1

Respiratory Health Needs Assessment for Hillingdon 2017

March 2018

2

Contents

Summary ................................................................................................................................................. 4

Recommendations .................................................................................................................................. 5

1. Introduction .................................................................................................................................... 6

2. Why is respiratory disease important to Hillingdon? ..................................................................... 7

3. Hillingdon's demographics .............................................................................................................. 8

4. The local and national context ........................................................................................................ 9

5. Organisation of respiratory services in Hillingdon ........................................................................ 10

6. Burden of Respiratory disease in Hillingdon ................................................................................. 11

6.1 Risk factors .................................................................................................................................. 11

6.2 Mortality ..................................................................................................................................... 19

6.3 COPD ........................................................................................................................................... 20

6.4 Asthma ........................................................................................................................................ 22

6.5 Pneumonia .................................................................................................................................. 23

6.6 Tuberculosis (TB) ......................................................................................................................... 24

7. Future need ................................................................................................................................... 25

7.1 Future prevalence of COPD ......................................................................................................... 25

7.2 Future prevalence of asthma ...................................................................................................... 26

8. Respiratory services in Hillingdon ................................................................................................. 28

8.1 Prevention: Smoking cessation ................................................................................................... 28

8.2 Prevention: Vaccination .............................................................................................................. 30

8.3 Prevention: COPD screening ....................................................................................................... 31

8.4 Treatment: Respiratory care services ......................................................................................... 32

8.5 Rehabilitation: Pulmonary rehabilitation ................................................................................... 33

8.6 Cost of care ................................................................................................................................. 34

9. Overview of best practice in respiratory care ............................................................................... 35

10. Guidelines and Resources ......................................................................................................... 37

11. References ................................................................................................................................ 38

3

List of figures Fig 1: Causes of death in Hillingdon 2015 ............................................................................................... 7

Fig 2: Primary cause of admission 2014-17............................................................................................7

Fig 3: The projected Hillingdon population by ethnicity 2016-2021 ...................................................... 8

Fig 4: The projected Hillingdon population by age group 2014-2024 .................................................... 8

Fig 5: Smoking prevalence in Hillingdon and England 2012-2015 ........................................................ 11

Fig 6: Sources of air pollution in Hillingdon .......................................................................................... 12

Fig 7: Annual NO2 concentration and focus areas................................................................................ 13

Fig 8: Non-elective admissions for COPD by ward 2013-2015.............................................................. 13

Fig 9: Excess mortality (relative to summer low) in coldest and warmest 25% of homes ................... 15

Figure 10: Hospital admissions for respiratory disease 2014/15 (admissions/10,000 pop) ................ 16

Fig 11: Age-standardised rate of hospital admissions for respiratory disease by deprivation rank in

Hillingdon 2013-2016 ............................................................................................................................ 17

Fig 12: TB notifications by place of birth and ethnic group, England 2015 .......................................... 18

Fig 13: Mortality from respiratory disease (2009-2015) ....................................................................... 19

Fig 14: Mortality from respiratory disease by ward 2015 .................................................................... 19

Fig 15: Excess winter deaths in England by main cause (2012-2016) ................................................... 20

Fig 16: COPD admissions by age 2014-2016 ......................................................................................... 20

Fig 17: COPD admissions by month 2014-2016 .................................................................................... 21

Fig 18: Age-adjusted COPD admissions by ward 2014-2016 ................................................................ 21

Fig 19: Care for COPD in Hillingdon in comparison to peers 2015/16 .................................................. 21

Fig 20: Non-elective admissions for asthma by age 2014-2016 ........................................................... 22

Fig 21: Asthma admissions by month 2014-2016 ................................................................................. 22

Fig 22: Age-adjusted Asthma admissions by ward 2014-2016 ............................................................. 22

Fig 23: Care for Asthma in Hillingdon in comparison to peers 2015/16 ............................................... 23

Fig 24: Pneumonia admissions by age 2014-2016 ................................................................................ 23

Fig 25: Pneumonia admissions over time 2014-2016 ........................................................................... 23

Fig 26: Pneumonia admissions by ward 2014-2016 ............................................................................. 24

Fig 27: TB incidence compared to England 2000-2015 ......................................................................... 24

Fig 29: Schematic of the transition states of the COPD prevalence model .......................................... 25

Fig 30: Projected prevalence of COPD by scenario ............................................................................... 26

Figure 31: The number of smokers per 100,000 population setting a quite date and successfully

quitting Apr to Sep 2016 ....................................................................................................................... 28

