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Topic last reviewed: Mar-19

JSNA Topic: Chronic Obstructive Pulmonary Disease

Background

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) defines Chronic Obstructive Pulmonary Disease (COPD) as a 'progressively disabling disease, characterised by airflow obstruction that interferes with normal breathing. Typical symptoms include; increased breathlessness, persistent phlegm based cough and frequent chest infections.'

In the UK, it is estimated that more than 3 million people have COPD; with the disease undiagnosed in about 2 million of these people. COPD kills about 25,000 a year in England and Wales, accounting for approximately 5% of deaths. It is the fifth biggest cause of mortality in the UK.

COPD is the second most common cause of emergency admissions to hospital and one of the most costly inpatient conditions to be treated by the NHS.

The most common cause of COPD is smoking. Other causes of COPD can be attributed to workplace exposure, the Health and Safety Executive (HSE) suggests that about 15% of COPD cases can be linked to workplace exposures such as fumes, chemicals and dusts.

Poor housing is linked to respiratory disease. Mould spores and dust mites can lead to asthma and general respiratory irritation; these are most common in damp and poorly constructed houses.

COPD can be treated to improve the sufferer's quality of life but not cured. The most important preventative measure and treatment is to stop smoking. In England alone, one- third of all deaths from respiratory disorders are attributable to cigarette consumption, while smokers are 25 times more likely to die from lung cancer compared to those who have never smoked.

Most people are not diagnosed with COPD until they are 50 years of age or older. The prevalence of COPD increases with age and varies significantly by region. COPD is linked to social deprivation and it is more common in men. However, in recent years, the prevalence has reached a plateau in men but has increased in women. This reflects the increase in smoking among women.

Smoking prevalence is higher in Lincolnshire than the national average. There are an estimated 17,478 people with COPD in the county. The prevalence of COPD is significantly higher than the national average in all the Lincolnshire CCG’s except for South West Lincolnshire CCG. (Source: Public Health England)

Context

National Strategies, Policies & Guidance

The National Institute for Health and Clinical Excellence (NICE) COPD Clinical Knowledge Summary provides background information.

The NICE Pathway for Chronic obstructive pulmonary disease addresses both prevention and management of COPD.

The NHS planning guidance: Everyone Counts: Planning for Patients 2014/15 to 2018/19 asked commissioners for the first time to agree and set levels of ambition in their two and five year plans. A resource to support commissioners has been developed through partnership working between NHS England, the Commissioning Assembly, NHS Improving Quality, and Public Health England, with a section dedicated to respiratory disease.

The NHS Long Term Plan published in January 2019, makes lung health an NHS priority. The plan covers four main areas that are important for people affected by lung disease:

  • It proposes new ways of getting diagnosis right, this means that when people go to their GP with breathlessness or a cough that won’t go away, they should be referred for the right tests as quickly as possible.
  • Making more pulmonary rehabilitation available to people who need it, ensuring local clinics and sessions are accessible and offer flexible times. Pulmonary rehab helps people feel less breathless, be more active and be less likely to go to hospital.
  • Making sure everyone is on the right medication, with regular checks.
  • Looking at how health care workers can support people to manage their own condition, so they can keep doing the things that are important to them.

The Long Term Plan also places a greater emphasis on prevention. It commits more money to help people in hospital quit smoking, and promises to reduce the amount of air pollution which is caused by the NHS.

An Outcomes Strategy for Chronic Obstructive Pulmonary Disease and Asthma in England (DoH, 2011) sets out six broad outcomes to address COPD and asthma through high-quality prevention, detection and treatment, and care services.

The NHS Companion Document to the Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma sets out the evidence-based interventions that the NHS can take across the five domains to improve outcomes for people with COPD and asthma.

The Quality and Outcome Framework (QOF) financially rewards general practices for the provision of quality care, and helps to standardise improvements in the delivery of primary medical services. COPD is one of the clinical domains in the Framework, and has a range of associated indicators, including records and ongoing management (e.g. people with COPD who have had influenza immunisation).

