Dr Rhoda Williams, team leader of an initiative short-listed in the Guidelines in Practice Awards 2006, discusses the benefits of local respiratory clinics and patient passports

Chronic diseases such as asthma have profound physical and psychosocial implications for patients, as well as making appreciable demands on NHS resources. The aim of the initiative undertaken at the North Swindon Practice was to address all aspects of asthma management, in order to improve outcomes, provide holistic care, and empower the patient to take a leading role in their own health management.

Multidisciplinary teams for chronic disease

In 2004, we began the process at our practice of developing new multidisciplinary teams and protocols. We developed handheld ‘patient passports’ to improve care of patients with chronic diseases. Initially, disease areas included asthma, cardiovascular disease, cerebrovascular disease, chronic obstructive pulmonary disease (COPD), diabetes, hypertension, and peripheral vascular disease.

All the chronic disease protocols at our practice were reviewed and rewritten in light of local and national guidelines available in 2005.1,2 We concentrated on diagnostic and monitoring requirements, as well as on stepwise treatment plans. Emphasis was placed on which member of the team was responsible for what aspects of care. These protocols are reviewed yearly. Computer data entry templates were developed for recording details of respiratory monitoring, advice given, and treatments offered, which can be updated following protocol changes, or if additional fields are requested by clinical team members.

Expanded role of the healthcare assistant

Four receptionists at the practice were trained in the role of healthcare assistant (HCA), which enables them to: carry out procedures such as spirometry, phlebotomy, and microalbuminuria testing; monitor blood pressure, hypertension, and body mass index; and advise on health education.

Respiratory clinics

We now hold loosely termed ‘respiratory’ clinics, at which our HCAs and nurses each have their own list of patients to review. When they were first set up, a GP was assigned for the duration of the clinic to discuss individual patients, give advice, alter medication, and sign prescriptions. All asthma patients are encouraged to attend these clinics rather than see their usual GP. As a result of time constraints, GPs often find it hard to stick to protocol and carry out the full assessments/monitoring requirements, so patients may receive a better check-up at the asthma clinic. Asthma checks are now seldom undertaken by the GPs, except in the case of housebound patients.

Clinic appointments are long enough to allow the healthcare professional to focus on patient education, lifestyle advice, and preventive measures in line with current guidance.3 Recommendations to patients from the healthcare professionals at the clinics concentrate on smoking cessation and weight loss (for obese patients). Advice is also given on triggers for asthmatic patients, such as house dust mites and animal contact.

During the first year of the project, the clinics did increase the overall time spent by nurses and HCAs on chronic disease management, as so many patients had poorly controlled conditions and required frequent review. Two years after starting these clinics, however, this rate of review is now easing. We have the pleasure of seeing many patients come back for their annual review with all parameters still well controlled and little more for us to do other than offer encouragement and update their personalised management plan and ‘passport’.

Patient passports

Our asthma initiative included the development of an asthma ‘patient passport’ (Figure 1). This has general lifestyle advice on the front, a record on monitoring inside, and additional information on testing and management on the back. The management plan box, as well as showing when the next appointment is due, can be used to give other details, including information on stepping treatment up or down, what to do if there is an exacerbation of the patient’s condition, and contact telephone numbers. Patients carry these passports with them, which has numerous benefits to both the patients and the practice. These include:

  • giving information on what targets are aimed for — preset targets for body mass index and smoking are already inserted, while the peak flow target is individual to each patient and is written in by hand once calculated
  • encouraging patients to be active in improving their own health
  • aiding improvement in general health education
  • demonstrating to patients how well they are doing, highlighting trends, and allowing them to review their progress
  • giving clear details of medication, allergies/sensitivities, diagnosis, vaccinations, test results, and monitoring information—this can be vital to the patient, their usual doctors/nurses, hospital services, and any emergency services involved in care
  • reminding the patient when monitoring/tests are due
  • offering encouragement for patients to attend chronic disease clinics rather than visit their GP, and ensuring they see the correct healthcare professional once there —after each clinic appointment the return visit date is recorded in the ‘Due date’ box of the passport, with details of who the patient will see then (e.g. nurse/HCA)
  • making sure that full monitoring is carried out at appropriate intervals, with no items missed
  • providing confirmation whether basic tests, such as spirometry, have been done and making the results readily available at the regular review
  • allowing best utilisation of the skills of our practice staff.

