinical Excellence. Chronic Obstructive Pulmonary Disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care. NICE Clinical Guideline 12. London: NICE, 2004.
  6. National Public Health Service for Wales. A Profile of Long Term and Chronic Conditions in Wales. June 2005. www.wales.nhs.uk/sites/documents/368/Prevalencew.pdf
  7. QOF Database.www.gpcontract.co.uk.
  8. Mendip PCT. Somerset Health and Social Care Extranet. February 2005. http://extranet.somerset-health.org.uk/area4/cg/gpinfo/INDEX.HTM.
  9. Pearson MG, Bucknall CE, editors. Measuring clinical outcome in asthma: a patient-focused approach. London: Royal College of Physicians 1999.

Guidelines in Practice, September 2005, Volume 8(9)
© 2005 MGP Ltd
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