KEY POINTS

—  There are serious inequalities in health outcomes for people with asthma.

—  The NHS can play a key role in reducing these through ensuring that people with asthma receive tailored information and joined-up care.

—  People in deprived communities should be better supported to manage their condition through measures such as regular asthma reviews and the provision of written personal asthma action plans.

—  Central and local government departments need to work together to develop cross-cutting strategies to address the roots of these problems.

1.  ABOUT ASTHMA UK

  1.1  Asthma UK is the charity dedicated to improving the health and well-being of the 5.2 million people in the UK whose lives are affected by asthma[159]. We work together with people with asthma, health professionals and researchers to develop and share expertise to help people increase their understanding and reduce the effect of asthma on their lives.

  1.2  Asthma UK is delighted to have the opportunity to respond to the Health Committee's inquiry on health inequalities. Inequalities in asthma incidence, treatment and outcomes are a key concern for the charity, and we are very pleased that the Committee is seeking to address these inequalities.

2.  DEFINING THE PROBLEM

  2.1  There are serious inequalities in health outcomes for people with asthma. Many of those experiencing the worst outcomes are also subject to other social and economic disadvantages. For example, South Asians are three times more likely and Afro-Caribbean people are twice as likely to have an emergency hospital admission for their asthma compared to the white population[160].

  2.2  Also, people based in North-West England (where there are high levels of Spearhead PCTs) were 65% more likely to be admitted to hospital than people in the East of England in 2004 and between neighbouring PCTs, emergency admission rates for asthma can differ by four times[161]. Differences are even more striking for children as the PCT with the highest admission rate admits almost ten times more under-15s than the PCT with the lowest rate[162].

  2.3  Asthma UK's opinion research has revealed that people from socio-economic categories D and E have significantly lower expectations of the outcomes of asthma treatment than others[163] and are twice as likely as those from group A and B to expect asthma to make them compromise the way they live.

  2.4  Those who need NHS and social care services the most are often the ones who fail to get the care they require, for example, though poor communication and follow-up after hospital admission or through a lack of specialists.

  2.5  These negative health outcomes have broader consequences. Poor health can partially determine life chances, as well as being determined by them and long-term conditions can limit people's ability to work, or to learn. For example, over 12.7 million working days are lost to asthma each year, and almost a quarter of children with asthma miss at least six school days a year as a result of the condition. Social policies dealing with health, education, work and incomes should therefore be mutually reinforcing to address the roots of this problem.

3.  HOW THE NHS CAN CONTRIBUTE TO REDUCING HEALTH INEQUALITIES

  3.1  Inequalities in outcomes for people with asthma are likely to reflect endemic problems in the quality of the care provided throughout the system and as such, asthma treatment and outcomes can be used as a litmus test for the NHS. This is because asthma is a very common chronic condition which, for most people, can be manageable through effective primary care services relating to diagnosis, treatment, information and case management.

  3.2  Below outlines Asthma UK's recommendations on how the NHS should be addressing this problem:

3.3  Targeted information:

  People will not be empowered to better control their condition unless they have access to good information about their condition and about local health and social care services.

  3.4  Ensuring that people can access this in formats appropriate to all ages and communities is key. In particular, Asthma UK has carried out some research into the kinds of information that older people with asthma would find most useful in order to inform one of our own projects. The greatest number (90%) would like to receive their information from their GP's practice, often directly from their own doctor. Similar research should be carried out with those communities who are not benefiting from the NHS and social care services that they need to ascertain how services might be tailored to better suit them.

  3.5  Asthma UK provides information in a variety of formats and languages and we would like the Department of Health to adopt a similar approach. In some communities, change will only happen from within and not from a glossy website or brochure. Recent projects such as NHS Choices appear to be wholly web-based and such an approach might well widen inequalities.

  3.6  Asthma UK is currently focusing its efforts to support the needs of people with asthma in deprived communities and is undertaking a Department of Health Information Prescriptions pilot with Hammersmith and Fulham PCT. The pilot, which ended in December and is currently being evaluated, regularly consulted people in this spearhead PCT, looking at issues such as the reading age of health promotion materials and access to specialist telephone support. This will ensure that patients—many of whom have English as a second language—can effectively access the support and information they need to take control of their condition.

  3.7  Finally, patient groups are recognised as a trusted source of information. As such, Asthma UK calls upon the Government and the NHS to work more closely with patient groups to ensure that this information is accessible to those that could benefit most from it. This might include NHS Choices highlighting our literature on their site or NHS professionals more frequently offering or signposting patients to it.

3.8  Holistic care:

  It is important that health and social care systems are able to address all of the conditions that a person has and not just focus on a particular condition to the detriment of others.

  3.9  This is a particular issue for people from lower socio-economic backgrounds as people from social groups D and E are 1.5 times more likely to report having co-morbidities compared to people with asthma in all other social groups. Also, people with asthma who also have disabilities are far less likely to achieve international goals for treatment outcomes, which means that they are more likely to have asthma symptoms, more likely to experience limitations on their daily activities and are more likely to need reliever treatment.