In January 2018, the NHS RightCare » Improving outcomes in Chronic Obstructive Pulmonary Disease (COPD) was published, developed in association with NHS England’s National Clinical Director for Respiratory Services, the British Lung Foundation, the British Thoracic Society, Respiratory Futures, the Primary Care Respiratory Society (PCRS-UK), and the National COPD Audit Programme and a range of clinical and patient representatives and stakeholders. The pathway sets out to health commissioners and providers how to ensure early detection with accurate diagnosis and optimise long-term management to reduce exacerbations, hospital admissions and premature mortality. The plan looks to support people and patients with or at risk of, COPD achieving better health outcomes.

The pathway provides a national case for change and a set of resources to support local health economies to concentrate their improvement efforts where there is greatest opportunity to address variation and improve population health.

Local Strategies & Plans

The Joint Health and Wellbeing Strategy, approved by the Health and Wellbeing Board in June 2018, include a strong focus on prevention and supporting people to improve their own health and wellbeing.

The Joint CCG Operational Plan 2017-19 supports COPD prevention and management through implementation of multispecialty community providers (MCPs) within Integrated Neighbourhood teams, recruiting and upskilling staff to become COPD specialists and progressing the Self Care and prevention agenda.

Lincolnshire's Tobacco Control Strategy has six core strategic themes to support tobacco control including, helping tobacco users to quit and reducing exposure to second hand smoke; these strands are very relevant to COPD.

What is the picture in Lincolnshire?

What the data is telling us

The national prevalence of COPD is 1.9% according to 2017-18 QOF data. Lincolnshire data for 2017-18 at CCG level demonstrates a statistically significant higher prevalence of COPD in the Lincolnshire East CCG (2.7%) compared to the three other CCGs which have a prevalence of 2.1% in South West Lincolnshire and 2.0% in both Lincolnshire West and South Lincolnshire. (Source: Public Health England (PHE))

The COPD age standardised rate of death in the East Midlands is not substantially different from the national average; 53.0 per 100,000 population (England average 52.7 per 100,000 population). In Lincolnshire the age standardised rate for deaths from COPD is 50.6 per 100,000 population similar to the 2015-17 East Midlands and national averages.

Mortality for under-75s, considered preventable for respiratory diseases is a similar level in Lincolnshire (17.4 per 100,000 population) compared to England (18.9 per 100,000) and the East Midlands (18.6 per 100,000) for the period 2015-17. In Lincolnshire, Lincoln district has the highest rate of mortality for under-75s, considered preventable for respiratory diseases, with 24.4 per 100,000 population and South Kesteven the lowest rate at 11.4 per 100,000 population.

Both Lincolnshire (370 per 100,000 population) and the East Midlands (407 per 100,000 population have a significantly lower rate of emergency admissions for COPD in 2016/17 than the England average of 417 per 100,000 population.

In 2017, the Global Burden of Disease states that COPD is behind 6,917.07 years of life lost (YLL) and 4450.01 years lived with disability (YLD) in Lincolnshire. In total the Lincolnshire population had a disability adjusted life years (DALY) of 11,367.08 years and the number three cause of DALYs.

Smoking is the greatest risk factor for developing COPD; therefore it is important this need is addressed. Smoking prevalence in adults, in Lincolnshire currently stands at 16.3% (2017), higher than the England average (14.9%) and East Midlands at 15.7%.

Smoking prevalence in routine and manual jobs is higher at 26.9% in Lincolnshire, a decrease from 2016 of 0.3%.

Countywide 94.3% of COPD patients that continue to smoke are offered smoking cessation support and treatments. Lincolnshire West and Lincolnshire East areas fall significantly below this level with support offered to 90.2% and 89.5% respectively (Source: PHE).

Whilst uptake of smoking cessation services has improved, Lincolnshire still falls below the national average, which aims for 100% of COPD patients to accept support offered by smoking cessation services. COPD patients receiving support for smoking cessation are at least twice as likely to stop as those with no professional support (Source: Bartlett, Y.K. et al, 2013).

For further information see the JSNA Smoking Reduction in Adults topic.

