Halton Joint Strategic Needs Assessment 2015/16. Long-term conditions: Respiratory Disease. 1 P a g e

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1 Halton Joint Strategic Needs Assessment 2015/16 Long-term conditions: Respiratory Disease 1 P a g e

2 Respiratory Disease 2015/16 Reader information Author Sharon McAteer Contributors Sarah Johnson-Griffiths Jennifer Oultram Reviewer Sarah Johnson-Griffiths Number of pages 71 Date release March 2016 Description The document describes the policy context, estimated prevalence, risk factors and sub-groups of need, current service provision and national best practice in relation to (topic) amongst (if chapter only covers certain parts of the population add this here) in Halton. Contact Related documents Halton Respiratory Strategy 2015/16 JSNA Tobacco Control 2015/16 JSNA Healthy Weight Please quote the JSNA We would like to know when and how the JSNA is being used. One way, is to ask people who use the JSNA when developing strategies, service reviews and other work to quote the JSNA as their source of information. 2 P a g e

3 Halton Joint Strategic Needs Assessment 2015/16 List of Abbreviations AOT AQMA BLF BME BMI BTS CCG COMEAP COPD DALY DLA EIA GP HSCIC HSE ILD JSNA MRC NHS NICE NIV NRAD ONS OSA PCV PHE PHOF PPV QOF SPOT SUS TB Ambulatory oxygen therapy Air Quality Management Areas British Lung Foundation Black & Minority Ethnic Body Mass Index British Thoracic Society Clinical Commissioning Group The Committee on Medical Effects of Air Pollution Chronic Obstructive Pulmonary Disease Disability adjusted life years Disability Living Allowance Equality Impact Assessment General Practitioner Health and Social Care Information Centre Health Survey for England Interstitial lung disease Joint Strategic Needs Assessment Medical Research Council National Health Service National Institute for Health and Clinical Excellence Non-invasive ventilation National Review of Asthma Deaths Office for National Statistics Obstructive sleep apnoea Pneumoccocal conjugate vaccine Public Health England Public Health Outcomes Framework Pneomoccocal polysaccharide vaccine Quality Outcomes Framework Spend and Outcomes Tool Secondary user system Tuberculosis 3 P a g e

4 Respiratory Disease 2015/16 Contents Key findings Introduction Policy Context Level of need in the population Risk factors Smoking Housing Environmental indoor and outdoor Indoor environment Outdoor environment Occupational risk Genetic Obesity Protected characteristics Age Gender Ethnicity Marital status Religion and Beliefs Sexual Orientation Disability Pregnancy Gender reassignment Other vulnerable groups People with Learning Disabilities Migrants, Asylum Seekers and Refugees Homeless People Drug Users People Living in Care Homes Social class Prevalence of respiratory diseases National prevalence P a g e

5 Halton Joint Strategic Needs Assessment 2015/ Estimated local prevalence Known local prevalence Estimates versus known prevalence Service provision Prevention and promotion Smoking prevention Adult Stop Smoking Service Primary Care: Prevention of infectious respiratory conditions: Influenza and Pneumococcal Vaccination programmes Management of people with respiratory disease: QOF performance Secondary Care: hospital admissions Overall admissions due to respiratory disease Asthma Bronchiectasis Bronchiolitis COPD Interstitial Lung Disease Pneumonia Other respiratory conditions Community Care: Halton Rapid Response Respiratory Team Oxygen Therapy Integrated Breathe Easy Project Pulmonary rehabilitation Impacts of respiratory disease Financial impact on the NHS Programme Budgeting Spend Versus Outcomes: The Spend and Outcome Tool (SPOT) To wider society including the economy Morbidity and Disability Mortality Projected levels of need User views P a g e

6 Respiratory Disease 2015/16 8. Best practice interventions References Figures Figure 1: Excess Winter Mortality Index, by cause of death, Halton 2009/10 to 2014/ Figure 2: QOF asthma prevalence 2014/15, Halton practices, CCG average and comparators Figure 3: QOF COPD prevalence 2014/15, Halton practices, CCG average and comparators Figure 4: Influenza uptake in people aged 65+, 2014/ Figure 5: Influenza uptake in all pregnant women, 2014/ Figure 6: Influenza uptake in children aged 2, 2014/ Figure 7: Influenza uptake in children aged 3, 2014/ Figure 8: Influenza uptake in children aged 4, 2014/ Figure 9: Influenza uptake in people aged under 65 years in an at-risk group, 2014/ Figure 10: Influenza uptake in people aged under 65 with Chronic Respiratory Disease, 2014/ Figure 11: Emergency admissions due to asthma, by age group and gender, 2011/12 to 2013/ Figure 12: Emergency admissions due to asthma, by electoral ward, all ages, 2011/12 to 2013/ Figure 13: Emergency admissions due to asthma amongst 0-18 year olds, by electoral ward, 2011/12 to 2013/ Figure 14: Admissions where bronchiectasis is present, by age and gender Figure 15: Admissions where bronchiectasis is present, by electoral ward, 2009/ Figure 16: Emergency admissions due to COPD, by age and gender, 2011/12 to 2013/ Figure 17: Emergency admissions due to COPD, by electoral ward, 2011/12 to 2013/ Figure 18: Relationship between emergency admissions due to COPD and average regional temperature, 2012/ Figure 19: Admissions where Interstitial Lung Diseases was present, by age and gender2011/12 to 2013/ Figure 20: Emergency admissions due to pneumonia, by age and gender, 2011/12 to 2013/ Figure 21: Emergency admissions due to pneumonia amongst those aged 18 and over, by electoral ward Figure 22: Admissions due to pneumonia in Halton and average regional monthly temperature, 2013/ Figure 23: Correlation between monthly admissions for pneumonia and average regional temperature, 2011/12 to 2013/ Figure 24: Admissions where sleep apnoea was present, by age and gender, 2011/12 to 2013/ Figure 25: Admissions where sleep apnoea was present, by electoral ward, 2011/12 to 2013/ Figure 26: Programme Budgeting Expenditure Comparison across Main Programme Budgeting Categories, NHS Halton CCG, 2013/ Figure 27: Expenditure on respiratory disease, percentage splits across care settings, NHS Halton CCG compared to England average, 2013/ Figure 28: All CCG expenditure for respiratory disease, per 100,000 population, 2013/ Figure 29: SPOT quadrant analysis Figure 30: SPOT: Programme spine chart for respiratory disease, Halton CCG, Figure 31: Disability Adjusted Life Years lost in Halton, by disease/condition group Figure 32: Directed age-standardised rate of mortality from respiratory disease in persons less than 75 years per 100,000 population, 2001/03 to 2012/ Figure 33: Directed age-standardised rate of mortality from respiratory disease, males and females aged less than 75 years, per 100,000 population, 2001/03 to 2012/ P a g e

7 Halton Joint Strategic Needs Assessment 2015/16 Tables Table 1: The COPD and Asthma Outcomes Strategy six policy objectives Table 2: National Outcome Framework indicators Table 3: Prevalence of self-reported long-term respiratory illness in adults, by sex and age. Great Britain, Table 4: Self-reported doctor-diagnosed COPD by age and gender, 2010 Health Survey for England Table 5: Estimated prevalence of COPD amongst adults, by gender and ethnicity, Table 6: Estimated prevalence of COPD amongst adults, by age group, Table 7: Estimated prevalence of asthma, by age group and gender, Table 8: Observed prevalence of asthma in Halton GP registered patients, 2004/05 to 2014/ Table 9: Observed prevalence of COPD in Halton GP registered patients, 2004/05 to 2014/ Table 10: Asthma estimated and observed prevalence, 2014/ Table 11: COPD estimates and observed prevalence, 2014/ Table 12: Pneumococcal Conjugate Vaccination (PCV), primary and booster vaccination in childhood, 2014/ Table 13: Pneumococcal Immunisation Vaccine Coverage Monitoring Programme, PPV coverage (%) in 65 years and over broken down by age group (cumulative data up to end of 31st March 2015) Table 14: Pneumococcal Immunisation Vaccine Coverage Monitoring Programme, PPV coverage (%) in 65 years and over, Halton CCG (cumulative data up to end of 31st March 2015) Table 15: 2014/15 QOF asthma management indicators Table 16: Percentage of eligible patients receiving asthma management interventions, Halton and comparators, 2014/ Table 17: 2014/15 QOF COPD management indicators Table 18: Percentage of eligible patients receiving COPD management interventions, Halton and comparators, 2014/ Table 19: Number of admissions due to bronchiectasis, elective and emergency, 2011/12 to 2013/ Table 20 : Number of admissions where ILD was present, by year Table 21: Admissions for Asbestosis amongst those aged 60 and over, 2011/12 to 2013/ Table 22: Estimated expenditure splits across care settings, respiratory disease, expenditure per 100,000 population and percentage of total spend, NHS Halton CCG, 2013/ P a g e

8 Risk Factors Respiratory Disease 2015/16 Key findings Priority Recommendation Description Close the gap between Smoking remains the single most important overall prevalence of preventable cause of respiratory disease smoking and amongst Adult smoking prevalence has fallen in Halton over those in routine & recent years. However, data from the lifestyles survey manual occupations suggests it may be higher than given in the national /those living in areas of health profiles Smoking deprivation Both sources of smoking prevalence point to the gap Smoking cessation for between routine and manual workers/ those living in both parents during and areas of deprivation and the overall population after pregnancy and for prevalence rates those asthma or COPD, Passive smoking in the home poses a particular risk to including those with the respiratory health of children. learning disabilities Warm Homes Obesity Prevalence Care home residents Increase efforts to ensure those at risk have warm homes Increase awareness amongst professionals and the public of the additional risk to respiratory health during the winter months Continue efforts to reduce child and adult obesity levels especially amongst those: in middle and older age groups with long-term conditions with learning disabilities Ensure high uptake of influenza vaccination amongst residents and staff and pneumococcal vaccination amongst residents Ensure case findings continue to continue to reduce the gap between the estimated and observed prevalence of COPD Respiratory disease is a significant contributor to excess winter deaths. In England it accounts for the second highest proportion of excess winter deaths. In Halton it is generally accounts for the highest single proportion Hospital admissions for COPD and pneumonia are higher during the winter months and early spring and show a clear relationship with falling outdoor air temperatures. This underlines the importance of being able to keep homes warm and free from damp and mould and have energy efficient homes Obesity can have a negative impact on the respiratory system, including on sleep apnoea, COPD and asthma Halton has high early childhood obesity levels (as measured during Reception Year) as well as adult overweight and obesity levels. Adult levels increase with age, being highest in middle age and also high in older age Rates of respiratory disease such as influenza and pneumonia are higher amongst care home residents than amongst older people living in the community Influenza and pneumococcal vaccination uptake rates are not known for this population, nor amongst staff providing direct care. However, overall over-65 uptake rates do not meet the 75% targets Death rates due to respiratory disease in the UK are the second highest in Europe Asthma has become more common over the last 30 years The estimated prevalence of COPD is lower in Halton than for England Observed prevalence rates for asthma and COPD are higher in Halton than the North West and England. This may be due to more vigilant case finding, as estimates suggest the prevalence rate is lower locally than nationally. This means about 90% of those estimated to have COPD have a diagnosis and about 74% of those with asthma do 8 P a g e

