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Select Committee on Health Written Evidence

Memorandum by the British Lung Foundation (HI 50)

HEALTH INEQUALITIES

INTRODUCTION

1. Together with cancer and circulatory diseases, respiratory disease is one of the three greatest diseases of inequality in the UK. This submission from the British Lung Foundation focuses on the extent to which the NHS can help to achieve a reduction in health inequalities associated with respiratory disease, through primary and public health services.

EXECUTIVE SUMMARY

2. Respiratory disease is the UK's second biggest killer[1] and the most common cause of emergency hospital admissions[2]. Almost half of all respiratory disease deaths (44%) in the UK are associated with social class inequalities.[3]

3. Incidence and mortality rates from respiratory disease are higher in deprived populations due to: low birth weights; childhood chest illnesses; damp housing conditions; poor diet; smoking; and dusty occupations such as mining and milling.

4. Respiratory diseases associated with social class inequalities include lung cancer, COPD (Chronic Obstructive Pulmonary Disease), asthma, TB and childhood respiratory illnesses.

5. Deprived populations have the highest prevalence and highest under-diagnosis of COPD, a progressive lung disease caused mainly by smoking.[4]

6. The prevalence of smoking has declined greatly over thirty years but has remained over 60% in the poorest groups, despite changes in policy and social climate.[5] Current evidence suggests that smoking cessation services are not reaching all sectors of society.[6]

7. A general lack of public awareness of COPD means that there are an estimated 2.8 million people in the UK who don't know they have the disease. If left untreated, it could severely restrict their lives and eventually kill them.[7]

8. Misdiagnosis of COPD is a common theme in the UK, as are repeated admissions to hospital and poor outcomes of care. On average 15% of those admitted to hospital die within three months.[8]

9. Action on diagnosis, treatment and care of COPD would make a great difference to the delivery of the PSA target on health inequalities.

10. Research by the British Lung Foundation identifies communities at highest risk of future COPD hospital admission at postcode level and facilitates the precise targeting of at risk groups with social marketing campaigns. Many of these communities are in Spearhead areas.[9]

11. The BLF recommends the actions on pages 4-6 below. They include the following:

12. Existing QOF points in relation to spirometry testing should be linked to levels of spirometry training, ensuring that QOF points are attributed to GP practices who guarantee that testing is carried out by appropriately trained individuals.

13. Existing registers of people with COPD in primary care should be developed to include stages of disease progression, current treatment plans and whether end of life care is needed. Existing QOF points in relation to the register should be amended to reflect this change.

14. Smoking cessation services and nicotine replacement therapy should be made available for as long as is needed and delivered in a non-judgmental manner.

15. Each PCT should ensure that one of the 6 awareness campaigns it is obliged to carry out every year should be a respiratory disease campaign. Targeted awareness and diagnosis campaigns should be undertaken, particularly in the most deprived communities in the UK, to find people with undiagnosed COPD and ensure they receive appropriate treatment and care.

16. A written information pack should be given to all those diagnosed with COPD. New QOF points should be introduced for delivery of such information.

17. The tariffs for Acute Care should be unbundled so that community care for people with COPD can be funded and unnecessary hospital admission avoided.

18. PCOs should identify those at risk of COPD in the community and introduce services aimed at preventing unnecessary hospital admissions (outlined below).

BACKGROUND

19. Respiratory disease is the second biggest killer in the UK, accounting for 117,456 deaths a year. It is the most common cause of emergency hospital admissions and costs the NHS and society as a whole £6.6 billion a year.[10]

20. Almost half of all respiratory disease deaths (44%) in the UK are associated with social class inequalities compared with 28% of deaths from ischaemic heart disease.[11]

21. Respiratory diseases associated with social class inequalities include lung cancer, COPD, asthma, TB and childhood respiratory illnesses. The issue of lung cancer is being addressed by the Department of Health under the Cancer Plan and the Cancer Reform Strategy.