Trend

Prevalence of COPD has remained steady in each of the four Lincolnshire CCGs. South West Lincolnshire CCG has had the lowest levels of COPD prevalence and until 2016/17 it remained with levels similar to the national prevalence. The three other CCG areas have all had significantly higher prevalence of COPD than the national average since 2005/06 and as in South West Lincolnshire; there has been a steady rise in COPD prevalence. In 2009/10 there were 14,601 people on the COPD register, compared to 17,876 in 2016/17, an increase of 3,275.

The age standardised rate of COPD death rates in the East Midlands have been increasing year on year since 2009/11 when the rate was 46.6 per 100,000 population. Until 2013/15, Lincolnshire had always had significantly lower levels compared to England, but is now at a similar rate. There has been a slow increase in these rates in Lincolnshire since 2009/11, when the rate was 43.6 per 100,000.

Emergency admissions rates for COPD in Lincolnshire have remained consistently significantly lower than the national rate since 2010/11.

Mortality in under-75s considered preventable for respiratory diseases in Lincolnshire had a significantly lower rate than the national average until 2010/12 but has shown similar rates since. Compared to 2010/12 the number of deaths per year has increased by 88.

Smoking prevalence in Lincolnshire has decreased since 2015 by 0.8% to 16.3% in 2017. Lincolnshire has had a similar smoking prevalence compared to the national prevalence since 2011.

Key Inequalities

The battle for breath | British Lung Foundation 2017 explored the link between lung disease and levels of social deprivation, identifying inequalities in a range of lung conditions. Overarching observations show:

  • Lung cancer and COPD are considerably more common in the most deprived communities, due to their association with smoking.
  • Outdoor air pollution, which is generally higher in deprived urban areas, is known to worsen symptoms of lung disease and can cause lung disease to develop - diesel is a classified carcinogen.
  • Around 80% of mesothelioma (a benign or malignant tumour of the lining of the lungs, heart, or abdomen) cases occur in men. Those most at risk are people who have been exposed to asbestos while working in heavy industry or the armed forces.

Deprived populations have the highest prevalence and highest under-diagnosis rates for COPD. There are ethnic disparities with black men in deprived urban areas having particularly high risk.

COPD accounts for a large proportion of the gap in life expectancy between the areas with the worst health and deprivation and the average – around 8% of the gap for men and 12% of the gap for women (Source: Department of Health).

Long-term smokers have the highest levels of mortality and illness related to their smoking activity.

There are a range of strategies and programmes to address health inequalities. The Marmot Review, a strategic review of health inequalities, identified six policy objectives for addressing health inequalities, for example, strengthening the role and impact of ill health prevention services.

There is an established link between the prevalence and impact of outdoor air pollution and socio-economic deprivation: (Source: The battle for breath - the impact of lung disease in the UK | British Lung Foundation).

The Active People's Survey (APS) identified higher levels of smoking prevalence in some areas across Lincolnshire, including Boston and East Lindsey; incidents of smoking prevalence, coupled with an aging population and a higher level of deprivation, in both districts would suggest greater health inequalities (Source: Sport England).

Current Activity & Services

General practices maintain a register of people with COPD; this register is linked to the Quality and Outcomes Framework (QOF), which is used to register the prevalence rates of specific health conditions within the population.

Patients with COPD are supported to manage their condition; the NHS currently provides specialist COPD services for patients with complex and intermediate COPD issues.

United Lincolnshire Hospitals NHS Trust and other secondary care providers across the county also provide services and provision of care for COPD patients.

Lincolnshire Community Health Services currently provide a county-wide respiratory service for patients with COPD including Pulmonary Rehabilitation. This Service provides programs of education and exercise for patients with COPD across the county. The programs consist of tailored exercise for each individual and a comprehensive educational package. The focus is on improving physical fitness, exercise tolerance, breathlessness management, quality of life and mood state.