9 Service provision Halton Joint Strategic Needs Assessment 2015/16 Immunisations Reduce variation in uptake at GP practice level Increase efforts to achieve uptake to 75% target overall and across all GP practices Overall, Halton does not meet the 75% national target for influenza vaccination. Uptake is higher for 65+ population than for those under 65 in at risk groups For the 65+ age group, some practices do reach the 75% target although there is wide practice level variation Vaccination uptake amongst those under 65 with chronic respiratory conditions ranges from 37.3% to 64.1% at GP practice level, with the CCG average being 51.5%. This means that not only is the CCG average significantly below the national target but also than no practice reaches it Pneumococcal vaccination rates in children are higher than comparators, including the England average However, uptake amongst 65+ year olds is lower than the Merseyside average (but similar to the England average) The CCG average uptake rate is 70.8%, some way off the 75% target. At GP practice level it varies from 56.2% to 85% Primary Care Reduce practice level variation on management of those with asthma and COPD Asthma and COPD management against evidence-based interventions is overall similar to comparators As with vaccinations, there are practice level variations. In some cases this means around a third of eligible patients do not receive evidence-based interventions to manage their condition Hospital admissions Assess the extent to which Halton is meeting NICE guidance on the management of children with bronchiolitis Assess if the increase in emergency admissions due to ILD is as a result of increasing prevalence Assess if local community and primary care management and services achieve quality standards to prevent emergency admissions Asthma admissions are highest in 0-4 and 5-9 year olds. For women, they are also high amongst those aged 70 to 84 Asthma admission rates are also much higher in some wards than others For both all ages and amongst 0-18 year olds asthma admissions rates are highest in Windmill Hill, Norton South and Hough Green wards There has been a steady rise in the number of emergency admissions for bronchiectasis and interstitial lung disease over recent years. Rates are low until age 60 and are higher for males than females 79% of admissions due to lower respiratory tract infections are amongst those aged less than 1 year. Whilst there is ward level variation, there is no correlation with either deprivation or lifestyle factors. This may indicate a possible link with management in primary care COPD admissions rates rise from age 60 and are highest amongst the age group for both men and women. Admission rates are generally higher in the more deprived wards and lower in the least deprived ones. They also rise during the colder months, with levels highest in January The winter pattern is also seen in admissions due to pneumonia, where rates are highest in the 85+ age group 9 P a g e

10 Respiratory Disease 2015/16 Impacts Respiratory disease accounts for the fourth highest spend for Halton CCG during 2013/14. A third of the spend was on prescribing and a third on emergency admissions. Spend on prescribing in Halton was higher than the England level but generally the split across care settings was similar With a spend of just over 7.56million per 100,000 population, Halton was in the fourth highest spending quintile nationally, higher than the England level of 7.1 million per 100,000 population and the CCG cluster average of 7.49 million Halton was in the high spend, worse outcomes quadrant due to higher emergency admissions and mortality rates. As a result of these outcomes, respiratory disease accounts for the fourth highest disability adjusted life years lost, although the level was much lower than for mental health, cardiovascular disease and cancers 10 P a g e

11 Halton Joint Strategic Needs Assessment 2015/16 1. Introduction The World Health Organisation defines respiratory diseases as diseases that affect the air passages, including the nasal passages, the bronchi and the lungs. They range from acute infections, such as pneumonia and bronchitis, to chronic conditions such as asthma and chronic obstructive pulmonary disease. The UK has the second highest death rate in Europe from respiratory diseases [1] Evidence shows asthma has become more common over the last 30 years possibly as a result of our changing lifestyles, homes with central heating and fitted carpets with little ventilation and diets with fewer fresh foods. A European Commission survey [2] reported that 13% of people over the age of 15 years in the UK have had asthma at some point in their lives. Asthma UK reports there are 5.4 million people in Britain currently receiving treatment for the condition, 1.1 million children and 4.3 million adults. [3] Respiratory disease has a substantial impact on population health at all ages and levels of ill health (morbidity). The major risk factor for developing many respiratory diseases is smoking or exposure to tobacco smoke. Socioeconomic factors such as poor diet, poor housing conditions, and fuel poverty contribute to the incidence of respiratory diseases and exacerbate these conditions. Other factors such as work-related conditions and exposure to outdoor air pollution also play a role in the development and exacerbation of respiratory disease. Respiratory diseases reduce life expectancy and have a negative effect on healthy life expectancy and levels of morbidity. It is estimated that one third of the UK population attend their GP at least once a year for respiratory conditions. This makes respiratory conditions the most common reason for GP consultation and the second most common reason for emergency admissions to hospital. Asthma alone cost the NHS 890 million a year in 2006, despite 75% of asthma admissions being avoidable through high quality routine care. The savings from this are estimated to be 43 million per year. The total burden to both the NHS and society from respiratory disease is about 6.6 billion per year. This is broken down into 3 billion in care system costs, 1.7 billion in illness costs, and 1.9 billion in mortality costs. [4] Chronic obstructive pulmonary disease (COPD) results from lung damage that is gradual in onset and that result in progressive airflow limitation. This lung damage, when fully established, is irreversible and, if it is not identified and treated early, leads to disability and eventually death. COPD predominantly affects adults over the age of forty years with a history of smoking. Other factors include workplace exposure, genetic make-up and general environmental pollution. The main symptoms of COPD are shortness of breath and reduced capacity to exercise, together with a cough and production of phlegm, which may get worse in winter. COPD is a progressive illness, and the likelihood of people dying as a result of COPD increases with age. It is not curable, but it is treatable. Its progress can be halted and can be managed to minimise the burden it imposes. It remains the fifth most common cause of death in England and Wales, accounting for more than 28,000 deaths in 2005 and is the second largest cause of emergency admission in the UK, with one in eight (13,000) emergency admissions to hospital as a result of COPD. One fifth (21%) of bed days used for respiratory disease treatment are due to chronic obstructive lung disease, such that COPD accounts for more than one million 'bed days' each year in hospitals in the UK. [5] 11 P a g e

12 Respiratory Disease 2015/16 Asthma is a long-term condition that affects the airways in the lungs. Symptoms include breathlessness, tightness in the chest, coughing and wheezing. Patients with asthma have sensitive airways which can become irritated. The airways narrow and can produce too much mucus, making it difficult to breathe. The aim of asthma treatment is to achieve freedom from symptoms. The causes of asthma are not well understood, so primary prevention of asthma is not currently possible. The benefits of prompt diagnosis of lung disease are significant, particularly in such conditions as asthma, COPD, sleep-disordered breathing, occupational lung diseases and a wide range of interstitial lung diseases. There is a need for greater public awareness of the symptoms of such lung diseases, of the risks posed by smoking and by any delay in diagnosing smoking-related lung conditions such as lung cancer and COPD. A number of other respiratory conditions are also covered briefly in this report: Asbestosis Bronchietasis Bronchiolitis and lower respiratory tract infection in children Interstitial lung disease Pneumonia Obstructive sleep apnoea The report does not include analysis of lung cancer as this is already covered in the JSNA cancer profile. There are also separate chapters on tobacco and weight management so these are only covered briefly in this report. 12 P a g e

13 2. Policy Context The National Outcomes Strategy for COPD & Asthma Halton Joint Strategic Needs Assessment 2015/16 Asthma and COPD are key indicators for both the NHS and public health so both services will need to work together, along with social care services, to achieve the best possible results and improved outcomes for sufferers. The 2011 national COPD and asthma outcomes strategy [6] areas for action in public health and prevention are: developing prevention strategies for respiratory disease raising awareness of good lung health persuading the public to take lung health seriously ensuring employers (particularly those in at risk environment) are doing all they can to protect staff and encourage good lung health empowering partners/communities to support the process of encouraging prevention Table 1: The COPD and Asthma Outcomes Strategy six policy objectives Objective 1 To improve the respiratory health and well-being of all communities and minimise inequalities between communities. Objective 2 To reduce the number of people who develop COPD by ensuring they are aware of the importance of good lung health and well-being, with risk factors understood, avoided or minimised, and proactively address health inequalities. Objective 3 Objective 4 Objective 5 Objective 6 To reduce the number of people with COPD 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 enhance quality of life for people with COPD, across all social groups, with a positive, enabling, experience of care and support right through to the end of life. To ensure that people with COPD, across all social groups, receive safe and effective care, which minimises progression, enhances recovery and promotes independence. To ensure that people with asthma, across all social groups, are free of symptoms because of prompt and accurate diagnosis, shared decision making regarding treatment, and ongoing support as they self manage their own condition to reduce need for unscheduled health care and risk of death. The National Outcome Frameworks for the NHS, Adult Social Care & Public Health Since 2010, the Department of Health has published three outcomes frameworks, one for each part of the health and care system. The outcomes frameworks for Public Health, Adult Social Care and the NHS are intended to provide a focus for action and improvement across the system. Each of the outcomes frameworks has a number of domains which cover, at a high level, the main areas where the government would like to see improvement. In turn, these domains are supported by more detailed indicators to enable progress in improving outcomes to be tracked. 13 P a g e

14 Respiratory Disease 2015/16 The aligned and complementary nature of these outcomes frameworks ensures that local partners across the health and care system identify common ground, providing the basis for more integrated working locally. With regards to respiratory health the key indicators across all three national outcome frameworks are: Table 2: National Outcome Framework indicators National Indicator NHS Adult Social Care Public Health Reducing the under 75 mortality rate from respiratory disease Proportion of people feeling supported to manage their 2.1 condition Employment of people with long term conditions 2.2 1E 1.8 Unplanned hospitalisation for chronic ambulatory case 2.3 sensitive conditions Health related quality of life for carers 2.4 1D Emergency re-admissions within 30 days of discharge from hospital 3.b 4.11 Proportion of older people (65 and over), who were still at 3.6 2B home 91 days after discharge from hospital into reablement/rehabilitation service Bereaved carer s views on the quality of care in the last months of life. Social care related quality of life. 2 1A Proportion of people who use services who have control over their daily life 1B Proportion of people who use services and their carers, who 1I 1.18 reported they had as much social contact as they would like Permanent admissions to residential and nursing care homes 2A per 100,000 population Delayed transfers of care from hospital and those which are 2C attributable to social care Overall satisfaction of carers with social services 3B The proportion of carers who report that they have been 3C included or consulted in discussions about the person they care for. The proportion of people who use services and carers who find 3D it easy to find information about support. Fuel poverty 1.17 Smoking prevalence (adults over 18) 2.14 Population vaccination coverage 3.3 Health related quality of life for older people 4.13 Excess winter deaths 4.15 The Better Care Fund The creation of the Better Care Fund, a single pooled budget for health and social care services to work more closely together in local areas, based on a plan agreed between the NHS and local authorities, offers a substantial opportunity to bring resources together to address immediate pressures on services and lay foundations for a much more integrated system of health and care. The Better Care Fund has been implemented in the context of an ageing population and an increasing number of people who have one or more long-term conditions. These two factors mean 14 P a g e