Figure 32: The number of smokers per 100,000 population setting a quite date and successfully

quitting by type of setting Apr to Sep 2016 .......................................................................................... 28

Figure 33: The number of smokers per 100,000 population setting a quite date and successfully

quitting by method Apr to Sep 2016 .................................................................................................... 29

Figure 34: The cost per quit for Hillingdon in comparison to regional peers Apr to Sep 2016 ............ 29

Fig 35: Childhood pneumococcal vaccine uptake in Hillingdon and comparators 2014-2017 ............. 30

Fig36: Adult pneumococcal vaccine uptake in Hillingdon and comparators 2014-17.......................... 30

Figure 37: Proposed Integrated Care Model (Hillingdon CCG) ............................................................. 32

Fig 38: Rate of referral of COPD patients for pulmonary rehabilitation 2013-2015 ............................ 33

Fig 39: Cost of respiratory care 2015/16 .............................................................................................. 34

Fig 40: Respiratory spend versus outcomes for Hillingdon in comparison to peers 2015 ................... 34

4

Summary

Respiratory disease is the third highest cause of health issues in Hillingdon. It contributes

to at least 15% of hospital admissions and costs approximately £10m to the health

service in Hillingdon annually.

Smoking is the strongest risk factor to developing respiratory disease and is estimated to

contribute to more than 300 deaths in Hillingdon annually. 16.9% of Hillingdon residents

smoke, which is comparable to the England average. A higher proportion of younger

adults in Hillingdon smoke in comparison to the London average.

Poor air quality is thought to contribute to a sizable proportion of acute exacerbations of

asthma and COPD as well as up to 90 deaths in Hillingdon annually. The Government's

new air quality plan places greater emphasis on local authorities to tackle air pollution

through a combination of planning and transport policies.

Respiratory disease disproportionately affects people of lower socio-economic status

due to lifestyle and environmental factors. In Hillingdon there is a clear link between the

rate of hospital attendance for acute respiratory disease and how deprived an area is.

3.5% of adults in Hillingdon are thought to have COPD but only 1.2% of them have been

identified. The number of residents with COPD is expected to increase to 10,799 by

2030.

Approximately 5% of Hillingdon residents have been diagnosed with asthma. This is

expected to increase to 33,041 by 2030

The annual incidence of TB in Hillingdon is 36.5 per 100,000 which is the 6th highest rate

in London.

Smoking cessation services in Hillingdon have comparable effectiveness to peers but lag

behind them in terms of the proportion of the smoking population engaged.

There has been a steady decline in the coverage of childhood pneumococcal vaccination

in Hillingdon resulting in lower rates than both the London and England average.

Hillingdon is transitioning to an integrated model of care that is expected to provide a

more coordinated and higher quality service to patients.

Referral rates to pulmonary rehabilitation for patients with COPD are lower than peers

5

Recommendations

1. There is an opportunity to review the cost-effectiveness of Hillingdon's smoking

cessation service.

2. Hillingdon council and its partners have a key role in improving air quality through a

variety of planning and transport policies as well as targeted support for the more

vulnerable. This is especially important given the proposed third runway at Heathrow

airport and other projects that will likely impact air quality in the borough.

3. Many of the risk factors for respiratory disease intersect in communities where

deprivation is high. Lower-quality housing, proximity to major highways and higher

prevalence of smoking make these communities more susceptible to respiratory disease

and result in significant health inequality. Focus on improving awareness and mitigating

environmental factors will help reduce risks in these communities and ultimately the

burden on healthcare and the wider economy.

4. Emerging evidence suggests that proactive COPD screening is easily implemented and

very cost-effective. There is an opportunity for Hillingdon council and the CCG to

collaborate on enhancing the pharmacy-based COPD screening initiative currently in

operation.

5. Hillingdon has the 6th highest rate of Tuberculosis in London. While the numbers starting

and completing treatment compare favourably with peers, there needs to be focus on

improving diagnostic services as they lag behind the rest of the capital.

6. There should be further investigation into the reasons behind the higher rate of non-

elective admissions for COPD and marginally higher costs as compared to peers.

7. In transitioning to an integrated model, focus should be on ensuring specialists provide

strategic and clinical input across the pathway, enabling effective communication

between teams and providing adequate training and education for staff. There is also an

opportunity to collaborate with other partners to ensure patients' home, social and

school environments enable rather than hinder good respiratory health.

