Welcome to Bedford Borough Council

 
Our Services A - Z :
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
 
 

Respiratory Health

Introduction

The Department of Health published ‘Living Well for Longer’, 2013, which is about reducing avoidable, premature deaths caused by the big killer diseases.  This includes lung disease.  ‘Premature death’ is under 75 years of age and it is intended that in England, premature death rates will become the lowest amongst our European peers.  It has been shown that we have a long way to go.

 

The Longer Lives website compares overall and specific disease premature deaths against similarly deprived local authorities.  It shows that Bedford Borough was ninth out of 15 for premature deaths caused by lung disease compared to similar councils and 63rd of 149 of local authorities overall (1 is the best, 2013-15).

 

Influenza, pneumonia and COPD are the main reason for emergency admissions in the over 65s for ambulatory care sensitive conditions.  These are conditions for which it is possible to prevent acute exacerbations and reduce the need for hospital admission through active management, such as vaccination; better self-management, disease management or case management; or lifestyle interventions.

 

There are two main conditions affecting the respiratory tract: Chronic Obstructive Pulmonary Disease and Asthma.

 

Chronic Obstructive Pulmonary Disease

 

Chronic Obstructive Pulmonary Disease (COPD) is an umbrella term that includes chronic bronchitis and emphysema.  It is characterised clinically by airflow obstruction and is usually progressive, not fully reversible and does not change markedly over several months.  This disease is predominantly caused by smoking and the prevalence is strongly associated with age.  However, other factors, such as occupational exposures, may also contribute to the development of COPD.

 

Facts, Figures and Trends


Numbers of people affected by COPD

National Picture

  •  An estimated 3 million people have COPD in the UK and, of those, 2 million remain undiagnosed - mainly those with milder symptoms
  • COPD is estimated to be the fifth largest cause of death in the UK.  It causes 25,000 deaths per year
  • COPD website including numbers of people diagnosed with COPD, deaths from COPD and emergency hospital admissions
  • COPD is often associated with other long-term conditions; 40% of people with COPD also have heart disease and significant numbers have depression and/or an anxiety disorder
  • Smoking is the main cause of COPD and is thought to be responsible for around 90% of cases.  The lining of the airways becomes inflamed and permanently damaged by smoking and this damage cannot be reversed.
  • Fumes and dust- exposure to certain types of dust and chemicals at work, including grains, isocyanates, cadmium and coal, has been linked to the development of COPD, even in people who do not smoke.  The risk of COPD is even higher if you breathe in dust or fumes in the workplace and you smoke
  • Air pollution- according to research, air pollution may be an additional risk factor for COPD.  However, at the moment it is not conclusive

 

Local Picture


 

The prevalence of COPD in Bedford Borough was 2,490 (1.4%) and Bedfordshire CCG was 466,465 (1.6%) in 2015/16, an increase since 2010/11 (Figure 1).  This is mainly due to the population ageing as COPD is strongly associated with age.  The prevalence of COPD over the next 3-5 years in Bedford Borough and nationally are forecast to show a slow increase of about 0.05% per year.

Figure 1  Percentage of Practice Populations on register for COPD, trend 2010/11-2015/16

Respiratory
Source: QOF, 2016

 

NHS RightCare Commissioning for Value- respiratory focus pack compares Bedfordshire CCG with the best five of 10 similar CCGs for a number of indicators.  Amongst these are:

  • COPD patients who have had flu immunisation (2014/15, p57)
  • Bedfordshire CCG was statistically significantly better than the best five
  • COPD patients with a record of FeV1in the preceding year (2014/15, p59)
  • Bedfordshire CCG was statistically significantly worse than the best five

 

Local Bedford Borough’s figures were, QOF, 2015/16:

