Respiratory diseases

Respiratory diseases are conditions that affect the lungs such as asthma, chronic obstructive pulmonary disease (COPD); infections like influenza, pneumonia and tuberculosis; and lung cancer and many other breathing problems.  This section focuses on asthma and COPD which contribute hugely to health inequalities, ill health and premature death.

The similarities in the symptoms of both diseases can lead to misdiagnosis and poor management. Hence, expert assessments are required to separate their relative contribution to ill health. About 15% of patients with COPD also have asthma.

Asthma
Asthma is a chronic condition that affects airways in the lungs, causing them to become inflamed and swollen. Typical symptoms include breathlessness, tightness in the chest, coughing and wheezing. Environmental factors such as viral infections, allergens, pollution, tobacco smoke, workplace sensitisers and exercise can make the condition worse.

The causes of asthma are not well understood so prevention is not currently possible. However, the condition does not usually deteriorate over time and the aim of treatment is for people with asthma to be free of symptoms and lead a normal life.

It is estimated that about 5 million (1.4 million are children aged under 16 years) people in the UK are affected by asthma. There are between 1000 and 2000 deaths from asthma per year, but it is estimated that 90% of these deaths are associated with preventable factors.  Asthma is a common cause of large numbers of emergency admissions in those aged less than 19 years. High numbers of hospital admissions for asthma are considered to represent a mismanagement of the condition.


COPD
Chronic obstructive pulmonary disease is a chronic disabling disease which causes a gradual decline in lung function, with increasing episodes of chest infections and exacerbations as the condition progresses. It is a general term which includes chronic bronchitis and emphysema. It mainly affects people over the age of 40 and risk increases with age. Smoking is the main cause in the vast majority of cases.

COPD is incurable but treatments help to slow down the decline in the lung function, so early diagnosis and support for effective self-management and self-care can help patients live an active life.  About 835,000 people in the UK are currently diagnosed with COPD and an estimated 2.2 million people have the condition but do not know it.

COPD is the fourth biggest killer in the UK, the second most common cause of emergency admissions to hospital and one of the most costly in-patient conditions treated by the NHS.

Integrated working between health, social and leisure services and people with asthma and COPD is critically important to improve health and wellbeing and reduce the health inequalities associated with these conditions.

This topic links with the following JSNA topics:

 

Last updated: 2015-12-22 16:14:18
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1. What are the key issues?

Generally, there is a decreasing trend in the number of deaths from COPD in Stockton-on-Tees.

The number of people with COPD is increasing, placing additional demand on services.

There is a lack of community awareness of COPD and its risk factors.

There are high numbers with undiagnosed COPD that may lead to increased complications, ill health and health inequalities and inefficiencies in the system.

There are variations in the quality of diagnosis and management of asthma and COPD among general practices in Stockton-on-Tees.

There is need to improve the management of asthma in children and thereby reduce the numbers attending or admitted to hospital as emergencies.

There is need for integrated care pathways across relevant organisations to ensure effective care that relieves symptoms, reduces progression of disease, enhances recovery and promotes independence through to end of life.

 

Last updated: 22/12/15

2. What commissioning priorities are recommended?

 

2015/01
Reduce smoking prevalence by targeting high risk groups
, including improving access to smoking cessation services for people with asthma and COPD. Increase opportunities for smokers to access appropriate support in community settings.

2015/02
Improve public and professional awareness of asthma and COPD prevention, diagnosis and treatment
. This remains an important priority, with continuous education and training for health professionals and activities to increase awareness of conditions in the community.

2015/03
Identify mainstream funding to help sustain and improve on progress being made with early detection of COPD
.  A proactive, systematic and comprehensive approach to early detection of COPD (the Lung Health Check Programme) has been implemented in GP practices on Teesside. Community delivery of checks in Stop Smoking Service Clinics is being developed and will be piloted in Hartlepool and in Community Health Check Service in Redcar & Cleveland before roll out elsewhere in Teesside to improve availability and access. The priority is to identify mainstream funding to help sustain and improve on progress being made.