8. Referral to and delivery of pulmonary rehabilitation should be reviewed to ensure all

eligible patients benefit to a maximum degree.

9. Effective self-management is an important component of good care for patients with

COPD and asthma. A focus on self-care, supported by regular multi-disciplinary reviews

will help to improve outcomes and reduce unplanned admissions to hospital.

6

1. Introduction

1.1 Purpose and scope of this report

The purpose of this assessment is to estimate current and future need for respiratory care

and prevention services in Hillingdon. It will describe the key drivers of respiratory disease

and usage of health services. It will also compare the needs in Hillingdon with other

populations and incorporate the views of key stakeholders where available.

1.2 Health Needs

Need is defined as the population’s ability to benefit from health care or other

interventions, demand is what people would be willing to pay for in a market or might wish

to use in a system of free health care, and supply is what is actually provided

1.3 Methodology

The needs assessment was based on:

o Epidemiological analysis of available routine and local information. This included

population data from Office for National Statistics (ONS), risk factors from Public Health

England (PHE) and health service data from NHS digital.

o Comparative analysis of respiratory health in Hillingdon in relation to its peers and

regional or national average. The identification of Hillingdon's peers was based on NHS

England's 10 most similar CCGs (Clinical Commissioning Group) as well as CIPFA's

identification of the 15 most similar councils, both of which were based on relevant

population characteristics.

o A review of relevant published research: This involved a search of the MEDLINE

bibliographic database. MESH terms included 'respiratory, COPD, asthma, TB,

pneumonia, influenza' which were cross-referenced with terms such as ' incidence,

prevalence, mortality, burden, deprivation'. An additional search was carried out to

identify relevant publications from the Department of Health, NHS England, PHE, DEFRA,

British Lung Foundation, Respiratory Futures and several other organisations.

7

2. Why is respiratory disease important to Hillingdon?

Respiratory disease is the third highest cause of death in Hillingdon. It contributes to at least

15% of hospital admissions and costs approximately £10m1 to the health service annually.

Other costs, including working days lost, are estimated at £5.7m2. Most of this burden is

from asthma, chronic obstructive pulmonary disease and pneumonia (figure 2). Other

diseases include allergic rhinitis, obstructive sleep apnoea, bronchiectasis and lung fibrosis

but have lower population impact.

Fig 1: Causes of death in Hillingdon 2015 (BPT)i Fig 2: Primary cause of admission 2014-17 (HES)i

Chronic obstructive pulmonary disease (COPD) results from gradual but progressive lung

damage leading to irreversible airflow limitation. COPD predominantly affects those over

the age of forty with a history of smoking. Other factors include workplace exposure,

genetic make-up and environmental pollution. 3.5% of adults in Hillingdon are thought to

have COPD but only 1.2% of them have been identified.

Asthma is a long-term condition that affects the airways in the lungs. Symptoms include

breathlessness, tightness in the chest, coughing and wheezing. The aim of asthma treatment

is to achieve freedom from symptoms. Specific triggers such as air pollution can trigger

attacks. Approximately 5% of Hillingdon residents have been diagnosed with asthma.

Pneumonia is an inflammation of the lungs commonly caused by infection. Symptoms range

from mild malaise and cough, to life-threatening breathlessness. There are approximately

100 hospital admissions per month following a seasonal pattern that peaks in winter.

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis. It can

affect almost any organ in the body. Most cases occur in major cities, particularly in London.

If active TB is diagnosed early, it is curable in around 95% of cases. In Hillingdon the annual

incidence of TB is 36.5 per 100,000 which is the 6th highest rate in London.

Preventing a large proportion of these diseases is possible by addressing lifestyle factors

such as smoking as well as occupational and environmental factors such as air pollution and

damp housing. Furthermore earlier detection of respiratory disease provides significant

benefit to patients and the health service which should be a priority for Hillingdon.

i BPT - LBH Business & Performance Team, HES - Hospital Episode Statistics, supplied by Hillingdon CCG

URTI

Pneumonia

COPD

Asthma

Other LRTI

Other13% Respiratory

Cancer

Circulatory

Digestive

Mental and Behavioural

Trauma and injury

Other

8

3. Hillingdon's demographics

Greater London Authority population projections estimate that in 2017 there are 307,000

people living in Hillingdon3. Approximately 23,200 (7.6%) are aged 0-4 years and 42,400

(13.8%) are aged 5-15 years. 202,000 (65.6%) Hillingdon residents are of working age (16-64

years). 21,200 are aged 65-74 (6.9%) and 19,200 (6.1%) are aged over 75. Hillingdon is an

ethnically diverse borough with 45% of residents from Black and Minority Ethnic groups.