The Lincolnshire Sustainability and Transformation Plan (STP) currently supports a 100 day respiratory programme; the programme is trialling in a number of areas to promote self-care and referral optimisation. These are:

  • A COPD App for patients to use to support self-care; further promotion is needed to ensure maximum uptake.
  • Educational sessions for patients including respiratory nurse and physiotherapy to give patients skills to support self-care, sessions are held in local community settings.
  • Triage of referrals: United Lincolnshire Hospital Trust (ULHT) have a lead consultant and team who triage referrals, either providing advice or guidance back to the GP or referring onwards to the Lincolnshire Community Hospital Service (LCHS) community team. Further evaluation of this service is expected late summer 2019.
  • Virtual Clinics: A respiratory consultant lead and a community respiratory nurse meet with GP practices to discuss potential referrals and identification of the best pathways for the patients. This provides a double benefit; the patient is put on the most appropriate pathway and develops shared knowledge between the GP and consultant.

Lincolnshire South & South West CCGs will be rolling out the myCOPD App via LCHS later in 2019. The aim of the app is to support patients to better manage their COPD. (Source: myCOPD)

Acute Respiratory Assessment Service (ARAS), is provided by Respiratory Nurse Specialists in partnership with hospital staff, community nursing teams, GPs and social services. The service is for patients with a confirmed diagnosis of COPD experiencing an acute exacerbation (flare up) where patients have sustained worsening of their symptoms; including breathlessness, cough, increased sputum production and change in sputum colour. This service helps to support patients and their careers in their own home and can help prevent an admission to hospital.

Two Patient Self Support Groups have been set up in Mablethorpe and Holbeach St Johns. Breathe Easy support groups are now running in Lincoln, Grantham and Sleaford.

Since 2016 Quit 51 have provided a specialist stop smoking service for Lincolnshire. In addition to the general service the stop smoking service has specific target groups to engage in smoking cessation and these are based on evidence of those who would benefit the most from stopping smoking;

  • Pregnant women supported throughout their pregnancy
  • Mental health clients, targeting those with long term mental health conditions such as Schizophrenia or Bipolar Disorder
  • Acute clients which includes smokers who are due to go into hospital for surgery or who suffer from long term conditions such as heart disease or COPD.

The service offers behavioural advice and support, together with access to proven nicotine replacement therapies. Advisors are trained professionals with experience in the field of smoking cessation. The service is currently going through a re-tendering exercise and it is proposed to introduce an Integrated Lifestyle Service (ILS) which will include a stop smoking service, by July 2019.

The focus of Lincolnshire's Tobacco Control activity is led by the Safer Communities team in Lincolnshire County Council. The Tobacco Control lead in Public Health continues to work closely with external organisations to support them in the delivery of their enforcement and legislative responsibilities.

For further information see the JSNA Smoking Reduction in Adults topic.

Unmet Needs & Gaps

NICE provides guidance on the risk factors associated with poorly maintained residential properties with damp and mould and associated respiratory problems; however greater awareness is needed to ensure the pathway and associated recommendations are embedded within housing protocols and good practice models. (Source: Excess winter deaths and illnesses associated with cold homes overview - NICE Pathways).

Further information can be found in the JSNA Excess Seasonal Deaths and Fuel Poverty.

In addition to diagnosing the COPD population, there is a need to continually identify and offer interventions to people at risk of COPD, through the NHS Health Check Programme and other risk assessment tools.

Further research is needed into the risks of exposure to and incidents of workplace hazards in Lincolnshire; focussing on industries pertinent to Lincolnshire including; agriculture, quarrying, plastics manufacturing and the food industry.

Local Views & Insights

Following extensive engagement by the British Lung Foundation in early 2018, their latest Five Year Plan was published in December 2018.

Our five year plan | Taskforce for Lung Health focuses a framework for improving the nation's lung health and provide better care for people with lung disease. The report makes numerous recommendations centrered around:

  • Improved workforce upskilling and training staff/partners.
  • Living with lung disease: these recommendations focus on improved care planning, promotion of best practice and diagnosis.
  • Keep Lung Healthy explores recommendations to improve prevention; suggestions include stop smoking services.
  • Right Care end of life; suggests improved end of life care and solutions that are person centrered.

All these recommendations could easily be reflected in local health plans, policies and strategies.

Risks of not doing something

Smoking is the greatest risk factor for COPD; therefore it is essential that interventions to reduce smoking prevalence continue to be applied across all population groups, whilst specifically targeting those who are at greatest risk.