15 Halton Joint Strategic Needs Assessment 2015/16 that the needs of patients and service users increasingly cut across multiple health and social care services. Increasing demand and financial pressures mean there is a need to focus on prevention, reducing the demand for services and making the most efficient and effective use of health and social care resources. Currently, 58% of people aged over 60 have a long-term condition and people in the poorest social class have a 60% higher prevalence than those in the most affluent social class. By 2018, the number of people with three or more long-term conditions is expected to rise to 2.9 million; in 2008 this figure stood at 1.9 million. [7] The national metrics for how well the Better Care Fund is being used to develop integrated care will be: admissions to residential and care homes effectiveness of reablement delayed transfers of care total emergency admissions patient/service user experience. Halton s Better Care Fund plan identifies 4 key strategic aims: Health and Wellbeing of individuals in the community Supporting independence Managing Complex Care and Care Closer to Home Integrated Commissioning Delivery of these aims in Halton will be based upon: Providing access to good quality information Promoting health and active lifestyles Identifying people at risk through pro-active case finding The use of enabling technologies such as telecare and telehealth The development of integrated care through multi-disciplinary teams, particularly in support of primary care, care homes and discharge from hospital The re-design of primary care Engaging individuals and carers in the commissioning of joined up care The Kings Fund [8] has identified a series of evidence based approaches: Primary Prevention Self Care Managing Ambulatory Care-Sensitive Conditions Care Co-ordination Case Management Managing Emergency Activity, Discharge Planning and Post-Discharge Support Medicines Management Mental and Physical Health Needs Improving Management of End-Of-Life Care 15 P a g e

16 Respiratory Disease 2015/16 The National Review of Asthma Deaths (NRAD) is the first national investigation of asthma deaths in the UK and the largest study worldwide to date. The primary aim of the NRAD was to understand the circumstances surrounding asthma deaths in the UK in order to identify avoidable factors and make recommendations to improve care and reduce the number of deaths. The key findings of the study were: [9] During the final attack of asthma, nearly half had not sought medical attention The majority of people who died from asthma (112 of 190 or 57%) were not recorded as being under specialist supervision during the 12 months prior to death There was a history of previous hospital admission for asthma in 47% of deaths (90 of 190) Personal asthma action plans acknowledged to improve asthma care, were known to be provided to only 44 (23%) of the 195 people who died from asthma There was no evidence that an asthma review had taken place in general practice in the last year before death for 84 (43%) of the 195 people who died Exacerbating factors, or triggers, were documented in the records of almost half (95) of patients; they included drugs, viral infections and allergy. A trigger was not documented in the other half Of 155 patients for whom severity could be estimated, 61 (39%) appeared to have severe asthma. Fourteen (9%) were being treated for mild asthma and 76 (49%) for moderate asthma. It is likely that many patients who were treated as having mild or moderate asthma had poorly controlled undertreated asthma, rather than truly mild or moderate disease The expert panels identified factors that could have avoided death in relation to the health professional s implementation of asthma guidelines in 89 (46%) of the 195 deaths, including lack of specific asthma expertise in 34 (17%) and lack of knowledge of the UK asthma guidelines in 48 (25%) There was evidence of excessive prescribing of reliever medication, underprecribing of preventer medication and of inappropriate prescribing of long-acting beta agonist bronchodilator inhalers There were also a number of patient factors and perception of risk of poor control: The expert panels identified factors that could have avoided the death related to patients, their families and the environment in 126 (65%) of those who died. These included current tobacco smoking in 37 (19%), exposure to second-hand smoke in the home, non-adherence to medical advice and non-attendance at review appointments Particularly in children and young people, poor recognition of risk of adverse outcome was found to be an important avoidable factor in 7/10 (70%) children and 15/18 (83%) young people in primary care, and in 2/7 (29%) children and 3/9 (33%) young people in secondary care The median age at the time of the initial diagnosis of asthma was 37 years. Most people who died, and for whom this information was available, were diagnosed in adulthood, with 70/102 (69%) diagnosed after the age of 15 years Psychosocial factors contributing to the risk of asthma death and its perception were identified by panels in 51 (26%) of those who died, and included depression and mental health issues in 32 (16%) and substance misuse in 12 (6%) 16 P a g e

17 Halton Joint Strategic Needs Assessment 2015/16 3. Level of need in the population 3.1 Risk factors Smoking Reducing the prevalence of smoking will have the greatest impact upon respiratory disease prevention. Improving access to smoking cessation services and encouraging long term quit rates would have a significant impact on reducing prevalence of a variety of respiratory disease, including COPD, lung cancer, adult and childhood asthma amongst others. Increasing work within schools and youth settings and identifying innovative and best practice techniques to prevent young people taking up the habit of smoking will help limit future impacts of respiratory ill health. There is evidence that young people may be using e-cigarettes as a gateway to smoking. Whilst current data suggests most users of electronic or e-cogarettes are amongst current or ex-smokers, there is evidence that e-cigarette use has increased amongst young people and may act as a gateway to smoking. [10][11][12][13] Smoking prevalence amongst young people has been reducing over recent years both nationally, [14] regionally and locally [15]. In Halton this means the rate has fallen from 24% of young people aged 14 to 17 to 10% in The 2015 rate is the same as the regional average. The national survey used a younger age cohort (11 to 15 year olds) and so is not directly comparable. Current data on smoking prevalence varies, with national data from the Integrated Household Survey suggesting that adult smoking in Halton is the same rate as the national average but other local lifestyle surveys suggest that as many as 30% of the local population (and even higher in the more deprived parts of the borough) may smoke Housing Halton has seen a general increase in excess winter mortality over recent years (although the most recent data is lower). Nationally, respiratory diseases account for the second highest proportion (32%) of excess winter deaths. [16] Cold homes are a considerable contributor to the excess deaths resulting from respiratory illnesses (particularly exacerbations of COPD) and fuel poverty is a significant cause of cold homes. Damp living conditions are also a major cause of respiratory illness, ranging from allergy to mould resulting in significant rhinitis, wheeze, coughs and exacerbations of asthma and COPD, to increased rates of infections ranging from flu like symptoms to significant lung damage. Fuel poverty and cold homes can have severe and life-long effects on children. Studies show that long-term exposure to a cold home can increase hospital admission rates for children and increase the severity and frequency of asthmatic symptoms. Children in cold homes are more than twice as likely to suffer from breathing problems and children in damp and mouldy homes are up to three times more likely to suffer from coughing, wheezing and respiratory illness, compared to those with warm, dry homes. [17] During 2013/14 there were 82 emergency admissions for asthma in children under the age of 14. Figure 1 shows the proportion of excess winter deaths attributable to different causes, in Halton from 2008 to This shows that respiratory disease generally account for the highest single proportion of these deaths. 17 P a g e

18 Respiratory Disease 2015/16 Figure 1: Excess Winter Mortality Index, by cause of death, Halton 2009/10 to 2014/15 During 2011/12 to 2013/14, of all emergency admissions for lower respiratory tract infections in 0-18 year olds, 81.5% were for those under 1 year of age (the England average was 70%) and 79% of these were for acute bronchiolitis. Bronchiolitis can be best prevented by good hygiene and living conditions. Children who are exposed to passive smoking, can suffer more severely with bronchiolitis. Halton Housing Strategy identifies key actions around developing the affordable warmth strategy and promoting energy efficiency and green deals to help reduce the local burden, although further multidisciplinary and health involvement would benefit the development and promotion of these interventions Environmental indoor and outdoor The environment that we live in can have a great impact upon our respiratory health, both indoor and outdoor environmental factors, predominantly air quality, can significantly influence our chances of experiencing good respiratory health. Breathing fine particles (those produced through burning), high levels of gases such as nitrogen oxide and sulphur dioxide, and low level ozone can all irritate the lungs. In the short term they can cause breathlessness, and exacerbate symptoms of asthma and COPD. In the long term they could lead to reduced lung function, initiation of asthma, and cause scaring and damage to the lung or cause some forms of interstitial lung disease (a range of conditions which include most commonly idiopathic pulmonary fibrosis). Indoor environment Our indoor environment plays a significant role on our health, particularly so for young children who may spend considerable amounts of their time indoors. Indoor environmental tobacco smoke is the main indoor environmental pollutant to affect people s, especially children s, respiratory health. Passive smoking is breathing in the smoke from someone else s tobacco. Passive smoking can be either secondary of tertiary; secondary smoking is exposure to smoke from other peoples cigarettes, and tertiary smoking is exposure to residual smoke on persons, clothing and furniture etc. as a result of smoking. The predominant source of passive smoke exposure in children is smoking in the home 18 P a g e

19 Halton Joint Strategic Needs Assessment 2015/16 by parents. The best way to prevent passive smoking in the home is therefore to reduce the prevalence of smoking among parents and would-be parents. [18] Passive smoking can have a significant impact on health, increasing the likelihood of recurrent lower and upper respiratory infections, recurrent pneumonia, development and worsening of asthma, as well as a significant cause of lung cancer in smokers and non-smokers: Smoking by the mother increases the risk of lower respiratory infections in children by about 60%, and smoking by any household member increases the risk by over 50%. Most of this increase is due to an effect on bronchiolitis, which is about 2.5 times more likely to occur in children whose mothers smoke [19] Secondary smoking increases the risk of wheezing at all ages. Again, the effect is strongest for amongst children whose mothers smoke, with increases in risk of 65% to 77% according to the age of the child. The risk of asthma is increased by household smoking by about 50% [20] Other indoor environmental factors which can impact upon respiratory health include: Mould - Poor quality damp housing and lack of ventilation in humid places such as kitchens and bathroom can lead to the growth of mould. There are many types of mould, many of which harmless, but some people can have allergic reactions to mould or mould spores which can lead to respiratory symptoms including persistent sneezing, eye irritation, rhinitis (runny nose), coughing and wheezing, which can be worse in children Pets fur and feathered pets are sources of allergies. Some people are allergic to certain proteins and substances found in the skin or some secretions (saliva etc.) from some animals. Pet allergies can lead to long term rhinitis, coughing and wheezing. Identifying the source of the respiratory ill health can be difficult to detect and can develop even when pets have been present for a long time Dust dust can harbour mites. Faeces from dust mites are also a very common allergen that can be a significant contributor to the development of asthma and/or triggering asthmatic attacks. Mites accumulate in or on surfaces that accumulate human skin cells or sweat etc. They also thrive in conditions of high humidity and temperature. They accumulate in bedding, pillows, mattresses, carpets and furniture. People are exposed by inhalation and can result in allergic respiratory symptoms as well as asthma Ensuring that the environment is clear of potential allergens, when there is a known or likely link (family history) is key to preventing poor respiratory health, and removing/ limiting contact with potential allergy sources where respiratory allergy symptoms are present is key to preventing ongoing or worsening conditions. Outdoor environment Outdoor air pollution is also a key determinant of respiratory health. There are several kinds of pollutants which affect health, and are of major concern; these are pollutants for which there are national and international criteria to monitor their levels and limit the impact that they have upon health. Councils have a responsibility to regularly monitor, review and assess air quality as part of the Environmental Act (1995) and National Air Quality Strategy. 19 P a g e