Fig 3: The projected Hillingdon population by ethnicity 2016-2021 (Hillingdon JSNA 2016)3

The population of Hillingdon is expected to grow substantially over the next few years due

to developments in the borough. The majority of the population growth will be in the 20-39

and 40-64 age groups (70% of total growth). Uxbridge North will account for half of all the

growth in the borough up to 2021. Net international migration will account for

approximately half of the annual population increase in Hillingdon. In terms of respiratory

disease this will mean an increased need for respiratory care services.

Fig 4: The projected Hillingdon population by age group 2014-2024 (Hillingdon JSNA 2016)3

54% 50%

10%11%

20% 22%

1% 2%9% 9%

5% 6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2016 2021

Other

Other Asian

Chinese

South Asian

Black

White

0

50

100

150

200

250

300

350

400

2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024

85+

65 to 84

40 to 64

20 to 39

5 to 19

0 to 4

9

4. The local and national context

In recent years there has been renewed focus on improving respiratory health. The

outcomes frameworks for Public Health, Adult Social Care and the NHS contain at least 42

domains particularly relevant to respiratory disease. The National Outcomes Strategy for

COPD and Asthma4 set out a vision to empower those who are at risk or have COPD and

asthma to lead the lives they want and stay healthy as well as supporting staff to deliver the

care people need. The need to deliver this vision has been reinforced by recent national

audits on COPD care and asthma deaths that recommend better coordination of care,

assisted discharge and empowerment of patients to care for themselves more effectively.

The Five Year Forward View5 and the subsequent Sustainability and Transformation Plan

(STP)6 for North West London have placed emphasis on maintaining health in the population

and delivering services in a more integrated manner but also require local systems to

collaborate to manage increasing demand with fewer resources. Upgrading prevention,

reducing unwarranted variation in the management of long-term care (LTC) and ensuring

people access the right care, in the right place, at the right time are priority areas in the STP

particularly relevant for respiratory conditions. Hillingdon CCG has a LTC Transformation

strategy that aims to work with STP partners to reduce the prevalence of LTC needs whilst at

the same time empowering patients to better manage their conditions with fewer

complications, improved access to advice and support and better long term outcomes whilst

operating within the CCG’s financial envelope. Hillingdon's recent move to an integrated

care model for respiratory care is a positive step in this regard.

The Better Care Fund (BCF), a single pooled budget for health and social care services, is

another example of this collaborative approach and represents a further opportunity to

further improve care for people with long-term respiratory conditions. In Hillingdon the BCF

is focused on improving community services, preventing admissions to hospital and

facilitating their discharge back home all of which are important for people with long-term

respiratory conditions such as COPD.

Improving air quality has also become a greater priority as pollution levels have increased in

recent years and more evidence has emerged about its effects on health. It is thought that

the switch to diesel cars has reduced CO2 emissions but contributed to greater levels of

nitrogen oxides and particulate matter that is now thought to impact on health. Local

authorities are required to review air quality in their area and designate air quality

management areas where action plans are put in place. A new government plan on

improving air quality published in May 2017 which places emphasis on local authorities to

designate clean air zones, encourage uptake of cleaner fuel technology and enhance public

awareness of air quality and measures to improve it7. In Hillingdon the expected work on

the high-speed rail-link and the recent announcement for a third runway at Heathrow

Airport represent a further challenge to local air quality placing greater urgency on an

effective response to ensure their effects on respiratory health are minimised.

10

5. Organisation of respiratory services in Hillingdon

A number of different organisations deliver care in relation to preventing or treating

respiratory disease in Hillingdon. These include:

Prevention services: The Hillingdon Stop Smoking service runs regular community clinics

and commissions cessation activity through community pharmacies and general

practice. NHS England commissions immunisations for pneumonia and influenza from

general practice and school-vaccination teams.

Primary care services: There are 46 practices in Hillingdon that provide services such as

diagnosis, monitoring and ongoing management of respiratory disease as well as

prevention activities such as immunisation and smoking cessation.

Community district nursing: This is currently delivered by community matrons who visit

people with long-term respiratory conditions to help manage their condition.

Secondary care and specialised services: Hillingdon Hospital provides the majority of

secondary care services for people with respiratory disease including emergency

services, inpatient ward care and consultant clinics. The Royal Brompton Hospital

provides pulmonary rehabilitation for people with COPD, oxygen assessment as well as

highly specialised care for more complex respiratory conditions.