22. COPD (Chronic Obstructive Pulmonary Disease) is a progressive lung disease caused mainly by smoking. Deprived populations have the highest prevalence and highest under-diagnosis of COPD.[12]

23. COPD "hotspots" are concentrated in Scotland, ex-industrial and inner city areas of Northern England, and pockets of deprivation in otherwise affluent areas. Many of these hotspots have been identified as Spearhead areas.[13]

24. In women, respiratory disease accounts for 21% of the life expectancy gap between Spearhead areas and the rest of England—only circulatory diseases account for more (30%). COPD accounts for more than half of the respiratory total.[14]

25. In men, respiratory disease accounts for 15% of the life expectancy gap between Spearhead areas and the rest of England—only circulatory diseases and cancers account for more. COPD accounts for more than half of the respiratory total.[15]

ISSUES CONCERNING HEALTH INEQUALITIES ASSOCIATED WITH RESPIRATORY DISEASE.

26. Social class and poverty have an important effect on determining who has respiratory disease and who dies from it.

27. Incidence and mortality rates from respiratory disease are higher in poorer social groups due to:

(a) Antenatal and early life experiences: low birth weights; childhood chest illnesses; poor housing where families are exposed to damp and mould; poor diet; obesity; exposure to second hand smoke

(b) Occupation—respiratory diseases such as COPD are high amongst occupations such as coalmining and other dusty jobs. The UK is about to experience an epidemic of the chest cancer mesothelioma, which occurs amongst those exposed to asbestos in the workplace.

(c) Smoking—just under half of respiratory diseases are caused by smoking. The prevalence of smoking has declined greatly over thirty years but has remained over 60% in the poorest groups, despite changes in policy and social climate. Poorer smokers are much less likely to have quit and take in substantially more nicotine from their smoking and are more dependent.

28. At present about 24% of adults, or 10 million people, are smokers. At current reduction rates, it will take around 20 years to reduce this figure to 5 million. Half of this number will die prematurely from smoking, and social inequalities in mortality are likely to become more pronounced. Current evidence suggests that smoking cessation services are not reaching all sectors of society.

29. Communities in greatest need are least likely to receive the health services that they require. The diagnosis and treatment of lung disease has been neglected by local and national health care services in the UK, partly because of its association with smoking and partly through a lack of awareness amongst the public and health care professionals, particularly in primary care, of diseases like COPD.[16]

30. Misdiagnosis of COPD is a common theme, as is repeated admission to hospital and poor outcomes of care. On average 15% of those admitted to hospital die within three months.[17]

31. A general lack of public awareness of COPD in particular means that there are an estimated 2.8 million people[18] with the condition who don't know they have a disease which, if left untreated, could severely restrict their lives and eventually kill them. Most people are currently diagnosed when the disease is in its later stages when symptoms are severe and extensive lung damage is not reversible.[19]

32. Research by the British Lung Foundation carried out by Dr Foster Intelligence shows that most of the "missing millions" of people with COPD are likely to be found in the most deprived communities in the UK. The research predicted COPD future hospital admissions in every PCO in the UK using various data sources including hospital admissions data; GP surgery registrations data; Experian's Mosaic lifestyle segmentation and TGI Target Group Index Analysis. The research identifies communities at highest risk of COPD hospital admission at postcode level and facilitates the precise targeting of at risk groups with social marketing campaigns.[20]

33. Equity of provision is likely to widen health inequalities from COPD.

34. The government is unlikely to meet its PSA target in respect of health inequalities unless it addresses the above points. Action on the diagnosis, treatment and care of COPD would make a great difference to the delivery of this target.

35. BLF specialist respiratory nurses in Glasgow have made significant progress in providing treatment and care in the community of people with COPD, improving their quality of life and in reducing unnecessary hospital admissions.

THE BLF RECOMMENDS THE FOLLOWING COURSES OF ACTION FOR THE NHS TO REDUCE HEALTH INEQUALITIES IN RELATION TO RESPIRATORY DISEASE:

36. Ensure health professionals, particularly in primary care, receive better education and training in the causes and symptoms of respiratory disease.

37. Ensure health professionals in primary care have the skills and equipment to carry out regular and efficient spirometry testing (a simple lung test) on every individual from the age of 7 onwards, to be repeated every ten years or more often for those at increased risk of respiratory disease.

38. Care should be provided according to need, with the aim of achieving equity of outcome across different groups and areas.

39. Existing QOF points in relation to spirometry testing should be linked to levels of spirometry training, ensuring that QOFs are only paid to GP practices which can prove that testing is carried out by appropriately trained individuals.

40. Existing registers of people with COPD in primary care should be developed to include stages of disease progression, current treatment plans and whether end of life care is needed. Existing QOF points in relation to the register should be amended to reflect this change.