20 Respiratory Disease 2015/16 The Committee on Medical Effects of Air Pollution (COMEAP) estimate that air pollution accounts of 29,000 deaths nationwide every year. [21] The most recent COMEAP Report looks at the proportion of deaths in a local area that can be attributable to particulate pollution. The proportion of deaths attributable to long term exposure to manmade particulate air pollution in Halton is 5.5%. Whilst this still represents a fraction of deaths for which preventive action must be sought, it is reassuring that Halton has no greater risk than many other areas of the country. The average attributable risk across England is 5.6%. [22] Halton is an industrial area, with a long history of industrial processes. Historically it has had poorer air quality than other areas of the country. However, the reduction in industrial manufacturing, cleaner technologies and closer processes monitoring and permitted processes has significantly improved air quality in Halton over the decades. Halton currently collects data on air quality across the borough to regularly assess air quality. Halton is generally well within national criterial levels for common air pollutants (particulates, sulphur dioxide, nitrogen dioxide). However, there are 2 areas which have been identified as Air Quality Management Areas (AQMA) where nitrogen dioxide are above air quality objective levels. Both these areas are in Widnes Town Centre and are associated with high volume traffic flows. Halton Borough Council in partnership with other agencies is working towards improving transport options, increasing sustainable transport options, cleaner technologies, assessing traffic routes and active travel options (such as walking and cycling) Occupational risk A range of respiratory diseases can be caused by exposures in the workplace. The main categories of these diseases are as follows: Respiratory cancers include lung cancer, which may be caused by a range of exposures such as asbestos, silica, diesel engine exhaust emissions, and mineral oils and mesothelioma, a cancer of the lining of the lungs which is caused by asbestos COPD: A wide range of vapours, dusts, gases and fumes potentially contribute to causing the disease or making it worse Occupational asthma caused by agents that are present in the workplace or where there is an association between symptoms and work, including cases that are exacerbated by work Pneumoconiosis is defined in terms of their causative agents: coal worker s pneumoconiosis due to coal dust exposure, asbestosis due to exposure to asbestos fibres, and silicosis due to silica dust exposure Disease latency Most of the above diseases with the main exception of occupational asthma and other allergic respiratory disease are so called long latency diseases, meaning that symptoms usually start to become apparent many years after the time of first exposure to the agents that caused them. Currently occurring cases of long latency diseases will tend to reflect the effects of past working conditions, although, many of the causative agents can still be present in many workplaces and thus constitute a potential ongoing hazard. 20 P a g e

21 Halton Joint Strategic Needs Assessment 2015/16 National prevalence Based on data from the Labour Force Survey, an estimated 33,000 people who worked in the last 12 months currently have breathing or lung problems caused or made worse by work. An estimated 141,000 people who have ever worked currently have breathing or lung problems caused or made worse by work. The average age was 53 years with 25% aged 65 and over. The Labour Force Survey will tend to identify only those cases of disease where the individuals can make the link between their own health and work. Many cases of occupational respiratory disease may not be identified as being due to workplace exposures since the role of occupation may be overlooked in light of other common causes such as smoking Genetic Problems with specific genes can cause problems with lung development, leading to lung disease. In diseases like cystic fibrosis, the exact gene involved has been identified. However, for many other lung conditions the role of genes is far more complex and the relevant genes are more difficult to identify. A research study has shown that smokers who have brothers and sisters with severe COPD are at greater risk of developing the condition than smokers who do not. [23] Alpha-1 antitrypsin deficiency is an inherited disorder that may cause lung disease and liver disease. It is a rare, inherited condition that affects around one in 3,000 to one in 4,000 people in the UK. Alpha-1-antitrypsin is a protein that protects the lungs. Without it, the lungs can be damaged by other enzymes that occur naturally in the body. It causes emphasema, one of the conditions known as COPD. About 1% of people with COPD have this genetic deficiency. People who have an alpha-1- antitrypsin deficiency usually develop COPD at a younger age, often under 35. The earliest symptoms are shortness of breath following mild activity, reduced ability to exercise, and wheezing Obesity Obesity can have a very serious negative impact on the respiratory system, significantly reducing respiratory health. Some of the health effects of obesity on respiratory system include diseases like:- Exertion dyspnoea severe breathlessness as a result of only minor physical activity. This is a common feature among people who are obese Obstructive sleep apnoea syndrome (OSA) This condition leads to closing or narrowing of the airways during sleep leading to snoring, repeated waking and lack of adequate and restful sleep COPD a group of lung diseases that block airflow and make breathing difficult. Emphysema and chronic bronchitis are the two most common conditions Asthma Obese patients are more at risk of asthma exacerbations. The prevalence of asthma is around 38% higher in overweight patients and by 92% in obese patients. Obese patients with asthma also get more acute attacks, need more asthma medication, need more frequent visits to the emergency department, and have more hospital admissions than non-obese patients with asthma Pulmonary embolism This is a serious condition where a blood clot gets lodged in the blood vessels of the lungs leading to a life threatening medical emergency. Pulmonary embolism may lead to death. Respiratory illnesses for which obesity can represent a significant cause have a great impact upon the health of people in Halton and the health services across Halton. There are estimated to be 21 P a g e

22 Respiratory Disease 2015/16 1,328 adults with moderate to severe sleep apnoea (OSA). [24] The cost of treating all people with moderate to severe OSA would be 1,092,406 per year. Encouraging people to lose weight and maintain a healthy weight through a healthy balanced diet and regular exercise is the only way in which the population can stay within a healthy weight range and reduce the likelihood of obesity related respiratory disease. Halton has a number of services to promote healthy lifestyles, diet and exercise. Current programmes range from interventions in schools (food and nutrition awareness, cooking skills, exercise programmes) to adult weight management programmes to encourage healthy weight loss, provide healthy food skills and supporting regular exercise programmes and opportunities across the borough and we need to work across partner agencies and the public to a greater extent to ensure that everyone has an equal opportunity to benefit from the services available. Halton has some of the highest levels of adult obesity in the country. Data from the Active People Survey 2012 suggests 35.2% of adults are obese, the highest percentage nationally, with 70.2% being overweight (including obese). This is a much higher percentage than indicated in the Merseyside Lifestyle Survey 2013/14. It showed that men were significantly more likely to be overweight than women. In total, 40% of men are classified as overweight, compared to 33% of women. However, the level of obesity was higher in women than men (28% compared to 22%). A greater propotion of younger adults in Halton tend to be a healthier weight. More than half of those aged (55%) and 43% of those aged are in the healthy weight bracket, compared to 31% of those aged 45-54, 26% of those aged and 32% of those aged 65 and over. Just 13% of year olds are obese, compared to 30% of those aged between 45 and 64. People with a long-term illness, disability or health problem are significantly more likely to be obese than those without (33% compared to 21%). Similarly, those who say their overall general health is poor are significantly more likely to be obese than those who consider their health to be good (40% compared to 20%). 22 P a g e

23 Halton Joint Strategic Needs Assessment 2015/ Protected characteristics Research commissioned by the Department of Health to inform its Equality Impact Assessment of the National COPD and Asthma Strategy [25] identified eight priority audience segments most at risk of lung disease They are: Those working in routine and manual occupations Older people Ex-smokers Parents who smoke Pregnant women Tweens (children aged 7-12) Bangladeshi Men Details in this section are from the EIA unless otherwise indicated. Further details can be found in the EIA Age Analysis by the British Thoracic Society shows that there has been an increase in prevalence between 1995 and 2004 for all ages groups except those younger than 45. Prevalence increases with age. Numbers of deaths from COPD increase with age, as the lungs become more obstructed over time. In the UK, deaths from COPD are very low in the age range 0-40 (less than 500 per year) but much higher in the 75+ age range for both males and females (about 20,000 per year). More than half the deaths from asthma are in the over 80 age group, although asthma impacts people of all ages Gender There are differences in the incidence of COPD according to sex. COPD has, certainly until recent years, disproportionately affected men (because of sex differences in smoking and employment in industries that may expose the individual to risk, such as coal mining). In the UK, the rate of lung disease has been increasing nearly three times faster amongst women than men. Women are more susceptible to developing lung disease than men, as their lung function worsens with lesser duration of smoking or intensity of smoking than that of men. Recent figures show that chronic lung disease (predominantly COPD) is the primary cause of death for a higher proportion of men than women. It accounts for almost 5.5% of all deaths in men, and just over 4.5% in women. Twice as many females die from asthma as males. However, prevalence of asthma in children tends to be higher in boys than girls. Occupational risk is higher in men than women, predominantly due to certain types of occupations which place people at risk of exposure to things like astbestosis being male-dominated. Thus mesothelioma mostly affects men. 23 P a g e

24 Respiratory Disease 2015/ Ethnicity There are no reliable estimates for the number of people with COPD in minority ethnic groups. However, given that 85% of COPD is related to smoking, Health Survey England 2004 figures would suggest that Bangladeshi men (40% smoking prevalence) are most at risk, followed by men who are Irish (30%), Pakistani (29%), Black Caribbean (25%), Black African and Chinese (21%), or Indian (20%). Amongst women, the figures are high for Irish (26%) and Black Caribbean (24%) women, dropping significantly for Black African (10%), Chinese (8%), Indian and Pakistani (5%) and Bangladeshi (2%) women. Whilst overall smoking prevalence has decreased since 2004, it is likely these groups remain more at risk. Despite this increased risk research undertaken for the national strategy found much lower diagnosis and enagement with both preventative and therauputic services amongst people from minority ethnic communities. This may be cultural, sociological, practical or even physiological reasons and there may be an issue with older Asian women or people with poor spoken English that can be overcome with additional support. Asthma UK research showed that compared with the white population, people from black and minority ethinic (BME) groups have poorer outcomes, less access to information about their condition, and poor access to services. There were considerable differences between the groups surveyed, which comprised African, Bangladeshi, Caribbean, Chinese, Indian, Irish, Polish and Pakistani people with asthma. Compared with the white population, South Asian people are three times more likely to require an emergency hospital admission for their asthma, with black people twice as likely. There is a particularly high rate of asthma in black Caribbean children under 16 years old Marital status The EIA did not find any obvious impact of marriage and civil partnership on either COPD or asthma Religion and Beliefs Lack of religious and/or cultural awareness amongst service providers may be a barrier to people engaging with them. This included the relationship with other aspects of identify (for some cultures ethnicity and religion are virtually inseparable). Service data show that more people from BME backgrounds identify themselves as religious. By failing to address religion and culture, services disproportionately affect people from BME backgrounds Sexual Orientation There is some evidence that smoking rates are high among lesbian and gay people, which is significant since smoking is the primary cause of COPD Disability COPD is a progressively disabling condition that cannot be cured, and in time will lead to death. People with COPD also often have other disabling conditions, such as heart disease, which complicates the nature of the care they require. People with respiratory disease may meet the criteria within legislation for being classified as disabled. 24 P a g e

