HEALTH NEEDS ASSESSMENT: DISEASES OF THE RESPIRATORY SYSTEM. A report assessing the respiratory health need of the population of Bolton

Transcription

1 EXECUTIVE SUMMARY HEALTH NEEDS ASSESSMENT: DISEASES OF THE RESPIRATORY SYSTEM January 2009 A report assessing the respiratory health need of the population of Bolton

2 AUTHOR Mark Cook Public Health Intelligence Debra Malone Consultant in Public Health Andy Thompson Assistant Manager Unscheduled Care RESPIRATORY HEALTH NEEDS ASSESSMENT STEERING GROUP Andy Thompson Assistant Manager Unscheduled Care Debra Malone Consultant in Public Health David Holt Public Health Intelligence Specialist Mark Cook Public Health Intelligence Ali Rehman Information Services Vipin Ganatra Information Services Elizabeth Lees Information Services Dr. Lorraine Lowe General Practitioner Bolton 2

3 EXECUTIVE SUMMARY: Health needs assessment for respiratory conditions in Bolton Contents 1. Introduction NHS burden Key issues and gaps Who s at risk and why? The level of need in the population Current services in relation to need Projected future service use and outcomes Effective interventions Importance of early diagnosis and treatment Expert opinion and evidence base Unmet needs, inequalities in service use, and service gaps Recommendations for commissioning Recommendations for needs assessment work Overview of future need and impact of meeting this need Appendices Appendix a. Principal evidence base

4 EXECUTIVE SUMMARY This document summarises the key findings of the full needs assessment into respiratory conditions undertaken by. There are serious health inequality issues around respiratory disease where mortality in the most deprived areas is double that of Bolton as a whole, and these areas suffer very low COPD detection rates. Deficiencies with the current service means Bolton are outliers for COPD and pneumonia SMR s; identified problems from the Request for Needs and Opportunities Evaluation are that spends less (40%) than similar PCTs but with mixed performance and there is an issue of raising awareness and education amongst clinicians. Ideas to address this need focus on education, social marketing techniques, collaborative care plans, and beginning with the younger population especially women and the most deprived sections of the population. (A glossary of terms used is given in the full needs assessment). 1. Introduction The Strategic Plan for identified respiratory disease as a priority health concern for Bolton. It was also highlighted as a priority in the Joint Strategic Needs Assessment for Bolton, the feedback from the National Support Team for Health Inequalities and in the analysis of major killer illnesses for Bolton. The outcome target concerning respiratory disease in the Strategic Plan is aimed at reducing the mortality rate (DSR) from bronchitis, emphysema, and other COPD. This needs analysis included data on all diseases of the respiratory system (ICD10 J00-99), however, the focus has been on the major diseases of the lower respiratory system asthma (J45-46), bronchitis, emphysema and other COPD (J40-44) and pneumonia (J12-18). The major risk factor for developing COPD is smoking. High levels of deprivation are linked to high smoking and COPD prevalence. Reference should be given at this point to the fact other respiratory diseases have been considered. There are service redesign programmes currently under way at a North West and Greater Manchester level the concentration here has been guided by the current local need and services. These commissioning groups are concentrating on the following areas of respiratory disease: Sleep related breathing disorders; Occupational lung disease; Difficult to control asthma; Long term ventilation & respiratory intensive care; Interstitial lung disease; Chronic cough; Tuberculosis. The epidemiological data and service mapping of this work has been considered during this assessment. Additionally, it is relevant to point out that there are other reviews currently ongoing, particularly cardiovascular disease, where overlap is evident in the contributing factors, evidence base and some services. 4