  • 75.4% patients with COPD had the FeV1 checked in the previous 12 months; this proportion was higher to that of Bedfordshire CCG (73.4%) and England (72.1%)
  • 82.3% COPD patients had vaccination against seasonal flu; this proportion was higher than that of Bedfordshire CCG (82.9%) and England (79.9%)
  • 78.9% of known COPD patients had a review within the preceding 12 months; this figure was similar to Bedfordshire CCG (78.9%) and slightly lower than England (79.3%)

 

Figure 2 shows the directly age-standardised mortality rate (DSR) for COPD in Bedford Borough.  The mortality rate for males was higher than females, though the gap between them has reduced over time as the smoking prevalence decreases.  Women mortality rates were lower compared to England and male rate is roughly the same over the time period.

 

Figure 2  All age mortality rates for bronchitis, emphysema and chronic obstructive pulmonary disease in Bedford Borough by sex and year (Directly standardised)


Respiratory

 

Respiratory

Source: NHS Digital, 2016

Figure 3 shows COPD premature deaths (up to age 75 years) in males and females.  Premature deaths among females in Bedford Borough were lower for men and women compared with England but not significantly.

Figure 3  Premature deaths from bronchitis, emphysema and other COPD (DSR, pooled data), 2012-14

 
Respiratory

 

Figure 4 shows mortality rates of COPD by age and sex.  The majority of deaths were in the over 75 year age group; few were recorded in the 0-34 year age group.

 

Figure 4: Age specific death rates from bronchitis, emphysema and other COPD (pooled 2012-14)

Respiratory

 

Source: NHS Digital, 2016

 

Years of Life Lost (YLL) measures the number of years a person would have lived if they had not died prematurely at an age of less than 75 years.  Figure 5 shows years of life lost due to COPD premature death.  Bedford Borough figures were significantly lower than England for males but not significantly higher than England for females.

Figure 5  Years of life lost due to mortality from bronchitis, emphysema and other COPD, 2012-14 (pooled) to the age of 75y

Respiratory

Source: NHS Digital, 2016

 

The proportion of COPD patients that are registered and the mortality rates at Bedford Borough appear favourable compared to England.  However, some management indicators for COPD (Bedfordshire CCG) and premature mortality rates for lung disease (Bedford Borough) are worse than average when compared with similar local authorities (9th out of 15).

 

Asthma

Asthma is a chronic inflammatory disorder of the airways with reversible airway obstruction.  There is an increase in airway resistance to certain triggers, for example animal hairs, exercise and cold air.  Obstruction is usually reversible spontaneously or with treatment.  In England, 5.9% of adults had asthma in 2015/16.

 

Figure 6: Registered Asthma Patients, 2015/16

Respiratory

Source: QOF, 2015/16

 

It is difficult to define what constitutes asthma.  However, most studies think that there has been an increase in the prevalence of asthma in the UK since 1991, possibly with a reduction in children in recent years.

 

NHS RightCare Commissioning for Value- respiratory focus pack (2016) compares Bedfordshire CCG with the best five of 10 similar CCGs for a number of indicators.  Amongst these are


  • Emergency admissions by children (p51) Statistically significantly higher than the best 5
  • Asthma patients who have had a review (p61) Statistically significantly better than the best 5

 

Local Bedford Borough’s figures were, 2015/16:

  • 70.6% patients with asthma had an asthma review in the preceding 12 months that includes an assessment of asthma control; this proportion was lower to that of Bedfordshire CCG (71.3%) but higher than England (69.6%)

 

Figure 7  The percentage of patients with asthma who have had an asthma review in the previous 12 months that includes an assessment of asthma control

Respiratory

As asthma deaths are unusual, it is only with a big geographic area it can be seen that it has decreased although since 2009 the decrease may have become less, see Figure 8.