11

6. Burden of Respiratory disease in Hillingdon

6.1 Risk factors 6.1.1 Smoking

Smoking is the single biggest contributor to the development of respiratory disease.

Reducing smoking rates in the population will have a large impact on reducing the

prevalence of diseases such as COPD, lung cancer and asthma. It is estimated that between

2012 and 2014 955 deaths in Hillingdon were attributed to smoking-related disease8.

Smoking prevalence in Hillingdon, in keeping with the rest of the country, has been steadily

reducing with 17.8% of the population identifying as current smokers in 2012 in comparison

to 16.9% in 20158. However Hillingdon has higher rates of smokers in younger age groups

(8.4% in 15 year olds) in comparison to the London average (6.1%) as well as higher rates of

e-cigarette use (16.6% vs. 11.7% in London)8.

Fig 5: Smoking prevalence in Hillingdon and England 2012-20158

6.1.2 E-cigarettes (EC) as a gateway to smoking or an aid to quit?

Evidence remains limited and conflicting with regards to the role of e-cigarettes as an aid to

smoking cessation. A recent review of 4 longitudinal studies concluded that EC use was

associated with an increase in regular smoking, confirming earlier evidence of EC use as a

gateway to smoking especially amongst adolescents9. However a Cochrane review10 found

low-grade evidence from two trials that ECs help smokers to stop smoking in the long term

compared with placebo ECs. EC use as an aid to stop smoking has been recently endorsed by

Public Health England and the Royal College of Physicians with the view that they are less

harmful than tobacco and seem to be more popular than other cessation methods11,12. As

many as 53% of EC users in the UK said their main reason for EC use was to aid themselves

in quitting smoking13. Thus evidence suggests that local policy should aim to prevent the

uptake of ECs by young people in line with the voluntary code of EC vendors but explore

how best to accommodate ECs as a an aid to quitting smoking in established smokers.

7

9

11

13

15

17

19

21

23

2012 2013 2014 2015

Smo

kin

g p

reva

len

ce (

%)

Hillingdon England

12

6.1.3 Outdoor air quality

Air pollution is a mixture of particles and gases that can have adverse effects on human

health. Particulate matter and noxious gases such as NO2, O3 and SO2 have been linked with

the development of respiratory disease, acute exacerbations of disease as well as

premature mortality. Tackling these adverse effects has become an increasing priority

especially in London. A revised National Emissions Ceiling Directive which enforces stricter

emissions ceilings for the 5 main air pollutants came into force on 31st December 201614.

There has been a great deal of evidence linking levels of ambient air pollution to

exacerbations of asthma and COPD leading to emergency admissions to hospital15. More

recent evidence, despite the methodological challenges, suggests an association with

premature mortality. The Committee on the Medical Effects of Air Pollution in 2010

estimated that air pollution has an effect on mortality equivalent to 29,000 deaths in the UK

annually16. In Hillingdon this is equivalent to 90 deaths or 1100 life years lost17. Another way

of estimating the burden of air pollution is to rank the local mortality attributed to

particulate matter against local mortality due to other sources of disease. In Hillingdon

PM2.5 is thought to be attributable to 5% of adult mortality annually18.

Area Mortality rate per 100,000

Preventable mortality 173.6

Cardiovascular Disease 52.8

Cancer 75.9

Mortality attributable to PM2.5 15.7

Liver disease 14.2

Respiratory disease 13.2

Communicable disease 10

Suicide 10

The health effects of air pollution are distributed unequally across the population, with the

heaviest burden borne by those with greatest vulnerability and/or exposure. The elderly,

children and those with cardiovascular and/or respiratory disease are at greater risk from

the health effects of air pollution. Deprived communities are more likely to be situated near

polluted busy roads, and are more likely to experience adverse health impacts. In Hillingdon

the major sources of air pollution come from aviation and road transport (figure 6).

Fig 6: Sources of air pollution in Hillingdon (GLA 2013)19

0%

20%

40%

60%

80%

100%

NO2 PM10 PM2.5

Other

D&C

Industry

Rail

Aviation

Road

13

Fig 7: Annual NO2 concentration and focus areas19

6.1.4 Air quality in Hillingdon

The distribution of elevated levels of ambient air

pollution correlates to these sources with larger

concentrations around the major motorways

(M4 and M40), main roads (Uxbridge road in

particular) as well as Heathrow airport.