2015/04
Reduce variation in clinical management of asthma and COPD
to ensure that people with these conditions across all social groups receive safe and effective care, which reduces disease progression, enhances recovery and promotes independence.

2015/05
Provide co-ordinated support for people with asthma and COPD
to better self-manage their conditions. There is need to provide community based self-management  and self-care activities including peer support.

2015/06
Ensure resources for respiratory disease reflect the rising number of people with the condition
and the demand on health and social care.

2015/07
Develop, implement and monitor strategies for tackling the wider issues that increase the risk of asthma attacks and exacerbation of COPD
through effective partnership working. Improve access to seasonal flu immunisations, smoking cessation and other lifestyle interventions.

Previous commissioning priorities:

2012/01
Develop proactive, systematic and sustainable approaches to increasing the numbers of people diagnosed and treated for COPD.

2012/02
Reduce smoking prevalence by targeting high risk groups, including improving access to smoking cessation services for people with asthma and COPD.

2012/03
Improve public and professional awareness of asthma and COPD prevention, diagnosis and treatment.

2012/04
Reduce variation in clinical management of asthma and COPD to ensure that people with COPD, across all social groups, receive safe and effective care, which minimises progression, enhances recovery and promotes independence.

2012/05
Implement a systematic and co-ordinated proactive approach to early identification, diagnosis and intervention, and proactive care and management at all stages of the disease, with a particular focus on the disadvantaged groups and areas with high prevalence.

2012/06
Provide co-ordinated support for people with asthma and COPD to better self-manage their conditions.

2012/07
Ensure resources for respiratory disease reflect the rising number of people with the condition and the demand on health and social care.

2012/08
Develop, implement and monitor strategies for tackling the wider issues that increase the risk of asthma attacks and exacerbation of COPD through effective partnership working.

2012/09
Improve secondary prevention for people with asthma and COPD through increasing uptake of seasonal flu immunisations, smoking cessation and other lifestyle interventions.

 

Last updated: 22/12/15

3. Who is at risk and why?

Asthma

Age
Asthma affects people of all ages. About 40% of deaths from asthma occur in people under the age of 75.

Asthma is the most common chronic disease of childhood, affecting 12.5 % of children. There were nearly 54,300 emergency hospital admissions for asthma in the UK in 2014. Children accounted for the largest proportion of asthma emergency admissions where two in five were under 15 years (38%, or 20,500 out of 54,300). One in six emergency admissions for asthma were under five years of age (15.6% or 8,450).

Gender
In childhood, asthma is seen more frequently in boys than in girls. In  adulthood, females show a higher prevalence of asthma, more asthma-related health care utilisation and more hospitalisation for asthma than males.

Family history
A family history of diagnosed allergies, eczema and asthma is an important risk factor in developing asthma. The risk of a child developing asthma if both
parents have diagnosed allergies and or asthma is estimated to be about 75%.

Deprivation
Asthma is higher in children living in areas experiencing higher levels of deprivation. This is likely to be due to the higher levels of risk factors in these areas. Maternal smoking and home environment are important factors.

COPD

Age
Most people with COPD are 40 years old or over when symptoms begin. It is unusual, but possible, for people under 40 years of age to have COPD symptoms.

Gender
COPD is more common in men than women but the British Thoracic Society estimates that the rate of COPD among women is increasing. The decreasing number of deaths from COPD in men is not being observed in women. This may be associated with the increasing number of women smoking.

Smoking
Smoking is the main cause of COPD. Stopping smoking reduces the risk of developing COPD and can halt the progression of the disease and reduce the risk of death in those diagnosed with the disease.

Deprivation
COPD is highest in areas experiencing higher levels of deprivation. This is likely to be due to the higher levels of risk factors in these areas. It is estimated that about half of diagnosed and undiagnosed COPD in England are in people in the routine and manual occupational group.

