Good quality primary respiratory care

Hello. This talk is about what is needed if we want to deliver good quality primary respiratory care across the world. I’m using the WHO director general’s definition of primary care, which includes three things, community empowerment, multisectoral action, as well as the integrated delivery of quality primary care and public health services. That’s because it’s important to understand all the different elements that drive good primary respiratory care before we make any change. Then we can think how the change we intend to make fits into the bigger picture, what else we might need to change, and also ensure that the change is an improvement. And doesn’t damage something that’s already working well. Let’s imagine a fishbone.

The head represents our goal, good primary respiratory care. The spine is connected to the head and has six main bones coming off it. These represent the six main elements in the health system. I’ve adapted these somewhat from the WHO six building blocks, and I’ll explain where I’ve adapted as I go. Let’s move to the tail end. Our first big bone is the environment. This is a bone I’ve added because it’s critically important in respiratory health and entangled with it. What matters here is how you connect with it. Let’s imagine smaller side bones coming off that. One is air pollution. We know air pollution damages the air tubes and lungs.

That might be from tobacco smoke, the smoke from fires in the home used for cooking and heating, mosquito coils, fumes from vehicles, or dusts from farming processes. As health workers, you have a role to educate the public about the risks and what they can do to protect themselves. Is the environment conducive to physical activity? We know that physical activity is extremely important for health and respiratory health in particular, to ensure our bodies get enough oxygen. How can you encourage people to be physically active in their own local neighbourhoods? We should also consider access to clean water and good nutrition. Health workers have a role in helping their populations to navigate towards these. The next bone along is information.

There are two main side bones here. The first is the person’s medical record. It’s unrealistic to expect people to remember all the advice and medicines and services they’ve used in the past. Yet if you don’t know that history, how do you may not be giving them advice that didn’t work before or was harmful to them? How do you know what else they may be using now? How do you avoid asking patients to repeat their story unnecessarily. In short, how do you ensure continuity of care, which is regarded as important by patients with chronic diseases? In many countries, health records used to be on paper but are now computerised.

That makes it easier to share them with other parts of the system as long as they’re kept confidential. Where they’re not computerised, it can be helpful for people to keep their own records. Whatever system is available to you, it’s important to use it every time. It should be clear to someone looking at the record for the first time what diagnosis a person has or maybe diagnoses, what tests were used to reach those diagnoses, and when and what treatments were given. Over time, it’s likely that there’ll be more digital apps available that may enable patients to hold their own records to share with clinicians. The other side bone is public information.

Health care workers have a really important role to educate patients, their families, and the public about respiratory health. The third bone along, the top of the spine towards the head is access to medicines, vaccines, and devices. For people with respiratory problems, that means enabling access to all who need them without pushing them below the poverty line. WHO essential medicines for chronic respiratory problems include vaccinations, such as influenza, nicotine replacement therapy, inhaled corticosteroids to address asthma inflammation, with salbutamol to relieve symptoms. We’d like it to include large volume spaces to improve the use of the inhaled medicine, but it’s not there yet. Oxygen and potentially inhaled medicines for people with COPD as well.

But in your country, are these licenced and available at low cost to patients? What’s needed to ensure regular supply, no stock outs, no switches without checking the patient is able to use the new product and work with pharmacists to ensure people know how best to use their medicines. Now let’s move to the bones on the underside of the spine, starting at the tail end. Here we have the workforce delivering the services, which combines two of the WHO building blocks. That’s the element you’ll be most familiar with as there’s clearly a direct relationship between this and the head delivering good quality prime care. This has quite a few smaller bones coming off it.

For example, diagnostic skills, confidence to perform at the top of your scope of practise, and to apply what you know, competence and access to lifelong learning, motivation and reward. As a health care worker, you will have a responsibility to stay informed and the right to be supported and properly rewarded for your work. We need to ensure that the services make the best use of the available workforce, including managers and clinicians, and where possible, there’s shared multidisciplinary learning to ensure patients receive consistent care and it’s good care. In particular, with chronic respiratory disease, we need to ensure that primary care is equipped and trained to diagnose accurately and communicate the diagnosis effectively.

The next bone along is the way this can be achieved. Here I’ve combined two WHO building blocks, finance, leadership, and governance. And to leadership, I would add to followership. In a health system that provides good quality respiratory care, leadership should be judged by how many clinicians and patients are unable to do the right things in the right way and to reduce misuse, overuse, and underuse of effective treatments. Misuse is the incorrect use of an effective treatment, such as using an asthma inhaler incorrectly. In surveys in the UK, up to 90% of clinicians demonstrate at least one error when they’re showing a patient how to use an inhaler for asthma.

Overuse is the use of effective medicines for the wrong problem, such as overuse of antibiotics for viral problems. Underuse is insufficient use of effective medicines, for example, the use of nicotine replacement therapy for treating tobacco dependence. If we achieve the situation of the right use every time of the right medicines, it would reduce time spent on supporting people harmed by the use of wrong medicines. It would enable stocks of medicines to be better managed and potentially free up finance to spend on extending effective care to more people.

There is also a role for leaders to protect health care workers, not only through the supply of personal protective equipment during COVID-19 and other pandemics but also from personal threats, which remain a problem worldwide often due to misinformation. Finally, I’ve added another bone. This is the personal experience of health and risk. We know that health services deliver care to individuals who each have their own beliefs about health and what keeps them healthy. This depends on personal circumstances.

Good quality care depends on the health care worker recognising this and having the skills but also the confidence to personalise the advice and the care they give and also to influence what beliefs are held through the fishbone about public information, for example, that we talked about earlier. So to conclude, imagine a beautiful fish swimming calmly in the river. Underneath the flesh is spine and bone, each of which is necessary to enable a fish to swim well and drive it forwards. Each of those bones has a purpose. Now, imagine the head of the fish says good respiratory care is a long spine, and there are six bones growing from it.

Those bones have a label, environment, information, access to medicines, vaccines, and devices. On the other side, we had workforce and service delivery, finance, leadership, followership, and governance, and finally, personal health. Think about how you interact with each of these to drive good respiratory care.