If a patient's COPD condition is not carefully managed, serious health complications can occur, for example:

  • Increased mortality rates across the county
  • More frequent lung infections, such as pneumonia
  • Increased risk of osteoporosis, especially for those taking oral steroids
  • Heart failure affecting the right side of the heart
  • A collapsed lung
  • Respiratory failure
  • Arrhythmias, including atrial fibrillation.

(Source: Chronic obstructive pulmonary disease (COPD) - NHS Choices)

Financial implication of not addressing the need
It is estimated that the total costs of all respiratory illness across the UK is £165 billion including intangible costs such as (the human cost of excess morbidity and mortality).

Excluding intangible costs provides an estimated total cost to the UK of £11.1 billion; representing 0.6% of UK GDP in 2014. (Source: Probonoeconomics.NHS)

Some 25% of people with COPD are prevented from working due to the disease. (Source: Health and Safety Executive)

COPD is the second most common cause of emergency admission to hospital. COPD exacerbations are associated with poorer quality of life, faster disease progression and increased mortality. (Source: NHS COPD commissioning toolkit)

The total annual cost of COPD to the NHS is over £800 million. The annual cost of lost productivity to employers and the economy because of COPD has been put at £3.8 billion. (Source: NHS COPD commissioning toolkit)

Potential cost in Lincolnshire
It costs the NHS nearly ten times more to treat severe COPD than mild disease. The rate of lung function decline is faster in the earlier stages of the disease which can be modified by treatment. It is therefore of great importance to diagnose and treat early, yet it is believed that 3 million people in England have COPD but just under a million have been diagnosed with the disease. Of people with COPD, 10% are only diagnosed when they present to hospital as an emergency. The high re-admission rate of COPD sufferers also highlights the importance of self-care. (Source: Health and Safety Executive)

Emergency admissions to hospital due to acute COPD exacerbations, costs the NHS between £1,900 and £5,000 per patient for each admission. (Source: Academic Health Science Network)

By helping patients better control their COPD and reduce the severity and number of exacerbations, the NHS can avoid unnecessary costs and more importantly, help patients avoid the distress and disruption of emergency hospital admission.

What is coming on the horizon?

The full implementation of Lincolnshire Sustainability Transformation Plan (STP) aims to provide:

'More focus and resources targeted at keeping people well and healthy for longer; we will give them the tools, information and support within their community to make healthy lifestyle choices and take more control over their own care. This will improve quality of life for people who live with health conditions and reduce the numbers of people dying early from diseases that can be prevented.'

An essential element of the STP focuses on proactive care. This approach supports patients to self-care (manage their own conditions) more pro-actively with help from their local neighbourhood team, in turn reducing unplanned hospital admissions.

Lincolnshire County Council is currently commissioning an Integrated Lifestyle Service (ILS) which will provide services across four main areas: smoking cessation, weight management, physical exercise and excess alcohol consumption. This service will be primarily for those with long term conditions such as COPD, referrals will be taken from any health professional or self-referral in the case of smoking. The service will commence on 1 July 2019 and will run for up to 5 years.

The Lincoln Institute for Health (LIH) established in 2015, part of The University of Lincoln, aims to contribute towards available literature to create a better understanding and management of COPD. Current research focusses on non-pharmacological treatments for COPD. The Institute has also developed Lincolnshire’s first Joint Research Agenda (JRA) which is a collaborative project between the Lincolnshire NHS Trusts who provide community, primary and secondary care services, and the LIH, who provide access to a wide range of research expertise. This project aims to explore Lincolnshire’s COPD priorities, identify the key stakeholders and collaborators, and explore funding opportunities to develop this network and associated projects.

What should we be doing next?

Support and implement the joint Lincolnshire COPD objectives, which include:

  • Develop further smoking cessation services to support smokers with medical conditions, mental ill health and pregnancy.
  • Share the successes and learning from the STP 100 day programmes.
  • Increase the number of healthcare frontline staff trained to deliver advice.
  • Increases in screening appointments, increasing early diagnosis.
  • Greater structured support for patients with COPD within the community.
  • Explore the suggested recommendations in the British Lung Foundation – A National five year plan for lung health 2018.

 

If you need to contact us about this topic, please email JSNA@lincolnshire.gov.uk

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