 

Last updated: 22/12/15

4. What is the level of need in the population?

Summary
The Public Health England North East Respiratory Profiles (2013) show the impact of respiratory diseases in the area covered by Clinical Commissioning Groups (CCGs), in particular the causes and effects of both Asthma and Chronic Obstructive Pulmonary Disease (COPD).

Hartlepool and Stockton-on-Tees (HaST) CCG performs relatively worse than the England average for the majority of the primary and secondary care and mortality indicators.

Respiratory profile spine char part 1, Hartlepool and Stockton, 2013

North East Respiratory spine chart, Hartlepool and Stockton, 2013

There are significant variations in the prevalence and management of COPD and asthma in primary care in terms of prevalence of conditions, emergency admission rates and key elements of management.

Asthma

 

  • The prevalence of asthma in NHS Hartlepool and Stockton-On-Tees CCG has remained fairly stable in the past three years, in line with the national trend.
  • The emergency admission rate for asthma in Stockton-On-Tees has since 2011/12 fallen significantly below the England average and there is variation between general practices. There were 168 hospital admissions associated with asthma in under 19s from 2011/12 to October 2013/14
  • There is variation between general practices in key elements of asthma management in the NHS Hartlepool and Stockton-On-Tees CCG.  About 5,740 people with asthma did not have an annual review.

Prevalence
The prevalence of asthma for all ages in NHS HAST CCG has been consistently higher than the England average in the past five years. In 2014/15, 18,577 (6.33%) people of all ages from the general practice registered population were diagnosed with asthma (6.28% in 2013/14).

In 2013/14, the prevalence for HAST CCG  was 6.3%, compared with 5.9% in England.

Admissions
High numbers of hospital admissions for asthma are considered to represent a clinical and self-mismanagement of the condition. The emergency admission rate for children aged under16s in Stockton since 2011/12 is considerably lower than the England average. In 2012/13, the standardised emergency admission rate for children aged under 16 was significantly lower than England (136 vs. 231 per 100,000 population). Data from the Public Health England Child Health Profile show that there were 168 hospital admissions due to asthma in the under 19s in Stockton in three years, from 2011/12 to 2013/14.

There is variation in the emergency admissions rate for asthma between general practices.


Management
The proportion of people (aged 8 years and over) with asthma diagnosis confirmed with measures of variability or reversibility is slightly higher in HAST CCG compared to the England average.  Significantly higher percentages of patients with asthma in NHS Hartlepool And Stockton-On-Tees CCG received an annual review in the previous 12 months compared to the England average. However, about 5,740 people with asthma in the CCG area were not reviewed in 2014/15.

There are significant variations between general practices in the management of asthma. Only one practice had all asthma diagnosis confirmed with measures of reversibility. No  practice had all patients with asthma reviewed in the previous 12 months, 32 of 40  practices reviewed fewer than 80%, with seven reviewing fewer than 60%.

COPD

 

  • The number and rate of deaths from COPD have declined over 16 years in Stockton-on-Tees but the decrease is smaller for women than men.
  • The estimated prevalence of COPD in Stockton-on-Tees is 4.7% but only 2.1% of the population has been diagnosed. This means that about 3,200 people with COPD remain undiagnosed.
  • The COPD emergency admission rate in NHS Hartlepool& Stockton-on-Tees CCG is higher than the England average and there are variations between general practices.
  • Spirometry confirmation of COPD, annual lung function check and annual review rates in NHS Hartlepool and Stockton-on-Tees CCG are all lower than the England average.
  • There is variation between general practices in key elements of COPD management.

Mortality
Deaths from COPD for men in Stockton-On-Tees have halved in 19 years, from 106 per 100,000 population in 1995 to 76 per 100,000 population in 2013. A smaller reduction of about 10% was observed for women in the same period.

COPD mortality trend, Stockton, 1995-2014

 

Prevalence
The prevalence of COPD in NHS Hartlepool and Stockton-On-Tees CCG is consistently above the England average. The recorded prevalence increased from 2.2% in 2009/10 to 2.8% in 2014/15.