5 2. NHS burden Whilst respiratory disease is a key issue in terms of reduced life expectancy and seasonal excess deaths, it also impacts negatively on healthy life expectancy and relatively high levels of morbidity. This in turn means that the costs of ongoing treatment and care are also relatively high. For example, consultation rates in primary care for COPD and Asthma indicate that frequent primary and secondary care input is required to keep patients as well as possible. COPD is estimated to cost the NHS 500 million per year in direct costs, whilst the estimated costs for asthma are even higher at 890 million a year. It is known, however that 75% of asthma admissions can be avoided by high quality routine care. Across England, this could save the NHS an estimated 43 million per year. Furthermore, a quarter of the population will visit their GP because of a respiratory tract infection each year and respiratory tract infections account for 60% of all antibiotic prescribing in general practice. Respiratory conditions, involving infection of the upper and lower respiratory tracts, are a frequent cause for attendance at primary care level, with a third of the UK s population visiting their GP at least once a year with a respiratory condition. Respiratory disease remains the most common reason for GP consultation and emergency admission to hospital. The cost to the health service is more than any other disease area 1. In total respiratory disease is estimated to cost the NHS and society a total of 6.6 billion - 3 billion in costs to the care system, 1.9 billion in mortality costs, and 1.7 billion in illness costs. Respiratory disease is the second most common illness responsible for emergency admissions to hospital. There are an estimated one million admissions a year for respiratory disease in the UK, suggesting a cost of 1,496.4 million to secondary care 2. The local impact both financially and operationally mirrors the national figures. In 2008/09, the Royal Bolton Hospital managed approximately 5,855 spells for diseases of the respiratory system, with 4,516 being non-elective. This equated to almost 25,000 bed days. Over this period the expense, when combined with recurrently funded community services rises to over 10 million per annum, which continues to rise year on year and is an indication that to maintain the status quo is not an option. 3. Key issues and gaps The main respiratory diseases that contribute to reduced life expectancy and/or long term morbidity in Bolton are: Asthma; Pneumonia; Bronchitis; Emphysema; Other COPD. These conditions are examined in detail as part of the full health needs assessment and an overview of the relative impacts of these diseases is contained within this summary. However there are a number of other respiratory conditions that also contribute to health inequality and reduced (healthy) life expectancy in Bolton. These are: 1 British Thoracic Society (2006) Burden of Lung Disease: A statistics report from the British Thoracic Society, British Thoracic Society, London. 2 British Thoracic Society (2006) Burden of Lung Disease 2 nd Edition, British Thoracic Society, London. 5

6 Lung Cancer Whilst cancer is a key cause of premature mortality in Bolton, lung cancer does not impact on morbidity and mortality in the same way as COPD and asthma. Tuberculosis About three quarters of Tuberculosis cases in England are among people who were born abroad, and of these over three-quarters developed the disease after they had been in the country for two years or longer. This places the migrant population of Bolton at a higher risk of Tuberculosis than the populations born in the UK. These national figures are replicated locally with a greater proportion of sufferers being from BME populations. Seasonal Excess Deaths Each winter (December to March) excess deaths occur. Nationally, respiratory diseases account for about a third of all excess winter deaths, whilst CVD accounts for half. Cystic Fibrosis Cystic fibrosis is the UK s most common life threatening inherited disease. It is difficult to ascertain the exact prevalence of the disease in the population of Bolton but individuals born with the condition have limited life expectancy and require ongoing therapeutic input. There are 184 people with cystic fibrosis locally. Obstructive Sleep Apnoea Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is the combination of irregular breathing and excessive day time sleepiness and represents a significant public health problem. The consequences of untreated sleep apnoea include impairment of cognitive function, mood and personality changes and can impact on area where reduced alertness is dangerous e.g. when driving or operating machinery. OSAHS is also an independent risk factor for high blood pressure and is related to increasing age, male gender, obesity, sedative drug use, smoking and alcohol consumption. It is difficult to establish the true prevalence of OSAHS in the population as is often unrecognised. Nevertheless the NHS North West specialist commissioning Team are carrying out work which will assist commissioners ensuring the issue is addressed in a more comprehensive way in the future. Estimations for Bolton put the figure at 6,100 sufferers of OSAHS. The default position for patients with mild/moderate exacerbations of respiratory illness is attendance to the emergency department, and subsequent emergency admission. It is apparent that the current pattern of service utilisation is not the most cost effective, in particular the high rate of hospital admissions. This statement is supported by the figures which display that there has been a year on year increase in non-elective admissions at Royal Bolton Hospital for respiratory conditions. Opportunities to reduce costs include: Ensuring a more systematic evidence based approach to care management in primary care in line with NICE guidance and identified local areas of need; The further development of accessible community based respiratory services; 6