25 Halton Joint Strategic Needs Assessment 2015/16 The strategy also highlights two important aspects to the improvement of respiratory services for people with learning disabilities and autism: Pregnancy inclusivity of mainstream services for people with learning disabilities provision of appropriate skills (e.g. sign language) The EIA did not find any obvious impact of pregnancy and maternity on either COPD or asthma Gender reassignment The EIA did not find any obvious impact of gender reassignment on COPD. However, monitoring of gender reassignment by public services is very patchy and inconsistent, making it difficult to determine if there are any specific issues in relation to respiratory disease Other vulnerable groups People with Learning Disabilities Respiratory disease is possibly the leading cause of death for people with learning disabilities (46%- 52%), with rates much higher than for the general population (15%-17%). People with learning disabilities who have asthma were found to be twice more likely to be smokers than patients with learning disabilities who do not have asthma. More than half of women with learning disabilities and asthma are also obese. [26] Migrants, Asylum Seekers and Refugees Evidence on physical and mental health suggests there are poorer outcomes overall for non-uk born individuals residing in the UK compared to the UK-born population, but these vary according to migration histories and experience in the country. Both socio-economic circumstances and immigration regulations affecting some migrant groups impact negatively on access to and use of health care. Tuberculosis (TB) prevalence rates for UK and non-uk born ethnic groups, highlight a higher incidence of the disease among South Asian (particularly Indian and Pakistani) and Black African non- UK born populations compared to other migrant groups or UK-born South Asians and Black Africans. The highest rates of TB among migrants occur among people who are recent arrivals in the UK, particularly those arriving from countries of countries with a high prevalence rates (countries with an incidnce rate of 70/100,000 population are at highest risk), but less than a half are diagnosed within five years of arrival. [27] While reactivation of latent TB has been identified as a significant factor, this also highlights the possible importance of other contributory factors, such as low income and poor living conditions in the UK, especially documented among recent migrants, for example, poor nutrition, sub-standard and overcrowded housing in areas of deprivation where many newly-arrived migrants live. [28] TB is a disease that has always been associated with poverty and deprivation. [29] However there is no robust evidence in routine surveillance systems to explore socio-economic factors affecting TB among migrants. [30] Smoking rates may also be higher amongst certain migrant groups such as Eastern European men. 25 P a g e

26 Respiratory Disease 2015/ Homeless People Amongst people who are homeless mortality rates are four times higher than in the general population with levels of ill health (morbidity) being substantially increased in homeless populations, who have higher prevalences of mental disorders and infectious diseases than do general populations. Worldwide prevalence of TB amongst homeless people ranges from 0.2% to 7.7%. [31] The 2014 Homeless Link health audit revealed that that 77% of homeless people smoke, 35% do not eat at least two meals a day and two-thirds consume more than the recommended amount of alcohol each time they drink. 15.2% had long-standing chest and breathing problems compared to 5.8% of the general population. [32] Drug Users Cannabis use is associated with longer-term damage to the respiratory tract, with an increased risk of chronic bronchitis, asthma and potentially lung cancer. There is also a reported association between cannabis smoking and an increased risk of developing infectious lung diseases such as TB and Legionnaires disease. Education to reduce the levels of cannabis use, and prevent young people from using cannabis could help to reduce rates of chronic bronchitis and asthma People Living in Care Homes Care homes are unique ecological niches for infection because their residents have reduced function, have numerous comorbidities, and have higher rates of dementia. They live in communities in which they are grouped with other patients of similar age and vulnerability. A consequence of this is that the epidemiology of pneumonia and influenza in care homes, particularly in terms of outbreak management and infection control, is different from that in both the acute hospital and community sectors. In general, mortality from pneumonia in care home residents is high (12-21%), and residents are more likely to die of pneumonia than other healthcare associated infections. The higher mortality in residents is explained to a large extent by their pre-morbid status, with mortality rates attenuated compared to community controls when weight loss, dementia, aspiration risk and functional status are considered. Care home residents are susceptible to respiratory tract infections, with a prevalence of 0.5 to 4.4 per 1,000 resident days. Pneumonia, in particular, is important as the leading infective cause of death amongst care home residents, with mortality rates between 6% and 23%. Once introduced into a care home, influenza can spread rapidly because of close contact among residents, their poor overall health status and the challenges of infection control in care homes. As with pneumonia, the risk of mortality or significant morbidity from influenza increases with age and co-morbidities. Within the UK, the Department of Health recommends that all care home residents are annually vaccinated against influenza and pneumococcal infection. In addition, it is recommended that health and social care workers with direct patient contact receive annual influenza vaccination to reduce rates of illness, hospitalisation and mortality amongst vulnerable individuals that they are caring for. [33] 26 P a g e

27 Halton Joint Strategic Needs Assessment 2015/16 7.8% of care home residents in the 2009 Bupa census had lung or chest disease. [34] However, a more recent literature review put this figure much higher. It found 34% of care home residents have been diagnosed with respiratory conditions with respiratory disease accounting for 8% of deaths. [35] Social class There are clear social class gradients in respiratory disease mortality. Social class gradients are steeper for respiratory disease mortality than for mortality in general, with deaths from chronic obstructive pulmonary disease (COPD) and TB showing the most marked social class differentials. Men aged employed in unskilled manual occupations are around 14 times more likely to die from COPD and 9 times more likely to die from TB than men employed in professional roles. Social inequality causes a higher proportion of deaths in respiratory disease than in any other disease area. It is estimated that in the early 1990s, 3,800 deaths and 29,000 working years were lost each year in men aged years due to social class inequalities in death rates from respiratory disease. It is also estimated that 44% of all deaths from respiratory disease are associated with social class inequalities, and would have been prevented if all men had the same death rate for respiratory disease as men employed in professional and managerial classes. [36] 3.4 Prevalence of respiratory diseases National prevalence The last Health Survey for England (HSE) to include data on respiratory health was It found: [37] Respiratory symptoms 33% of men and 31% of women had a history of wheezing, while 18% of both sexes reported wheezing in the last 12 months Wheezing disturbed sleep at least one night per week in 3% of men and 4% of women. The same proportions reported that wheezing interfered with their normal daily activities quite a bit or a lot 21% of men and 28% of women reported having shortness of breath, breathlessness, or difficulty in breathing even when not doing strenuous exercise. 15% of men and 23% of women were graded 2-5 on the Medical Research Council (MRC) breathlessness scale a Asthma The prevalence of lifetime doctor-diagnosed asthma was 16% among men and 17% among women, and decreased with age for both sexes. 9% of men and 10% of women currently had asthma, having experienced symptoms of asthma, or with their symptoms controlled by medication, in the last 12 months. Unlike lifetime asthma, the proportion with asthma in the last 12 months did not vary by age group in either sex Both the prevalence of lifetime doctor-diagnosed asthma and the prevalence of current asthma varied by household income, with prevalence in each case highest in the lowest three income-level quintiles a See for example for an explanation of the MRC breathlessness scale 27 P a g e

28 Respiratory Disease 2015/16 In children [38] More boys than girls aged 0-15 had ever had any wheezing or whistling in the chest (30% and 23% respectively), although just under half of these children only had wheezing when they had a cold (13% of boys and 10% of girls). The proportion experiencing wheezing when they did not have a cold increased with age 17% of boys and 13% of girls had experienced wheezing or whistling in the chest in the last 12 months. Younger children were more likely than older children to report this Wheezing disturbed sleep at least one night per week in 4% of boys and 3% of girls. Only 2% of both boys and girls reported that wheezing interfered with their normal daily activities quite a bit or a lot The prevalence of lifetime doctor-diagnosed asthma was 17% among boys and 12% among girls. Current asthma, defined as symptoms in the last 12 months or symptoms controlled by medication for asthma in the last 12 months, was reported by 11% of boys and 8% of girls. Both lifetime and current asthma prevalence increased with age for both sexes There was significant variation by household income in the prevalence of both lifetime doctor-diagnosed asthma and those experiencing symptoms of asthma in the last 12 months. Those living in households with lower income were more likely to report lifetime asthma or current symptoms Analysis of the General Household Surveys between 1995 and 2004 was undertaken by the British Thorasic Society. [39] It showed prevalence increasing over time and with age, for both men and women. Table 3: Prevalence of self-reported long-term respiratory illness in adults, by sex and age. Great Britain, Data from the 2010 Health Survey for England shows levels of self-reported doctor-diagnosed COPD are similar for men and women, with the dominant factor continuing to be age. 28 P a g e

29 Halton Joint Strategic Needs Assessment 2015/16 Table 4: Self-reported doctor-diagnosed COPD by age and gender, 2010 Health Survey for England Source: 2010 Health Survey for England, Health and Social Care Information Centre Estimated local prevalence At a local level, it is only known how many people have a doctor-diagnosis of COPD and asthma. This is via the GP registers. Looking only at the numbers of patients currently being treated for a disease does not show the true prevalence and impact on the population s health. At any given time there are many people who have a disease but are not aware of it because they have not yet been diagnosed. A robust and well-researched disease prevalence model can help commissioners to assess the true needs of their community, calculate the level of services needed and invest the appropriate level of resources for prevention, early detection, treatment and care. Prevalence models provide estimates of underlying prevalence derived from population statistics and scientific research on the risk factors for each disease. The models can also be used to support case-finding by identifying those areas where detection rates are low and targeting enhanced diagnostic activity on them. 29 P a g e

30 Respiratory Disease 2015/16 Table 5: Estimated prevalence of COPD amongst adults, by gender and ethnicity, 2011 Table 6: Estimated prevalence of COPD amongst adults, by age group, 2011 It is likely that Halton s estimated prevalence is lower than the North West and England due to the younger age profile of its population and also that it is less ethnically diverse. However, as Halton s population is predicted to age at a more rapid rate than England, this gap may close. Using updated population estimates it is now thought that in Halton there are 4,168 residents over the age of 16 with COPD and by 2020, this will have risen to 4,420. The biggest increase is predicted to be in the 65 plus age group. Asthma estimated prevalence rates come from work undertaken by Doncaster PCT. [40] It is likley to underestimate as Asthma levels have risen. However, it remains the most robust source of population prevalence for the condition. Using GP registered populations April 2015, it is estimated that 11,9011 people in Halton have asthma. There are a greater number of boys with asthma than girls but a greater number of adult females than males with the condition. Table 7: Estimated prevalence of asthma, by age group and gender, P a g e