However, it is estimated that about 4.9% of Stockton population has COPD. This suggests that about 4,700 adults have undiagnosed COPD.

In general practices, the level of undiagnosed COPD varies considerably. The estimated ratio of reported to expected prevalence of COPD range from 10% to 120%, with no practice that has identified 100% or more of the people expected to have COPD.  Eleven practices have identified fewer than half of the expected number of cases.

The Tees Lung Health Programme with aim to increase the early detection of COPD has led to increased reported COPD prevalence and is likely to reduce the number with undiagnosed condition. (see section below on Primary Care).

Emergency admissions
The emergency COPD admission rate in NHS Hartlepool and Stockton-On-Tees CCG is significantly higher than the England average.  In 2005/06, there were 780 emergency admissions which increased to 1,000 in 2012/13.

Similarly, prescribing costs for inhaled corticosteroids in the CCG area continue to rise above the England average and the gap is widening. The reasons for both high prescribing and emergency admissions need to be investigated.

There is considerable variation in COPD emergency admissions at general practice level.

Management
The process measures of care for COPD in NHS Hartlepool and Stockton-On-Tees CCG are higher than the England average. The percentages of people with COPD confirmed with spirometry and those who received a lung function check (FEV1 - amount of air you can expel in the first second of a rapid breathing out), had an annual review and given flu vaccination are lower than the England average.

There are variations in the management of people with COPD between general practices. For example, only one practice had all patients with COPD reviewed in the preceding 12 months in the CCG.  About 1,700 people did not have an annual review.

 

Last updated: 22/12/15

5. What services are currently provided?

There are effective interventions which can improve the quality of life for patients with asthma and COPD. It is therefore important to monitor patients regularly and provide them with appropriate systematic support to self-manage the conditions and reduce complications.

Tees Respiratory Network
A Tees Respiratory Network comprising of commissioners, providers and public health has been established. It aims to promote good respiratory health through overseeing the development and implementation of evidence based guidelines and protocols and training for professionals; act as an advisory group to Clinical Commissioning Groups; and advocate effective self-management support for people with respiratory conditions.

The objectives of the network include:

  • To improve the respiratory health and well-being of all communities and minimise inequalities between communities.
  • To reduce the number of people who develop respiratory disease by ensuring that the public are aware of the importance of good lung health and well-being, with risk factors understood, avoided or minimised, and proactively address health inequalities.
  • To reduce the number of people with respiratory disease who die prematurely through a proactive approach to early identification, diagnosis and intervention, and proactive care and management at all stages of the disease, with a particular focus on the disadvantaged groups and areas with high prevalence.
  • To ensure that people with respiratory disease, across all social groups, receive safe and effective care, which minimises progression, enhances recovery and promotes independence.
  • To enhance quality of life for people with respiratory disease, across all social groups, with a positive, enabling, experience of care and support right through to the end of life.

Primary care
General practices maintain a register of people with asthma and COPD. They deliver day-to-day care to patients using locally developed and agreed shared care pathways. There are systems and processes in place to monitor and review patients annually. These activities are largely carried out by practice nurses.  Respiratory education and training activities are currently provided by commissioners, providers and Tees Respiratory Network to improve knowledge, skills and care provision.

Early detection of COPD - The Tees Lung Health Check Programme
The Tees Lung Health Check (LHC) programme was established in January 2013. It involves a face-to-face risk assessment aimed at people aged 35 years and over who are current smokers, and who are considered to be at risk of COPD but have not already received a diagnosis confirmed by quality-assured diagnostic spirometry.

Practices are provided with a list of eligible population and they send invites to them to attend check (may be opportunistically as patients attend surgery for other reasons). Patients are assessed and spirometry tests performed by appropriately trained practice staff. Practices are expected to prioritise for assessment those from the top 20% most deprived communities (list of patients provided) who are at greatest risk. Payment is made to practices for each check and an additional fee if patient live in the top 20% most deprived communities.

Significant progress has been made in implementing programme. Two and half years into programme 13.8% of the eligible population in Hartlepool have received a check (compared with an average of 15.7 % across Tees).