7 Based on admission data covering the previous three years, there has also been a year on year increase in non-elective admissions of 2 days or fewer, potentially indicating that an admission to acute hospital care was not required; The establishment of an alternative assessment and treatment service, could offer a more cost effective alternative to hospital admission for this group of patients. 4. Who s at risk and why? Respiratory disease has a substantial impact on the health of populations at all ages and every level of morbidity. However, COPD predominantly affects adults over 40 years of age with a history of smoking, asthma can be linked to a family history, and 70% of cases of tuberculosis are seen in patients from BME communities. The major risk factor for developing respiratory disease is smoking or exposure to tobacco smoke. Socio-economic factors such as poor diet and 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. 5. The level of need in the population Mortality Mortality in Bolton from bronchitis, emphysema, and other COPD is 33% higher than the national average for males and 24% higher for females; Mortality from lung cancer is 27% higher than the national average for males and 19% higher for females; Mortality from pneumonia is 36% higher than the national average for males and 48% higher for females. The female figure of 48% is the second highest for pneumonia of the entire peer PCTs after Salford; Respiratory diseases account for approximately 16% of deaths in Bolton. If you include lung cancer this rises to 21%. Pneumonia accounts for the majority of respiratory illness related deaths, followed by bronchitis, emphysema and other COPD. Male respiratory related mortality has declined due to falls in industrial related disease and smoking prevalence, the rates for women in Bolton have seen little change. Respiratory disease mortality is strongly associated with deprivation with such areas as Halliwell Road with 211% more deaths than expected when compared to England and standardised for age. Impact on life expectancy Other respiratory disease (outside of bronchitis and COPD) is the second largest contributor to our gap in female life expectancy. Lung cancer is the fifth largest contributor to the gap in male life expectancy. Prevalence QOF 2008/09 disease registers show prevalence rates in Bolton for respiratory related conditions as: COPD 2% (5,667 people), asthma 6.3% (18,222); 7

8 The Bolton Health Survey 2007 found the following prevalence rates amongst the adult population: COPD 2.7% (5400 people), chronic bronchitis 7.5% (15,050), chronic cough 13.5% (27,090), and wheezing 18.7% (37,525); Modelled expected prevalence data when compared to QOF registers suggests that there is currently unmet need for asthma and COPD; The prevalence of respiratory disease is unsurprisingly highest in the most deprived areas and those with the highest levels of current smokers, evidence shows that these groups are not engaging with the primary care prevention initiatives; The Asian Pakistani population show the highest levels of asthma and chronic cough in Bolton. Lifestyle risk and socio-economic factors Smoking: Smoking prevalence reduced from 30% to 23% between 2001 and However, in central deprived areas, the prevalence is still as high as 36%. Housing conditions: In Bolton, 13.6% of households are without central heating which is higher than the regional and national average. The Bolton Borough Private Sector House Condition Survey estimates that over 4,500 homes in Bolton are statutorily unfit (not suitable for occupation), representing 5% of all households. All three of Bolton s constituencies have higher proportions of households classified as suffering from fuel poverty than the average for England West 17.5%, NE 18.5%, SE 19.1%. 6. Current services in relation to need Specific services in Bolton for respiratory conditions 56 GP surgeries. Chronic Disease Management Team: service supporting general practice to improve the management of COPD and heart failure. Rapid Access Breathlessness Clinic: commissioned to provide assessment, diagnostic tests and treatment to new onset of symptom, breathless patients. Domiciliary Oxygen Assessment Service: assesses patients with demonstrated or suspected hypoxia in line with BTS Guidelines 2004; assess patients who have not been assessed but are receiving oxygen. Pulmonary rehabilitation service: provides pulmonary rehabilitation for those with a diagnosis of COPD meeting the access criteria. Bolton Adult Respiratory Service (BART): provides support for acute episodes of respiratory illness. 8

9 Secondary care activity For all respiratory related hospital spells only 14% are elective, while 78% are emergencies. In Bolton, the chance of entering as a respiratory emergency is influenced by deprivation, with those in the most deprived quintile being almost 10% more likely to enter as an emergency than their least deprived counterparts; In 2008/09, the Royal Bolton managed approximately 5,855 spells for diseases of the respiratory system, with 4,516 being non-elective. This equated to almost 25,000 bed days; The non-elective spells covered the following disease groups: 22% acute upper respiratory infections, 20% other acute lower respiratory infections, 16% pneumonia, 15% other COPD, 11% asthma; In terms of percentage of bed days for the non-elective spells, pneumonia accounted for 35% (with an average length of stay of 14.2 days), other COPD accounted for 19% (with an average length of stay of 8.2 days), other acute lower respiratory infections accounted for 12% (with an average length of stay of 4.1 days). The longest length of stay was for lung diseases due to external agents (21.3 days), followed by cystic fibrosis (19.1 days); Between August 2008 and May 2009 there were 4,245 A&E attendances at the Royal Bolton, accounting for 6% of all activity. The majority of attendances are from the central areas of the borough and from those nearest to the hospital. More than a third of attendances are seen in the under 21 age group; For the same corresponding time period, the cost to the PCT annually is above 8 million. Outpatient services at Royal Bolton Hospital There are currently 24 outpatient clinics based at Royal Bolton Hospital which are coded as being designated for respiratory conditions. Over 2008/09 there were 6,161 appointments at a cost of 941,620. From April to August 2009 there have been 2,504 appointments; this equates to a total increase on the previous year of 14.52% with projected costs expected to exceed the previous year. Outpatient services at other acute trusts Over 2008/09 there was 891 respiratory outpatient appointments for Bolton residents at other acute hospitals. This amounted to a cost of 115, Projected service use and outcomes in 3-5 years and 5-10 years Identification of the currently undiagnosed populations will lead to increased workloads in primary and community settings in future years. However, early diagnosis and appropriate treatment should eventually reduce demand on acute settings. Bolton s population is ageing, with the 50+ population projected to increase from 88,000 in 2008 to 103,100 in 2021, with obvious impacts on disease and services. Whilst smoking levels have declined in Bolton in recent years, those still smoking after the new smoking legislation are likely to be the most difficult to engage with concerning interventions. 9