Figure 1: Passport for patients with asthma

Figure 1: Passport for patients with asthma

Patient outcomes

After 2 years of running the clinics, they have helped us to make improvements in many areas of the practice. They have:

  • assisted us in identifying previously unrecognised disease, such as in asthma patients with COPD overlap — improved access to spirometry and reversibility testing in the practice has made this a routine part of assessment and monitoring rather than a specially requested test for ‘difficult to diagnose’ patients
  • improved patient satisfaction with their care, and patient participation in managing their condition (see Table 1)
  • vastly improved disease monitoring and control, which continue to improve year on year (see Table 2)
  • helped us to achieve maximum quality and outcomes framework points2 for the past 2 years, and the clinics are becoming a routine part of our work rather than an additional burden
  • increased the amount of health promotion, lifestyle advice, and patient education within the practice
  • allowed routine GP appointments to be freed up, enabling other patients to be seen
  • brought savings in nursing time—HCAs are now developing confidence in carrying out many traditional nursing roles
  • improved staff satisfaction—both HCAs and nurses agree they are now enjoying chronic disease management, and have been greatly encouraged by the improvements seen in care and the appreciation of the patients.

Table 1: Results of a patient satisfaction survey carried out in March 2006

Ratings for chronic disease clinics
Not bad
Appointment availability
Length of appointment
Advice received on health needs
Lifestyle advice received
Usefulness of passports
Standard of care
Patients were asked:
if they liked attending the clinic Yes = 37 / No = 2
If they felt the clinics were an improvement on the old system of seeing the doctor or nurse in a routine appointment Yes = 33 / No = 5

Table 2: Audit summary carried out in April each year from 2004*

Asthma patients
Recording of:
• Smoking status (%)
• Smoking advice (%)
• Asthma review (%)
Number on register
*Project was initiated in 2005

Future developments

We hope, in time, to incorporate into the respiratory clinics further educational sessions and advice from services traditionally provided in secondary care. This could include advice on pulmonary rehabilitation and physiotherapy, and expert patient programmes. Unfortunately, the implementation of practice-based commissioning (PBC) has held up incorporation of further services into clinics in the short term. However, we hope, that in the long term, PBC may allow us to employ respiratory specialist nurses directly in the community rather than via the hospital.

We are now starting to monitor hospital admissions for asthma, secondary care usage, morbidity, and mortality, and hope to see positive trends over the next few years as a result of our initiatives in asthma clinics and patient passports. When we looked at the past 2 years, we were expecting to find a decrease in the number of ‘acute exacerbations of asthma’ coded on our system, as this was our clinical impression, but this has remained fairly constant. As our use of read coding to record the exacerbations has improved (rather than using free text), this has offset the reduction in actual numbers. However, our use of secondary care services for exacerbations has reduced by about one-third, and most of these cases are now casualty attendances rather than admissions.

Our model of clinics and patient passports works well and can be extended with little effort to cover new disease areas. We are already working on implementing these in the areas of obesity, atrial fibrillation, and impaired glucose tolerance.


Our respiratory disease clinics have been found to be enjoyable for both patients and staff. Patients have benefited demonstrably, both physically and in terms of regaining control of their own conditions, their life, and their future.

We hope to be able to prove both time and cost savings, along with reduced morbidity and mortality. Our aim is to continue the clinics for asthma and other chronic diseases beyond their trial period and increase the number and range of conditions monitored. The reduced use of hospital services has obviously improved our PBC budgets. Asthma clinics have freed up GP appointments, and the use of HCAs has freed up nursing time, as well as making spirometry/reversibility testing easily available. The respiratory clinics are now so well established they no longer need designated doctor availability, and nurses/HCAs simply ask advice of whichever doctor is available, if needed.

We now also run chronic disease clinics for: diabetes; impaired glucose tolerance; hypertension; heart complaints (to include ischaemic heart disease, atrial fibrillation, and heart failure); vascular conditions (to include stroke/transient ischaemic attack/peripheral vascular disease); and COPD, as part of the respiratory clinics. This year we are also trialling obesity clinics. Each of these disease areas has their own protocols and patient passports. All clinics, with the exceptions of respiratory and obesity, have dedicated doctor time to oversee nurses and HCAs.

The PCT and other practices in the area have shown interest in our patient passports initiative, although they are not as yet using them in their current form. We are, however, using them as a starting point in many of our discussions with other practices, and community-based and hospital-based respiratory services as we develop plans for the delivery of respiratory services as part of PBC. We are considering how they may be best utilised in the coordination of care as more of this is provided in the primary care setting.

We feel we have achieved our aim of empowering the patient in the management of their asthma with many additional benefits being accrued along the way.


  • Good proactive primary care can help achieve QOF points, improve patients’ health, and save costly admissions
  • Patients with asthma are often unwilling to attend for review—a multidisciplinary approach including community pharmacists should be considered
  • In most cases, asthma reviews can be dealt with by the nurse or the healthcare assistant
  • Tariff price for asthma admission:1 £1166
  • Tariff price for thoracic medicine outpatient:1 £201 (new), £101 (follow-up)
  1. British Thoracic Society/Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma: A national clinical guideline. BTS/SIGN, 2004.
  2. British Medical Association. Investing in General Practice. The New General Medical Services Contract. London: BMA, 2003.
  3. British Thoracic Society/Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma: A national clinical guideline. Revised edition 2005. BTS/SIGN, 2005.G