Community  Lung Health Check in Stop Smoking Service Pilot
The Stop Smoking Service is commissioned by Public Health to deliver smoking cessation advice and support on Teesside. With around 7000 smokers accessing services in Tees each year, the service has ready access to the population at high risk of developing COPD and well placed to carry out Lung Health Checks. We are therefore piloting the feasibility of quality assured Lung Health Checks in selected drop-in clinics in Hartlepool for a year. Another pilot in workplaces and suitable community venues in Redcar and Cleveland is being planned. Both pilots will inform how to implement community checks in Teesside.

Secondary and community services
The North Tees Community Respiratory Service is hosted by the North Tees and Hartlepool Hospitals Foundation Trust. This is facilitating increased access to early diagnosis, supported discharge, acute respiratory assessment and COPD complex case management services in the community.

Hospital at Home COPD service
An enhanced care service for patients with COPD is being developed in Hartlepool and Stockton. The service will provide a patient centred, nurse delivered and consultant led ‘hospital at home’ for patients with exacerbations of COPD. The team will aim to deliver a complete package of care for these patients, including appropriate acute and ongoing medications, inhaler technique review, smoking cessation advice, pulmonary rehabilitation referrals and written self- management plans for each patient. The service aims to reduce admissions and readmissions for patients with exacerbations of COPD, by providing a high quality, safe and effective acute service in the community. As the team develops, the scope will expand to include early supported discharge, and the development of pathways for other respiratory problems such as bronchiectasis.

Community Respiratory Assessment and Management Service
Respiratory staff are available to provide bespoke education sessions to groups of staff on an ad hoc basis. The team have delivered education to hospice staff and care home staff in Hartlepool about a variety of topics including self-management of COPD, drug and non-drug management of breathlessness in respiratory disease, inhaler technique, safe and appropriate oxygen use and how to identify the deteriorating patient.

Outreach service
There are COPD Outreach and Oxygen Assessment services with physiotherapy input for COPD patients operating from the University Hospital of North Tees. These services support both respiratory and other acute medical wards giving advice on early supported discharge and home oxygen requirements. COPD patients are followed up in their own homes after discharge.

Pulmonary rehabilitation
The Pulmonary Rehabilitation Service is run by a Senior Physiotherapist with classes for groups of patients with COPD. The service works with primary care on the End of Life Care Pathway (Gold Service Framework) to improve the quality and organisation of care for all patients nearing the end of life.

Self-management and self-care
Work continues to promote Rescue Packs and Care Plan to promote education and self-management for people with COPD across Tees.

There are educational activities to promote self-management for people with COPD. The Hartlepool and Stockton Clinical Commissioning Group has commissioned a number of voluntary and community organisations to provide people with long term conditions with the support they need to manage their conditions and improve quality of life.

Stop Smoking Service Lung Health Risk Assessments
The North Tees Stop Smoking Service added the lung health risk assessment as a standard addition to the Stop Smoking Service drop in assessments for smokers setting a quit date from end of May 2013 in Stockton and from early June 2013 in Hartlepool.  The assessment tool contains five risk factors, and people with three or more risk factors are considered to be at risk of developing COPD and referred via fax to their GP for full assessment. Patients are also asked to contact their GP practice if they are not contacted for an appointment within two weeks.

 

Last updated: 22/12/15

6. What is the projected level of need?

Modelled prevalence (taking into account age, sex, ethnicity, smoking status and deprivation) suggests that the number of people with COPD will continue to rise. The model suggests that the number of adults with COPD in Stockton will reach nearly 9,000 by 2020.

This has important resource implications, in terms of ensuring appropriate systems and processes are in place to identify and effectively manage the condition to reduce deaths and associated illness.

COPD projected prevalence, Stockton, to 2020

No projections for asthma are available.

 

Last updated: 22/12/15

7. What needs might be unmet?

The capacity and capability of current services to cope with the projected increase in the number of people with COPD, from a registered prevalence of 2.1% in 2010 to 5.4% in 2020.