 

Figure 8  Asthma mortality in England, directly standardised, 1995-2014

Respiratory

 

Source: NHS Digital, 2016

 

Psychological conditions such as anxiety and depression may be up to six times more common in people with asthma than in the general population; depression may be present in 14% to 41% of those with asthma

 

Current programmes & pathways

COPD

  • COPD is mainly primary-care led and a community team service giving flexible provision.  Smoking cessation with patients who have COPD as part of their treatment is part of the contract with Bedford Hospital and Luton and Dunstable Hospital (L&D)
  • The Acute Respiratory Assessment Service (ARAS) was set up in April 2012 to provide a facility where GPs and Community Matrons can refer patients who experience a flare up of their COPD
  • Stop smoking with pharmacotherapy is a cost effective treatment at £2,000 per QALY
  • Although Community Matrons have a role in informal admission avoidance for exacerbations, there is no specialist service available
  • Breathe Easy support group helps patients self-manage
  • Public Health England has produced a web-tool called Inhale which brings together much of the information discussed here, both for COPD and asthma
  • Service for home oxygen assessment and pulmonary rehab

 

Asthma

  • GP diagnose most of the asthma cases and largely manage the patients within the practice with the help of a practice nurse
  • An asthma treatment pathway has been produced, both for adults and children and young people aged 5-12, which includes Bedfordshire CCG Medicine Formulary recommendations.  This is to comply with British Thoracic Society and SIGN guidelines on asthma in which a stepwise approach to asthma treatment is advised
  • Bedford Hospital and Luton & Dunstable Hospital see patients with uncontrolled asthma and either Addenbrooke’s Hospital or the Royal Brompton Hospital for specialist asthma
  • The patients have a self-management tool on leaving hospital

 

 

 

 

What do we know?

Facts, Figures, Trends

 

In Bedford Borough there were 11,535 patients and Bedfordshire CCG there were 30,049 registered with their GPs who had been prescribed an asthma medication within the previous 12 months, 2015/16, see Figure 6

 

 

Harm caused by asthma

  • Figure7 shows a time-line of indirectly age and sex standardised asthma emergency hospital admission rates for children up to 16 years.  For the past nine years rates in Bedford Borough have been similar to the national rate.- 
 

Figure 7  Emergency hospital admissions: children with asthma, 2003/4-2012/13

 

 

Source: Health and Social Care Imnofrmation Centre, 2015

Projected future position if no action taken & Scope for improvement

  • As asthma deaths are unusual, it is only iwth a big geographic area it can be seen that it has decreased , although since 2009 the decrease may have become less (England - see Figure 8)

 

Figure 8: Asthma Standardised mortality in England, 1995-2013

Resp9a

 

Source:  Health and Social Care Inofrmation Centre, 2015

Psychological conditions such as anxiety and depression may be up to six times more common in people with asthma than in the general population (Thomaset all, 2011),  depression may be present in between 14 to 41% of those with asthma.

 

Current activity and services

COPD

COPD is mainly primary-care led and a community team service giving flexible provision.  Smoking cessation with patients who have COPD as part of their treatment is part of the contract with Bedford Hospital and Luton and Dunstable Hospital (L&D)

The Acute Respiratory Assessment Service (ARAS) was set up in April 2012 to provide a facility where GPs and Community Matrons can refer patients who experience a flare up of their COPD

Stop smoking with pharmacotherapy is a cost effective treatment at £2,000 per QALY

Although Community Matrons have a role in informal admission avoidance for exacerbations, there is no specialist service available

Breathe Easy support group helps patients self-manage

Public Health England has produced a web-tool called Inhale which brings together much of the information discussed here, both for COPD and asthma

Service for home oxygen assessment and pulmonary rehab

 

Asthma
 

GP diagnose most of the asthma cases and largely manage the patients within the practice with the help of a practice nurse

An asthma treatment pathway has been produced, both for adults and children and young people aged 5-12, which includes Bedfordshire CCG Medicine Formulary recommendations.  This is to comply with British Thoracic Society and SIGN guidelines on asthma in which a stepwise approach to asthma treatment is advised

Bedford Hospital and Luton & Dunstable Hospital see patients with uncontrolled asthma and either Addenbrooke’s Hospital or the Royal Brompton Hospital for specialist asthma

The patients have a self-management tool on leaving hospital.