10 8. Effective interventions There are a range of effective interventions that can assist in preventing the development of respiratory disease or reducing its impact. These are: Immunisation against seasonal flu, pandemic flu and pneumonia; Smoke free environments; Environments will low levels of pollution and exposure to dust; Preventing and stopping smoking; Warm, well maintained homes that are not damp. These factors are discussed in detail in the full assessment. 9. Importance of early diagnosis and treatment In addition to the effective interventions outlined above, for many respiratory diseases, especially asthma and COPD, early diagnosis and effective treatment and management have a positive impact on long term health outcomes. Therefore, it is essential that: The public and professionals are aware of symptoms of respiratory disease; Individuals with suspected respiratory disease are encouraged to access early diagnostic and treatment services; Good disease management is promoted and people are empowered to use self care techniques; Health care professionals are able to offer effective treatment and support individuals in managing their condition. 10. Expert opinion and evidence base The National Service Framework for COPD is due to be published in 2009; it is anticipated it will highlight the following areas for improvement: Reduce inequalities in COPD care; Reduce healthcare utilisation costs; Develop a patient focused care pathway; Provide outcome measures for monitoring and measuring progress. There are NICE guidelines for the management of COPD in the community and clinically proven ways of adjusting therapy to reduce hospital admissions. NICE COPD Guidelines, Standards for Clinical Care, Clinical Guidelines 12 (February 2004). British Thoracic Society Guidelines, Standards for Clinical Care (2004). British Lung Foundation, Invisible Lives: Chronic Obstructive Pulmonary Disease (COPD) finding the missing millions (November 2007). Our Health, Our Care, Our Say (DoH 2006) highlights the importance of the movement of specialist care into a primary care setting, which is a key driver for the development of respiratory services. Supporting People with Long-Term Conditions (DoH 2005). 10

11 The principal evidence base for respiratory conditions is given in Appendix a. 11. Unmet needs, inequalities in service use, and service gaps Comparing QOF disease registers to expected prevalence and self reported prevalence of respiratory conditions suggests that there are many cases of undiagnosed asthma and COPD in the community. There are also major gaps evident concerning A&E attendances and lifestyle factors: In relation to GP surgeries, 30% are under their expected prevalence for COPD patients; for asthma 95% are below their expected prevalence; 57% of all A&E attendances come from people in the top two most deprived quintiles of deprivation; Smokers in the most deprived parts of Bolton are less likely to use the smoking cessation service and are generally less likely to have a successful outcome. 12. Recommendations for Commissioning Despite recent recurrent investment into community initiatives for respiratory services, and an increasing spend on acute services there has been no impact upon the number of nonelective (emergency) admissions, or the gap between predicted and actual prevalence and treatment of respiratory conditions. 13. Recommendations for needs assessment work We still require formal, comprehensive information regarding public views on their respiratory health and health needs and the barriers faced in addressing unhealthy lifestyles. We also require further consultation to enhance our understanding of patient s opinions on current services and interventions. The opinions of clinicians and other healthcare staff on respiratory related conditions and services need to be sought, and in line with the process of s commissioning toolkit this should be through to the visioning stage in order to further assess current and future service provision and need. 14. OVERVIEW OF FUTURE NEED AND IMPACT OF MEETING THIS NEED This section provides an overview of the future health needs of the Bolton population in relation to respiratory disease. Mortality from bronchitis, emphysema, and other COPD is decreasing in Bolton, the North West, and in England as a whole; though steady, the decline is not as swift as that of other major disease areas like circulatory diseases. In contrast, the mortality rate for lung cancer has been increasing in Bolton in recent years this is in contrast to both the North West and England s gradual decline. Pneumonia shows a similar pattern in Bolton to the North West and England but is significantly higher. Therefore, if we judge from past trends, the future looks varied for mortality from respiratory diseases in Bolton. The previously noted change from heavy industry to a more service led economy in Bolton has had an impact upon respiratory mortality and morbidity, especially in males, but lifestyle changes towards poor diet and sedentary behaviour are expected to have a profoundly negative impact on future need. 11