  3.10  To more effectively target health inequalities within these areas, the needs of people with multiple conditions must be better addressed. For example, evidence shows that long-term medical conditions may be overlooked if a patient also has a mental health condition and a recent regional study on asthma deaths has shown that in over 80% of cases, behavioural and psychosocial factors contributed to the patient's death, and the vast majority of these deaths may have been preventable[164]. The NHS needs to ensure that patients with complex needs have access to longer sessions with their healthcare professionals so that all of their needs can be fully addressed.

4.  THE ROLE OF GP SERVICES AND THEIR INFLUENCE ON HEALTH INEQUALITIES

  4.1  Improvements in services for people with asthma from the point of diagnosis and all along the care pathway could have real benefits in reducing inequalities of outcome. Given the differences in health outcomes that are noted above, we would like the Government to be more proactive in supporting people in deprived communities to manage their condition through measures such as regular asthma reviews and the provision of written personal asthma action plans.

  4.2  As an estimated 75% of emergency asthma admissions could be avoided, effective targeting of those who are more likely to have an emergency episode would be an effective use of government funds. This is particularly true as caring for people after an asthma attack costs the NHS 3.5 times more than caring for those whose asthma is well-managed.

  4.3  Asthma UK would be keen to see the inclusion of written personal asthma action plans within the Quality and Outcomes Framework. This is a valuable tool in helping people to self-manage their asthma and keep it under control. Research has shown that people who do not have a written personal asthma action plan are four times more likely to be admitted to hospital as a consequence[165].

  4.4  Self-management education has been proven successful in a broad range of populations. UK studies[166], [167] recruiting specifically from deprived populations have demonstrated that such techniques have reduced exacerbations and unscheduled GP consultations and A&E attendances, though sub-group analysis suggests that the effect may be less than in white European populations. This observation should focus attention on the need for individualised action plans, taking into account cultural and personal preferences as well as clinical need.

5.  THE ROLE OF PUBLIC HEALTH SERVICES IN REDUCING INEQUALITIES

  5.1  The health impact of smoking on asthma and other conditions is enormous: smoking reduces lung function, increases the risk of asthma attacks and can lessen the effectiveness of some asthma medicines. 82% of people with asthma tell us that smoke triggers their symptoms[168] and living with a smoker increases the risk of adult-onset asthma fivefold[169]. The risk to children from smoking parents is also considerable. Smoking during pregnancy increases by 35% the risk of a baby being wheezy or having breathing difficulties[170].

  5.2  Whilst there has been a reduction in the number of smokers in England over the past few decades, there has not been a significant change in the prevalence of smoking for people on lower incomes. This is clear when you compare the smoking prevalence among men in professional occupations (15%) to the smoking prevalence among men in unskilled manual occupations (42%)[171]. As such, Asthma UK considers it essential that the Government develops a comprehensive tobacco control strategy which focuses on the needs of those in the most deprived communities.

  5.3  Obesity is also a public health concern that disproportionately affects people from deprived communities[172] and people with asthma as people who are obese are 50% more likely to have asthma[173]. It is therefore essential that people are supported to be physically active by healthcare professionals as a part of their asthma management.

  5.4  This can be a particular issue for children as around one-third of children with asthma miss out on PE and sports about once a week because of their condition, despite the fact that most should be able to take part as long as their asthma is under control. Asthma UK calls upon the Department of Health and the Department for Children, Schools and Families to address the specific needs of children and young people with long-term conditions to ensure that they are encouraged and supported to participate fully in physical activity.

6.  CROSS-GOVERNMENT ACTION TO ADDRESS ALL THE DETERMINANTS OF HEALTH INEQUALITIES

  6.1  No one agency can address all of the factors contributing to health inequalities, so it is vital that different departments in national and local government work together to develop cross-cutting strategies to address the roots of these problems. Poor housing, pollution, poverty, disability, age and ethnicity all affect asthma outcomes, meaning that improvements will be limited without co-ordinated policies.

6.2  Housing:

  Children living in damp, mouldy homes are 1.5 to three times more likely to experience coughing and wheezing[174] and a recent Cardiff University study (partially funded by Asthma UK) found that removing indoor mould improved asthma symptoms. We recommend that national and local government liaise more effectively to improve the quality of existing housing.

6.3  Air quality:

  Asthma UK would like the Government to prioritise improvements in indoor and outdoor air quality. Traffic fumes and other airborne pollutants can trigger asthma attacks and 66% of people with asthma tell us that their symptoms are worsened by traffic pollution. Valuable steps, such as the development of Low Emission Zones, are already being taken in parts of the UK and we would like such action to be adopted more widely.

6.3  Children:

  Almost a quarter of children with asthma miss at least six school days a year as a result of the condition. Social policies dealing with health, education, work and incomes should therefore be mutually reinforcing to address the roots of this problem. Children and young people are among the most vulnerable to the effects of inequalities, so policies should be targeted to help them.

January 2008

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162   Unpublished data derived from hospital episode statistics 2004. Back

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