31 Halton Joint Strategic Needs Assessment 2015/ Known local prevalence Early diagnosis of lung disease delivers significant benefits, particularly in such conditions as asthma, COPD, and lung cancer. There is a need for greater public awareness of the symptoms of such lung diseases, of the risks posed by smoking and by any delay in diagnosing smoking-related lung conditions. This can be done by encouraging people to recognise early indications that there may be a problem and to seek medical attention early. In addition, there is a requirement to ensure that primary care are fully aware of the early symptoms of specific conditions and explore appropriate diagnostic tests, and referrals early. Whilst prevention of ill health remains the primary long term focus to safeguard respiratory health in to the future, significant improvements in health outcomes and mortality can be made by earlier diagnosis and interventions for respiratory illnesses. The number of people diagnosed with asthma and COPD is recorded on GP information systems, as part of their national contract to identify and manage people with a range of long term conditions, known as the Quality Outcomes Framework (QOF). In recognition of the importance of early diagnosis, much effort has been put into proactive case finding across Halton for a number of years Asthma The number of Halton patients with asthma has remained fairly static over the last decade, with minor ebbs and flows during the period. Prevalence was above the national average in 2004/05 and has remained so up to and including the latest reporting period 2014/15. Table 8: Observed prevalence of asthma in Halton GP registered patients, 2004/05 to 2014/15 The 2014/15 data shows rates vary by practice (Figure 2) from a low of 5.53% in West Bank to a high of 9.79% in Castlefields practice. The CCG position for 2014/15 was slightly higher than the Cheshire and Merseyside average and higher than the England average. 31 P a g e

32 Respiratory Disease 2015/16 Figure 2: QOF asthma prevalence 2014/15, Halton practices, CCG average and comparators COPD Unlike asthma, there has been an increase in COPD during the last decade by around 500 patients. As with asthma the observed prevalence in Halton was higher than the national picture in 2004/05. Both the Halton and national observed prevalence has increased by 0.4 percentage points during the decade, leaving the difference the same across the period. Table 9: Observed prevalence of COPD in Halton GP registered patients, 2004/05 to 2014/15 Observed prevalence varies from a low of 1.47% for Peelhouse Plaza to 4.49% for Murdishaw during 2014/15 The CCG average was above the Cheshire and Merseyside and England averages for the period. 32 P a g e

33 Halton Joint Strategic Needs Assessment 2015/16 Figure 3: QOF COPD prevalence 2014/15, Halton practices, CCG average and comparators Estimates versus known prevalence Estimates for asthma are available by age and gender. Applying the model developed by Doncaster to Halton CCGs registered population in 2014, it can be seen that all but one practice has modelled estimates higher than the observed number of GP disease registers. Table 10: Asthma estimated and observed prevalence, 2014/15 The Association of Public Health Observatories (now Public Health England (PHE)) developed a prevalence model for COPD. It is recognised that there is a level of undiagnosed COPD in the population. The model enables an estimate to be made at borough or practice level of the degree of this under-diagnosis. 33 P a g e

34 Respiratory Disease 2015/16 Table 11: COPD estimates and observed prevalence, 2014/15 The efforts to proactively case find people with COPD means the estimated difference is much smaller for COPD than for asthma, with the gap reducing over the last five years or so. These efforts mean 8 out of 17 practices have levels diagnosed above the estimates. However, two practices have over 100 patients potentially with COPD who have not been diagnosed. It should be noted that the modelled estimates can only be used as a guide and should not be used to set target numbers to find. Doing so may mean some patients remaining undiagnosed. Efforts to identify those most at risk should remain the mainstay of the local approach. However, the model does provide a starting point for discussions within practices where the difference between the estimate and the diagnosed numbers are substantial. 34 P a g e

35 Halton Joint Strategic Needs Assessment 2015/16 4. Service provision 4.1. Prevention and promotion Smoking prevention Through the Halton Healthy Schools programme, tobacco education sessions are delivered as part of the Healthitude programme. The sessions aim to provide children and young people with a greater awareness of the issues related to smoking and tobacco, including the effects of smoking, chemicals in a cigarette, financial implications, legislation, and the impact of advertising on smoking behaviours. The RUDifferent? social norms campaign aimed to challenge myths around smoking and other lifestyle issues to show pupils that smoking, drinking alcohol and drug taking are not the norm. This has been run in all secondary schools in Halton starting autumn of 2014 and through Adult Stop Smoking Service In 2014/15 in Halton 1131 people set a quit date and 57% successfully quit. This is higher than the North West of 45% and England average of 51%. Halton had a greater proportion of clients setting a quit date were women compared to the North West and England. Of Halton s 1,131 60% of those setting a quit date were women and 40% men. This compared to 54% (women) and 46% (men) in the North West and 52% and 48% respectively across England as a whole. Whilst the percentage of those under 18 who were successful quittters was lower in Halton than comparators, for all other age groups it was higher. This was the case for total successful quitters and the proportion of quits that were carbon monixide (CO) validated. Further details of Tobacco Control including local services can be found in the JSNA chapter on Tobaccohttp://www4.halton.gov.uk/Pages/health/JSNA/lifestyles/tobacco.pdf 4.2. Primary Care: Prevention of infectious respiratory conditions: Influenza and Pneumococcal Vaccination programmes Influenza vaccination Seasonal influenza (often refered to a flu) is usually a mild disease, but for some people who catch the virus, it can lead to serious complications and even death. About 8,000 people are estimated to die from it in the UK each year. The groups who are at risk are the over 65s, people with long term conditions such as cardiac, renal, liver, respiratory, neurological diseases, those who have had a stroke, are immunosuppressed or those that are pregnant. The NHS offers a free seasonal influenza vaccination to all those people in these at risk groups. Evidence shows that the majority of the population need to be immunised to provide herd immunity, reducing the risk to the whole population. The England target based on this evidence is that 75% of all at risk populations should be immunised annually to ensure the population is protected from the main strains of flu which develop each year. 35 P a g e

36 Respiratory Disease 2015/16 In 2013/14 the annual flu immunisation programme was extended to include 2 and 3 year olds, and during 2014/15 4 year olds were also included for the first time. For the 2014/15 flu season : Halton s average uptake in the over 65s age group was 73.8%, which is slightly below the target uptake of 75%, but higher than the England average. Only 46.7% of all pregnant women in Halton received the influenza vaccine. However, this was similar to the England average 44.1%, and was an improvement on the previous year (38.3%). All 17 practices in Halton submitted data for at risk patients by condition, over 65s, under 65 and at risk, pregnant women and 2, 3 and 4 year olds. Uptake in 2, 3 and 4 year olds in Halton was similar to England. Figure 4: Influenza uptake in people aged 65+, 2014/15 The average vaccine uptake in this group was 73.8%, which was similar to 2013/14 (73.5%). The Halton percentage was slightly higher than the uptake for England (72.8%). Vaccine uptake ranged from 67.2% to 79.4% and most practices had a similar uptake to 2013/14. Figure 5: Influenza uptake in all pregnant women, 2014/15 Average uptake for all pregnant women in Halton was 46.7%, which is higher than the 2013/14 percentage of 38.3%. None of the 17 practices achieved the 75% target for 2014/15. The Halton CCG uptake was higher than the average for England (44.1%). 36 P a g e

37 Halton Joint Strategic Needs Assessment 2015/16 Figure 6: Influenza uptake in children aged 2, 2014/ /15 was the second year that annual flu immunisation programme included 2 year olds. None of the practices in Halton achieved the 75% target uptake. The average uptake was 35.6% which was lower than the uptake for England (38.5%). Figure 7: Influenza uptake in children aged 3, 2014/15 The average uptake for children aged 3 in Halton was 37.2% and none of the practices achieved the target uptake. The uptake for Halton was lower than England (41.3%). The annual flu immunisation programme was extended to include 3 year olds during 2013/14. Figure 8: Influenza uptake in children aged 4, 2014/ /15 was the first year the flu immunisation programme was extended to include 4 year olds. The average uptake for Halton CCG was 32.6% which was slightly lower than the England average (32.9%). The uptake within Halton practices ranged from 6.5% to 53.2%. 37 P a g e

38 Respiratory Disease 2015/16 Figure 9: Influenza uptake in people aged under 65 years in an at-risk group, 2014/15 The average uptake for practices in Halton was 50.3%, which is lower than the 2013/14 value of 51.9%. None of the 17 practices achieved the 75% target uptake set by the Department of Health. The Halton CCG percentage was the same as the England value. Figure 10: Influenza uptake in people aged under 65 with Chronic Respiratory Disease, 2014/15 The average uptake for Halton CCG was 49.8% which was lower than the 2013/14 percentage of 51.5%, and none of the 17 practices achieved the 75% target uptake. The uptake ranged from 37.3% to 64.1% Pneumococcal vaccination The pneumococcal vaccine protects against pneumococcal infections. These are caused by the bacterium Streptococcus pneumoniae and can lead to pneumonia, septicaemia (a kind of blood poisoning) and meningitis. A pneumococcal infection can affect anyone but some people are at higher risk of serious illness and are therefore eligible for NHS pneumococcal vaccination. These include: babies adults aged 65 or over children and adults with certain long-term health conditions, such as a serious heart or kidney condition 38 P a g e

39 Halton Joint Strategic Needs Assessment 2015/16 There are two different types of pneumococcal vaccine: pneumococcal conjugate vaccine (PCV) this is given to all children under two years old as part of the NHS childhood vaccination programme pneumococcal polysaccharide vaccine (PPV) this is given to people aged 65 and over, and to people at high risk due to long-term health conditions More than 90 different strains of the pneumococcal bacterium have been identified, though only between 8 to 10 of them cause the most serious infections. The childhood vaccine (PCV) protects against 13 strains of the pneumococcal bacterium, while the adult vaccine (PPV) protects against 23 strains. The pneumococcal vaccine is thought to be around 50% to 70% effective at preventing pneumococcal disease. Both the PPV and PCV are inactivated or 'killed' vaccines and do not contain any live organisms. They therefore cannot cause the disease against which they protect. 41 Vaccination levels in children are high. Data for 2014/15 shows that Halton s rates were slightly higher than its comparators. Table 12: Pneumococcal Conjugate Vaccination (PCV), primary and booster vaccination in childhood, 2014/15 The percentage of eligible 65 and overs vaccinated against pneomococcal infections is lower than the childhood rates. Nevertheless 2014/15 data again shows Halton s rates above England although slightly lower than the Merseyside Area Team value. Table 13: Pneumococcal Immunisation Vaccine Coverage Monitoring Programme, PPV coverage (%) in 65 years and over broken down by age group (cumulative data up to end of 31st March 2015) 39 P a g e