 

Local views

 COPD

A mapping event took place in January 2010 and there were patient and third sector representatives there.  They contributed fully to the event and the priorities that came out included:

  • Education both for Health Care Professionals and patients
  • Communication across all agencies including links with social care, intermediate care and out of hours
  • Pulmonary Rehab, including patients that are hard to reach, and personal health plans

 

Impact & effectiveness

Respiratory focus pack for NHS Bedfordshire CCG is produced by RightCare.  It is an in-depth look at our spend, activity, quality and outcomes.

 

National and Local Strategies

Scope for Improvement

COPD

o   Opportunistically testing by primary care: late diagnosis has a substantial impact on symptom control, quality of life, clinical outcome and cost because undiagnosed people receive inappropriate or inadequate treatment.  NICE has estimated the costs and benefits of opportunistically testing smokers or ex-smokers who present at the GP with a chronic cough.  It found that opportunistically testing increased the life-time cost by £35.49 more than not testing and that the cost per QALY(Quality Adjusted Life Year) was £814.56.  This was a crude calculation and the model is quite sensitive to some of the parameters and assumptions.  All costs are for the year 2000/01

o   Exacerbations: Long-Acting Muscarinic Antagonists (LAMA) or Long-Acting β-Agonists together with Inhaled Corticosteroids (LABA+ICS) were found to be the most cost-effective strategy.  The results indicate fairly low uncertainty within individual analyses.  However, the fact that between analyses there is a disagreement about the most cost-effective option indicates considerable uncertainty based on the available clinical evidence

o   O2 assessment: one study studied a cost minimization analysis of providing oxygen by concentrator or cylinder in the home (Heaney et al, 2009).  Their conclusion is that as long as more than three cylinders a month are being used, independent of flow rate or duration of prescription, it is always to cheaper to prescribe a concentrator

o   Pulmonary rehabilitation: two studies estimated the cost effectiveness in the UK.  The cost per QALY was estimated at between £2,000 and £8,000 based on a minimum of four weeks rehabilitations(Wessex Institute, 2009).   Griffiths et al(2001)  undertook an economic evaluation alongside a clinical trial and estimated that pulmonary rehabilitation was cost saving and increased quality of life compared to usual care

o   NICE advises against routinely using mucolytic drugs to prevent exacerbations in people with stable COPD, and anti cough therapy for the management of stable COPD

 

In January 2015, NHS England published three new handbooks to support commissioners and practitioners in planning services for people with long term conditions (LTCs), in order to achieve more effective, personalised care for this group.  They are case finding and risk stratification, personalised care and support planning and multi-disciplinary team (MDT) working http://www.england.nhs.uk/resources/resources-for-ccgs/out-frwrk/dom-2/ltc-care/

 


Asthma

Recently, the Scottish Intercollegiate Guidelines Network published a document on the management of asthma (SIGN 153, 2016)

 

What are the key inequalities?

COPD is predominantly caused by smoking hence the main key inequalities are the same for smoking.  Smoking has a higher prevalence in deprived communities (see chapter on ‘Tobacco Control’)

Deprived populations have the highest prevalence and the highest under-diagnosis of COPD.  In the Segment Tool (Chart 5) the major cause of the life expectancy gap between the most and least deprived was 26% in men and 17% in females, 2012-14. 

Nationally, there are ethnic disparities with black men in deprived urban areas having particularly high risk

 

 

Recommendations

Bedfordshire CCG is currently reviewing all clinical pathways, using a RightCare approach, and the review will not be complete until early/mid 2017.  At this point, a full analysis of service provision, gaps and service needs will be summarised and shared with system partners.

 

 

Back to top

 

To download a PDF version of this chapter, please click here