There is low awareness of lung health and COPD in communities that are at high risk (for example current and ex-smokers and women).

Equitable access to high quality spirometry in primary care and community settings.

Inappropriate admissions imply unmet need for continuing care and education and support for patients.

Care process measures for asthma and COPD generally better in Stockton-On-Tees than the England average but emergency admission rates are higher; there is need to explore the reasons.

There is limited access in terms of capacity and location to supported self-management programmes based on Expert Patient evidence.

Patient support group especially for young people with asthma.

Many people with COPD don't have an end of life care plan.

 

Last updated: 22/12/15

8. What evidence is there for effective intervention?

Tees Respiratory Network (2014). Tees Chronic obstructive pulmonary disease treatment guidelines. Tees COPD and Asthma Pathways. Map of Medicine (This is only available to healthcare professionals).

Inhaler systems (devices) in children under the age of 5 years with chronic asthma. NICE Technological Appraisal 10 (2000: NHS Evidence accredited).

Inhaler devices for routine treatment of chronic asthma in older children (5-15 years). NICE Technological Appraisal 38 (2002: NHS Evidence accredited).

Corticosteroids for the treatment of chronic asthma in children under the age of 12 years. NICE Technological Appraisal 131 (2007: NHS Evidence accredited).

Omalizumab for severe persistent allergic asthma. NICE Technological Appraisal 133 (2007: NHS Evidence accredited).

Corticosteroids for the treatment of chronic asthma in adults and children aged 12 years and over. NICE Technological Appraisal 138 (2008: NHS Evidence accredited).

Omalizumab for the treatment of severe persistent allergic asthma in children aged 6-11. NICE Technological Appraisal 201 (2010: NHS Evidence accredited).

Chronic obstructive pulmonary disease (COPD) quality standard. (NICE)

Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. NICE clinical guideline 101 (2010; NHS Evidence accredited).

Commissioning services for people with COPD.  NICE commissioning guide (2011).

National Gold Standards Framework.

South Tees COPD and Asthma Pathways. Map of Medicine (This is only available to healthcare professionals).

South Tees Service Reviews for COPD and Asthma (2010).

 

Last updated: 22/12/15

9. What do people say?

There needs to be consultation with patients and engagement events with people with asthma and COPD to establish their needs. This remains an area of priority and work needs to be developed to explore how service users can be supported to engage effectively in the planning and delivery of services and performance monitoring.

More work needs to be done to identify issues for young people (older teenagers) with asthma.

 

Last updated: 22/12/15

10. What additional needs assessment is required?

A comprehensive assessment of the education and training needs for respiratory disease in primary care, including the management of asthma in children. Progress has been made in identifying training needs and these are being addressed.

Assess the local needs for asthma from patients’ perspectives.

Assess service and training needs for the management of asthma in children.

Audit of the quality of end of life care should be undertaken for all patients with severe COPD.

The high rates of emergency admissions require review. The HAST CCG has developed a number of initiatives to reduce admissions and the outcomes are being monitored.

 

Last updated: 22/12/15

Key contact

Name: Victoria Ononeze

Job title: Public Health Specialist

E-mail: victoria.ononeze@tees.nhs.uk

Phone number: 01642 745189

References

Local strategies and plans

 

North Tees COPD and Asthma Pathways. http://tees.mapofmedicine.com

 

National strategies and plans

 

Department of Health (2011). An Outcomes Strategy for people with chronic obstructive pulmonary disease (COPD) and asthma in England

Department of Health (2008). End of Life Care Strategy – promoting high quality care for all adults at the end of life
 

Other references

APHO Disease Prevalence Models

British Lung Foundation

NHS Indicator portal http://nww.indicators.ic.nhs.uk/webview/ (Access through NHS net only)

Department of Health (2010). NHS Outcomes Framework 2011/12.

NHS Choices (online). Chronic obstructive pulmonary disease

NICE (2011). Chronic obstructive pulmonary disease in adults. Quality Standard [QS10].