40 Respiratory Disease 2015/16 There is also a wide variation at GP practice level with a low of 56.2% of the eligible population being vaccinated to a high of 85%. Table 14: Pneumococcal Immunisation Vaccine Coverage Monitoring Programme, PPV coverage (%) in 65 years and over, Halton CCG (cumulative data up to end of 31st March 2015) Management of people with respiratory disease: QOF performance The Quality and Outcomes Framework (QOF) was introduced as part of the new General Medical Services contract on 1 April The objective of the QOF is to improve the quality of care patients are given by rewarding practices for the quality of care they provide to their patients. QOF is therefore an incentive payment scheme, not a performance management tool, and a key principle is that QOF indicators should be based on the best available research evidence. Participation by practices in the QOF is voluntary, though participation rates are very high, with most Personal Medical Services practices also taking part. Whilst all patients with the condition should form part of the disease register, some are age specific, others all age. Both the respirator disease registers are all age. However, depending on the specific indicator, not all patients on the register may be deemed eligible for each intervention. This is because each intervention is evidence based, aimed at those it is most clinically necessary for. Some patients who would normally be eligible may be exempted if they meet certain criteria. [42] It is important therefore to consider the percentage of eligible patients who receive each intervention and to be able to benchmark this achievement level. QOF is reviewed annually and indicators may be retired to release funds for new indicators. For 2014/15 this includes work on avoiding unplanned 40 P a g e

41 Halton Joint Strategic Needs Assessment 2015/16 admissions and delivering proactive case management for vulnerable people and 3 points transferred to the learning disabilities enhanced service. NICE provide an independent role in developing suitable indicators for QOF. Which ones are finally included is a negotiated process between NHS Employers on behalf of NHS England, and the General Practitioners Committee on behalf of the British Medical Association Asthma Table 15: 2014/15 QOF asthma management indicators Table 16: Percentage of eligible patients receiving asthma management interventions, Halton and comparators, 2014/15 Overall, Halton CCG perfoms similar to its comparators, slighlty better for AST002, more or less the same for AST003 and slightly lower for AST004. However, there is wide practice level variation. 41 P a g e

42 Respiratory Disease 2015/ COPD Table 17: 2014/15 QOF COPD management indicators Table 18: Percentage of eligible patients receiving COPD management interventions, Halton and comparators, 2014/15 As with asthma management, overall, Halton CCG perfoms similar to its comparators, except for COPD004 and COPD007 where performance is several percentage points lower than its comparators. Again, within this, there is wide practice level variation. 42 P a g e

43 Halton Joint Strategic Needs Assessment 2015/ Secondary Care: hospital admissions There has been a 22% rise in median emergency medical admissions since 2008, with COPD admissions having risen by 13%. A clinical audit of COPD exacerbations admitted to acute NHS units in England and Wales during February to April 2014 assessed performance against key quality standards, clinical guidelines and accepted best practice for COPD management. 43 It found improvements in the organisation of admissions processes, non invasive ventilation (NIV) and the availability of early/supported discharge services since Yet variation in care remains, such as availability of specialist respiratory services/weekend care and the coordination of care at discharge and beyond. Some important improvements in the management of COPD exacerbation incude: fewer patients are being treated inappropriately with high flow oxygen at the time of admission the management of acute respiratory failure has improved, with the overwhelming majority of patients receiving prompt assessment, appropriate measurement of blood gases (albeit with some unacceptable delays between the first and second samples) and management of respiratory acidosis with NIV there has been a significant increase in the number of patients referred into early/supported discharge services and a concomitant reduction in the length of stay since The audit raised particular concerns around the variation in care offered to COPD patients across England and Wales and need to improve care around: the access to specialist respiratory care the availability of care at weekends the observation that many patients are not cared for on respiratory wards poor recording of important diagnostic information suboptimal delivery of, and referral into, key evidence based services such as smoking cessation and pulmonary rehabilitation only half of the patients were under the care of a respiratory consultant at the time of discharge, although it was notable that those patients who were reviewed by, or under the care of, respiratory specialist teams received much better evidence based COPD care patients are not supported well at weekends, and this is associated with a major reduction in the rate of hospital discharge on Saturdays and Sundays (Mondays having the highest rate of COPD admissions) the highest in hospital mortality within the patient group is observed on a Tuesday following admission on a Monday (although the link between the high admission rates on Mondays and probably delays in assessment because of this is unproven) Overall admissions due to respiratory disease The overall level of emergency admission due to respiratory disease in higher in Halton than the national average. This can be seen for overall respiratory admissions and for specific conditions where data is available. During the three year period 2012/13 to 2014/15, there were 1,255,82 inpatient episodes in total (all causes), with 7,745 (6.2%) of them having a primary diagnosis of respiratory disease. More than 15% of episodes for respiratory diseases were due to bronchitis, emphysema and other chronic obstructive disease, with a further 22.2% of episodes due to pneumonia. 43 P a g e

44 Respiratory Disease 2015/16 In-patient admission rates provide useful information about the general level of illness and the use of hospital services within geographical areas. It is very important to note that admission rates depend on how willing people are to make use of medical services, the location and accessibility of services, as well as differences in referral patterns and practices within primary and secondary care. Furthermore, one patient admission can generate more than one clinician episode if their care transfers to a different department or under the care of a different clinician during their stay. Additionally, one patient could have multiple admissions over the three year period. The following sections look at the main types of respiratory disease which result in admissions, especially emergency admissions, within the borough Asthma Emergency admissions to hospital due to asthma are generally low apart from in the youngest members of the popualtion and rise again in the oldest. In the youner age groups rates are higher for males but the reverse is the case in the older age groups. Figure 11: Emergency admissions due to asthma, by age group and gender, 2011/12 to 2013/14 At an electoral ward level, admissions are generally higher in the more deprived wards and this is the case for both admission all ages and admission amongst the 0-18 age group, as Figures 12 and 13 show. 44 P a g e

45 Halton Joint Strategic Needs Assessment 2015/16 Figure 12: Emergency admissions due to asthma, by electoral ward, all ages, 2011/12 to 2013/14 Figure 13: Emergency admissions due to asthma amongst 0-18 year olds, by electoral ward, 2011/12 to 2013/14 45 P a g e

46 Respiratory Disease 2015/ Bronchiectasis There has been a steady rise in the number of emergency admissions involving bronchiectasis over the last few years, from 62 in 2011/12, 92 in 2012/13 to 121 in 2013/14. The causes of this are unknown. Primary care management of patients and early identification and treatment of infections could prevent admissions. Physiotherapy has a major role in the management of bronchiectasis and self-help to enable patients to manage signs and symptoms better, helping to reduce infections and hospital admissions. Table 19: Number of admissions due to bronchiectasis, elective and emergency, 2011/12 to 2013/14 Year Elective Emergency 2011/ / / It is mostly an issue of age with admission rates being negligible before the age of 60. Figure 14: Admissions where bronchiectasis is present, by age and gender Although there is considerable variation across the borough there is only one ward were the rate is statistically higer than the borough average,a lthough five wards are statistcally lower and one ward had no admissions due to bronchiectasis dueing the five year period 2009 to P a g e

47 Halton Joint Strategic Needs Assessment 2015/16 Figure 15: Admissions where bronchiectasis is present, by electoral ward, 2009/ Bronchiolitis Although bronchiolitis can usually be managed at home, approximately 3% of affected children are admitted to hospital. In 2011/2012 in England there were 30,451 secondary care admissions for the management of bronchiolitis. During 2011/12 to 2013/14, 62% of emergency admissions for lower respiratory tract infections were for males, and 81.5% were for those under 1 year of age. For England in 2012/13, the percentage that were under 1 year of age was 70%. Children in Halton are admitted as an emergency admission for lower respiratory tract infections (of which bronchiolitis is the most common) at a higher rate than the England average, and there is significant variation in the rate of admission across different wards within the borough. This suggests that there could potentially be variations in the primary care management for children with respiratory infections. Figure 11 shows the variation in emergency admission rate for lower respiratory tract infections for 0-18 year olds between 2011/12 to 2013/14 by ward across Halton. There is little correlation between the variations and the levels of local deprivation, or known lifestyle factors to explain the pattern in variation, which could suggest a potential primary care link (although the data is not presented by practice) There are 6 wards with significantly higher admission rate for lower respiratory tract infections than the Halton average, and 9 wards are significantly higher than the England average emergency admission rate. During 2011/12 to 2013/14, 81.5% of all emergency admissions in Halton for lower respiratory tract infections were for children under 1 year of age, 79% of these were for acute bronchiolitis; for England this was 70%. 47 P a g e

48 Respiratory Disease 2015/16 Figure 11: Emergency Admission due to lower respiratory tract infection in children 2011/12 to 2013/14 NICE published guidance for the diagnosis and management of bronchiolitis in children in May [44] This guidance needs to be assessed against local services provision and pathways to ensure that local case management and care follow the best practice guidance. 48 P a g e

49 Halton Joint Strategic Needs Assessment 2015/ COPD As COPD is rare before the age of 40 it is no surprise that there are very few admissions before this age and that the rate of admissions rises with age. Overall, rates are slightly higher for males than females. Again, this reflects prevalence rates which are higher for men than women. Emergency admissions may be the method of diagnosing COPD in those individuals unknown to primary care. However, many more will be due to excarbations of the condition and possibly sub-optimal management in primary care. Figure 16: Emergency admissions due to COPD, by age and gender, 2011/12 to 2013/14 There is also ward level variation with a rates being higher in the more deprived wards and lower in the less deprived areas. Figure 17: Emergency admissions due to COPD, by electoral ward, 2011/12 to 2013/14 49 P a g e

50 Respiratory Disease 2015/16 There is good evidence that cold houses increase mortality across all social classes. Indoor temperatures as well as outdoor temperatures, are related to increased risk of exacerbations and extra respiratory deaths. Figure 18 shows that there is a relationship between colder outdoor temperatures i.e. during the winter months and higher levels of admissions for COPD in those corresponding months. This is similar to the national picture. Figure 18: Relationship between emergency admissions due to COPD and average regional temperature, 2012/13 The data shows that, during 2012/13, as the average monthly temperature decreased the number of admissions for COPD increased Interstitial Lung Disease Interstitial Lung Diseases (ILD) comprises a large number (over 150) of diverse conditions which primarily affect the lung s smallest airways and alveolar air sacs. Whilst the cause of some ILDs is unknown, there is an overlap with occupational and environmental lung diseases such as coal and slate workers pneumoconiosis, asbestosis and farmer s lung. It is known that some ILDs are caused by cigarette smoke and others may occur as a reaction to medication and yet others occur in association with diseases such as rheumatoid arthritis. Finally, ILDs need to be distinguished from other lung conditions which they sometimes mimic. Idiopathic pulmonary fibrosis, the commonest ILD, has shown a greatly increased prevalence over the past 20 years although local prevalence data is not easy to determine as a result of the range of conditions that could be included under the ILD definition. The number of emergency admissions per year for ILD has increased in the last few years. An assessment is needed to identify if this increase is as a result of increasing prevalence. There is also a need to assess if local community and primary care management and services achieve quality standards to prevent emergency admissions. 50 P a g e

51 Halton Joint Strategic Needs Assessment 2015/16 Table 20 : Number of admissions where ILD was present, by year Year Elective Emergency 2011/ / / Hospital admissions for ILD increase with age (Figure 19). The higher rates of admission amongst men are likely to reflect the work related nature of some forms of ILD, but the crude rates represent a significant burden on secondary care capacity Figure 19: Admissions where Interstitial Lung Diseases was present, by age and gender2011/12 to 2013/14 The median survival for idiopathic pulmonary fibrosis is just three years a prognosis that is worse than many cancers. Lung transplantation is the only treatment proven to improve survival in some forms of ILD. 51 P a g e