41. Smoking cessation services should be improved by extending the follow up time to one year and by making nicotine replacement therapy available for as long as it is needed.

42. Each PCT should ensure that one of the 6 awareness campaigns it is obliged to carry out every year should be a respiratory disease campaign. Targeted awareness and diagnosis campaigns should be undertaken, particularly in the most deprived communities in the UK, to find people with undiagnosed COPD and ensure they receive appropriate treatment and care.

43. An information pack should be given to all those diagnosed with COPD. The pack should be given on diagnosis and should be relevant to the stage of the disease. It should contain high quality information in a format and at a level of complexity appropriate to their needs and be culturally appropriate. It should include information about treatments such as Non-invasive ventilation.

44. New QOF points should be introduced for the production and delivery of such information.

45. Everyone with COPD should be given a self-management plan. This, together with the information above, should help people to manage their own condition better and to enable them to stay out of hospital, reducing the burden and cost of emergency admissions.

46. Written Care Plans should be introduced for everyone with COPD, including self-management plans for each patient.

47. Managed Clinical Networks for COPD should be established.

48. Non-invasive ventilation should be available for people with COPD who want it and are admitted to hospital.

49. People with COPD tell us they prefer to be treated at home. At present most payments contribute to keeping people with COPD in hospital. The tariffs for Acute Care should be unbundled so that community care for people with COPD can be funded.

50. Early supportive discharge should be available to everyone admitted to hospital with COPD and best practice followed on the provision of support at home.

51. PCOs should identify those at risk of COPD in the community and introduce services aimed at preventing unnecessary hospital admissions. These services could include:

52. Specialist help, advice and interventions should be available 24 hours a day for people with COPD who experience acute breathing problems. Patients prefer to receive this advice by telephone; a 24/7 Helpline and Advice service should be introduced to prevent unnecessary hospital admissions and help medication management.

53. Community nurses skilled in the care of people with COPD should be increased, particularly in areas of greatest need, following the good practice examples set by BLF nurses in certain areas of the UK.

54. Pulmonary rehabilitation should be provided for everyone with COPD who needs it according to existing NICE guidance, and follow up exercise classes should be provided for everyone who could benefit from it throughout the UK.

55. Patients and carers affected by COPD should be notified when they have reached the stage where end of life care is needed. A different package of care should be identified of a standard equivalent to that currently received by people affected by cancer.

56. The forthcoming NSF in COPD should be funded and taken forward in a positive manner.

57. A Health Equity Audit should be undertaken with regard to COPD incidence, prevalence and mortality.

58. Managed Clinical Networks for COPD in Scotland are an important first step but they must operate to the standard set by the forthcoming NSF for COPD as the incidence in Scotland is extremely high.

59. Respiratory strategies have been introduced in Wales and Northern Ireland but no action has been taken to implement them. These strategies must follow the examples set by England and Scotland in improving diagnosis, treatment and care for people with COPD.

ABOUT THE BLF

60. The British Lung Foundation (BLF) is the only charity working to help the eight million people in the UK with all lung conditions.

61. The BLF runs a network of support groups across the country for people living with lung disease. There are more than 200 Breathe Easy Groups across the UK, all run by patients to support patients.

62. The BLF provides a wide range of information on more than 40 lung conditions, in the form of leaflets and fact sheets, all of which can be accessed via our website (www.lunguk.org).

63. The BLF also funds medical research into all forms of lung diseases.

January 2008

1 Burden of Lung Disease, British Thoracic Society 2006. Back

2 Ibid. Back

3 Ibid. Back

4 Association of Public Health Observatories. Back

5 GHS 1973 and 2004. Back

6 Northwest Public Health Observatory. Back

7 Shahab L, Jarvis MJ, Britton J, and West R, Prevalence, diagnosis and relation to tobacco dependence of chronic obstructive pulmonary disease in a nationally representative population sample. Back

8 Commission for Healthcare Audit and Inspection, Clearing the Air: A national study of chronic obstructive pulmonary disease, 2006. Back

9 Invisible Lives: Chronic Obstructive Pulmonary Disease (COPD)-finding the missing millions. British Lung Foundation, 2007. Back

10 Burden of Lung Disease, British Thoracic Society 2006. Back