12 Population projections show that in the future Bolton will have an increasingly older population; this follows national trends. At present Bolton has a younger population than the average for England, and as this changes we can expect mortality from pneumonia to increase. Pneumonia is a particular problem in Bolton and is strongly associated with the elderly. This review has found an association to subsist between respiratory conditions and ethnicity in Bolton. The South Asian population in Bolton is set to increase and this will further impact upon future need. Using ONS time series data, and other releases from ONS relating to specific ethnicities within the South Asian community, we can estimate the future South Asian population in Bolton. At present there are estimated to be 24,700 people of South Asian origin in Bolton. By 2015 we can expect this population to grow to 26,700. Interestingly, the Indian population, which is by far the largest South Asian population in Bolton, has been slowly decreasing, while the Pakistani population, the second largest, is increasing. The Asian Pakistani population have been shown to be more likely than any other ethnic group in Bolton to suffer from respiratory symptoms. has recognized that COPD detection rates are very low in Bolton s most deprived areas. Mortality in these areas is double the Bolton average; the potential identification of this unmet need will lead to a future increase of COPD prevalence. There are a large number of impacts that will be realised if is successful in commissioning a wide range of effective services that deliver high quality interventions to reduce respiratory disease. Whilst there is a specific focus in the health needs assessment process relating to monitoring and evaluating services, it is expected that needs that are fully met n terms of respiratory disease will result in a: Reduction in COPD mortality; Reduction in asthma mortality; Reduction in cancer mortality (especially lung cancer); Reduction in seasonal excess deaths; Reduction in mortality from other forms of respiratory disease; Reduction in infant mortality; Increase in life expectancy; Increase in healthy life expectancy; Reduction in TB transmission; Reduction in influenza transmission; Reduction in smoking rates; Increase in seasonal flu vaccination rates; Increase in pneumococcal vaccine rates; Decrease in disability; Decrease in mobility problems due to shortness of breath; Reduction in respiratory disease prescribing costs; Reduction in emergency hospital admissions; Reduction in non elective admissions; Reduction in hospital length of stay; Reduction in repeat admissions; 12

13 Reduction in outpatient follow up appointments/interventions; Reduction in primary care consultations relating to poor disease management; Improved healthy lifestyles; Reduction in health inequalities; Increase in self care; Increase in service provision within the community. (See full needs assessment for complete reference list) 13

14 APPENDICES Appendix a. This appendix details the principal evidence base for this needs assessment. 1. Healthier Horizons Strategy, NHS North West (2008) 2. Report of the Next Stage Review, NHS North West (2008) 3. High Quality Care for All (the Darzi Review) (2008) 4. Bolton s Joint Strategic Needs Assessment, (2008) 5. NICE COPD Guidelines, Standards for Clinical Care, Clinical Guidelines 12 (February 2004) (including information from draft updates currently available) 6. British Thoracic Society Guidelines, Standards for Clinical Care (2004) 7. British Thoracic Society and Scottish Intercollegiate Guidelines Network 8. British Guideline on the Management of Asthma, A National Clinical Guideline 9. Invisible Lives. Chronic Obstructive Pulmonary Disease (COPD): finding the missing millions, British Lung Foundation (2007) 10. Our Health, Our Care, Our Say, Department of Health (2006) 11. Supporting People with Long-Term Conditions, Department of Health (2005) 12. National COPD Strategy 13. Report of The National Chronic Obstructive Pulmonary Disease Audit: Resources and Organisation of Care in Acute NHS Units across the UK, Royal College of Physicians of London, British Thoracic Society, and British Lung Foundation (2008) 14. Policy Implementation Guidance NHS 15. Evaluation of the Met Office health forecasting project for primary care and NHS trusts, Public and Environmental Health Research Unit, London School of Hygiene and Tropical Medicine 14