52 Respiratory Disease 2015/ Pneumonia Pneumonia can affect people of any age; however, it is more common and can be more serious for: Babies, young children and the elderly People who smoke People will other health conditions, such as a lung condition or weakened immune system Mild pneumonia can usually be treated at home with antibiotics, rest and fluids. For people with other health conditions, pneumonia can be severe and may need to be treated in hospital. The data for 2011/12 to 2013/14 shows that the rate of emergency admissions increases from 55 year of age onwards for both males and females and is higher in males than females from age 60 onwards. However, the admission rate in the 0-4 age group is higher than the 5-9 to age groups. Figure 20: Emergency admissions due to pneumonia, by age and gender, 2011/12 to 2013/14 Five wards in Halton had a statistically significantly higher admission rate than the borough during 2011/12 to 2013/ P a g e

53 Halton Joint Strategic Needs Assessment 2015/16 Figure 21: Emergency admissions due to pneumonia amongst those aged 18 and over, by electoral ward Similar to COPD there is a relationship between pneumonia admissions and monthly temepratures, with an increase during the winter months. Figure 22: Admissions due to pneumonia in Halton and average regional monthly temperature, 2013/14 This relationship can be further analysed. The correlation coefficient of the two sets of data is 0.6. This indicates that there is a moderate strength correlation (relationship) between emergency admissions due to pneumonia and mean monthly temperature. 53 P a g e

54 Respiratory Disease 2015/16 Figure 23: Correlation between monthly admissions for pneumonia and average regional temperature, 2011/12 to 2013/ Other respiratory conditions Asbestosis (J61) Data on emergency admissions due to asbestosis (where the code (J61) was present in any diagnosis position) by year for people aged 60+ shows a slight increase annually. Nearly all (93%) of the emergency admissions (11/12 to 13/14) were amongst men. Table 21: Admissions for Asbestosis amongst those aged 60 and over, 2011/12 to 2013/14 Admissions DSR LCI UCI 2011/ / / Cystic Fibrosis Data for 2011/12 to 2013/14 shows that there were 75 admissions amogst people with cystic fibrosis, ie were the ICD-10 b code of E84 was present at any diagnosis level. The table below splits them by type of admission. Elective Emergency Maternity/Other Total 2011/12 to 2013/ b) ICD-10 is the World Health Organisation International Classification of Diseases, version P a g e

55 Halton Joint Strategic Needs Assessment 2015/16 Readmissions to hospital are a significant factor for people with cystic fibrosis. Of the 75 completed inpatients 62 ( or 82.7%) of them were readmissions. 29 individuals accounted for the 75 admissions, with just 16 people accounting for 62 of the admissions Sleep Apnoea Between 2011/12 and 2013/14 there were 57 admissions where sleep apnoea (ICD-10 code G47.3) was the primary diagnosis. Unlike many other resipratory diseases, most of these (53) were elective admissions. Considering when the condition is included in any level of the diagnosis code there were 539 admissions, 287 elective and 252 non-elective. 73% of admissions were amongst men. Figure 24: Admissions where sleep apnoea was present, by age and gender, 2011/12 to 2013/14 At ward level, those wards that are more deprived have the higher rates of sleep apnoea, which may reflect levels of obesity. Two wards had statistically higher rates than the Halton average and five statistically lower rates. Figure 25: Admissions where sleep apnoea was present, by electoral ward, 2011/12 to 2013/14 55 P a g e

56 Respiratory Disease 2015/ Community Care: Halton Rapid Response Respiratory Team This team provide services for patients with respiratory illness in the Halton area, assessing conditions such as COPD, asthma, pneumonia, bronchiectasis, ILD and lung cancer. The team also has expertise in non-invasive ventilation (NIV) to help support patients with neuromuscular disease, chest wall deformity and OSA. It provides an accessible and responsive service that strives to deliver the highest standards of care possible, to patients with respiratory illness. Available services and information include: Respiratory assessment in your own home Pulmonary Rehabilitation Long-term Oxygen Therapy Ambulatory Oxygen clinics Nurse Led Clinics Physiotherapy led clinics Oxygen Therapy Halton Oxygen Assessment Service for Long Term Oxygen Therapy was formed in January 2009, following the introduction of the NICE COPD guidelines which recommended that all oxygen assessments should be completed in secondary care. The service is run by Senior Respiratory Nurse Specialists, based at Halton General Hospital. The service provides an up to date assessment for the people who are already on oxygen therapy so that they know what their oxygen needs are. Ambulatory oxygen therapy (AOT) allows the patient to leave the home and improves daily activities and quality of life. It is only indicated in a number of conditions: Group 1. On Long Term Oxygen Therapy with low activity level. This group do not usually require a formal AOT assessment. There flow rate is usually set to their Long Term Oxygen Therapy flow rate Group 2. On Long Term Oxygen Therapy but are active Group 3. Not on Long Term Oxygen Therapy but demonstrates exercise oxygen desaturation. In this group AOT should be considered only if there is evidence of improvement in exercise tolerance and dyspnoea and the patient is motivated to use it Integrated Breathe Easy Project The British Lung Foundation (BLF) Integrated Breathe Easy project aims to increase self-care opportunities for people affected by respiratory illness. Halton Clinical Commissioning Group is working in partnership with BLF to support the development of two new groups (Widnes and Runcorn). The groups provide peer support and access to a wide range of information that enhances and supports wellbeing. The groups are part of a national project seeking to establish the value of group-delivered self-care. The national project is due to report in June P a g e

57 Halton Joint Strategic Needs Assessment 2015/ Pulmonary rehabilitation Pulmonary rehabilitation is a programme of exercise and education for people with long-term chest problems designed to help patients manage breathlessness due to respiratory conditions. Pulmonary rehabilitation aims to improve patients' exercise tolerance, quality of life, and reduce breathlessness. The service in Halton is provided by Warrington and Halton NHS Foundation Trust s Rapid Respiratory Team. The programme runs twice weekly for 6 weeks. Each session comprises of 1 hour of individualised exercise and 1 hour of education. Each person receives a resource pack on completion with all aspects of education topics included and encouragement for people to continue with exercises at home after they have completed the course in order to maintain the benefits it produces. There are a number of ongoing exercise classes arranged for pulmonary rehabilitation patients the Halton Health Improvement Team. Between March 2012 and December 2013, 420 patients attended Pulmonary Rehabilitation in Halton. 69% at Halton Hospital and 31% at Ditton Community Centre The largest referrers were GPs, Respiratory Consultant (Halton) and respiratory physiotherapists. Of the GPs, Castlefields, Weaver Vale and Grove House referred the most patients Of those that attended; 171 patients completed at least 9 of the 12 sessions, 64 patients partially completed (<9 sessions), 49 did not attend and 101 were unable to attend due to illness As of June 2015 there were 22 people waiting for an appointment for assessment with a waiting time to assessment of 10 weeks. The service currently sees around 17% of people with respiratory illnesses Additional services are detailed in the Halton Respiratory Health Strategy 2015 to P a g e

58 Respiratory Disease 2015/16 5. Impacts of respiratory disease 5.1 Financial impact on the NHS Programme Budgeting Respiratory disease accounts for the fourth highest Programme Budgeting area spend per 100,000 population for Halton CCG during 2013/14. Figure 26: Programme Budgeting Expenditure Comparison across Main Programme Budgeting Categories, NHS Halton CCG, 2013/14 This can be split into different types of expenditure and shows that overall for respiratory disease a third is spent on prescribing and a third on non-elective admissions. COPD and asthma have a higher proportion of spend on prescribing, with nearly all asthma expenditure being in this category. Even for COPD and asthma, the second highest percentage of expenditure is on non-elective admissions. Table 22: Estimated expenditure splits across care settings, respiratory disease, expenditure per 100,000 population and percentage of total spend, NHS Halton CCG, 2013/14 58 P a g e

59 Halton Joint Strategic Needs Assessment 2015/16 This split by care setting is similar to the England averages, with Halton s spend on prescribing being slightly higher (by four percentage points) and its spend on non-elective care being slightly lower. This is also the case when compared to Halton s CCG cluster average, althought the difference between Halton s prescribing and the cluster is less that one percentage point. Figure 27: Expenditure on respiratory disease, percentage splits across care settings, NHS Halton CCG compared to England average, 2013/14 With a spend of 7,561,673 per 100,000 population, this places Halton in the 4 th highest spending quintile nationally, above the England average of 7,103,620 (red line shown in Figure 28) and slightly above its cluster CCG average of 7,495,968 (not shown in Figure 28). Figure 28: All CCG expenditure for respiratory disease, per 100,000 population, 2013/14 59 P a g e

60 Respiratory Disease 2015/ Spend Versus Outcomes: The Spend and Outcome Tool (SPOT) The Spend and Outcome Tool (SPOT) gives an overview of spend and outcomes across key areas of business. SPOT includes a large number of measures of spend and outcomes from several different frameworks. Similar organisations can be compared using a range of benchmarks and potential areas for further investigation identified. The tool allows the identification of areas requiring priority attention where shifts in investment will optimise local health gains and increase quality. It uses programme budgeting data and selected outcomes for each programme budgeting area. Figure 29: SPOT quadrant analysis Figure 30: SPOT: Programme spine chart for respiratory disease, Halton CCG, P a g e

61 Halton Joint Strategic Needs Assessment 2015/16 Analysis shows that overall Halton falls in the higher spend, worse outcomes quadrant. Looking in more depth at selected measures, premature (under age 75) mortality and unplanned (emergency) hospital admissions are the main drivers for this positioning, together with higher observed prevalence. We need to take into account however, that this higher prevalence may be a reflection of better cse finding locally than nationally, as in Halton 90% of those estiated to have COPD are on GP disease registers To wider society including the economy To estimate production losses caused by mortality from respiratory disease it was assumed that men would have worked until 65 and women until 60, had they not died. The number of working years lost due to deaths from respiratory disease was estimated by multiplying the estimated number of deaths in each age-sex group by the number of working years left to those who died. An estimated 99,000 working years were lost from deaths due to respiratory disease in the UK in This figure was adjusted to take account of the fact that not everyone was in employment, and was then multiplied by the average annual earnings for men and women in April This gives an estimated cost of respiratory related mortality of 1,914.5 million. Additionally, the Department for Work and Pensions records show that in Great Britain 24.9 million working days were lost from certified incapacity due to respiratory disease. Multiplying this by the average daily earnings for men and women in April 2005 and scaling up for the UK population produces an estimate of million of lost production due to respiratory disease. This does not include days lost from self-certified sickness and so will under-estimate the true cost of morbidity production loss. For some people of working age, the progression of their respiratory condition means they are unable to work and are claiming out of work benefits 61 P a g e

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