In Hillingdon there are 11 focus areas that not

only exceed the EU annual mean limit value for

NO2 but are also locations with high human

exposure (figure 7). It is estimated that as many

as 60,000 people live in these areas representing

20% of Hillingdon's population. An Air Quality

Action Plan for Hillingdon is due to go out for

consultation.. Hillingdon uses an air quality alert

service (airTEXT) which sent out a total of 3195

alerts from June 2016 to January 2017. At the

time it only has 153 residents subscribed to the

service.

Fig 8: Non-elective admissions for COPD by ward

2013-2015 (Standardized admission ratio as

compared to national average)20

6.1.5 Non-elective admissions and air quality

Patterns of non-elective admissions for

respiratory disease seem to correspond to

areas of poorer air quality in the borough.

While other factors such as smoking and

quality of housing will contribute to this

picture making it difficult to interpret air

pollution's true impact, evidence has shown

that those living closest to major highways or

airports are more susceptible to acute

exacerbations.

Wards such as Heathrow Villages and West

Drayton have admissions that are

approximately 50% higher than the national

average as compared to areas to the north of

Hillingdon such as Eastcote and East Ruislip

and Northwood Hills which are approximately

50% below the national average.

14

6.1.6 High-Speed 2 (HS2) Rail

Phase one of the HS2 project will run between London and the West Midlands. It is

expected to run across Hillingdon through Ruislip and Ickenham. As this stretch of the route

will be underground, the main impact of the project will be during the construction phase.

While construction dust is made of up large particles (>10um) that do not penetrate the

lungs, they can cause irritation to people's eyes and throats. Construction traffic on the

other hand is likely to impact on air quality, particularly NO2 from heavy vehicles. A health

impact assessment21 identified "moderate adverse temporary NO2 effects on receptors on

Swakeleys Road" though given the temporary nature and limited area of impact it is thought

that the increased health risk is small21.

6.1.7 Heathrow expansion

The proposed Heathrow airport expansion is expected to add at least an extra 4.5million

road journeys (public transport use assumed at 55%) and 170-200,000 flights per annum.

This will increase ambient NO2 and PM by up to 10.8 and 6ug/m3 respectively in certain

residential areas surrounding Heathrow airport22. This will increase the risk of

exacerbations of COPD and asthma in this population. Studies have shown that even low-

levels of ambient air pollution can exacerbate respiratory conditions. One study fund that

for each ug/m3 increase in ambient of NO2 there was a 17% increase in COPD

exacerbation23, another study found a 2.14% and 7.52% increase in mortality for each 10

ug/m3 increase in short-term and long-term exposure to PM2.5 respectively24.

The impact of Heathrow expansion is through the initial construction phase and subsequent

operational state. The construction phase will have an impact on air quality through actual

construction activity, producing dust and emissions from heavy equipment, as well as traffic

to and from the site. When it becomes operational the majority of emissions will come from

aircraft activity and passenger traffic.

A health impact assessment has been consulted on. It does not quantify the health effects

of the airport expansion, but predicts that it would have a 'moderate adverse impact on

health outcomes including increased risk of respiratory disease, cardiovascular disease and

adverse, short-term, temporary and intermittent impacts. Furthermore it would have:

'Major adverse impact upon vulnerable groups where health effects could lead directly to

deaths, acute or chronic diseases' 22.

The full health impact will need further quantifying but it is clear that from this consultation

that there will be adverse health impacts across the population and that will be exacerbated

for vulnerable groups.

15

6.1.8 The indoor environment

Nationally, respiratory diseases account for the second highest proportion (32%) of excess

winter deaths25. 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. There is a clear difference in excess winter deaths between

the coldest and warmest homes (figure 9). In Hillingdon 9.3% of people are estimated to

experience fuel poverty as compared to the national average of 10.6%18.

Fig 9: Excess mortality (relative to summer low) in coldest and warmest 25% of homes 26

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. National surveys suggest that 4.3% of homes in the UK have significant damp

problems27.

Indoor environmental tobacco smoke is the main indoor environmental pollutant to affect

people, especially children. Passive smoking increases 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. As the

predominant source of passive smoke exposure in children is smoking in the home by

parents, the best way to prevent this is to reduce the prevalence of smoking among parents

and would-be parents28.

Improving indoor air quality can be simple and includes ensuring the house is sufficiently

ventilated by adequately maintaining air filters, regularly opening windows and avoiding

drying clothes indoors29.

16

6.1.9 Obesity

Obesity can have a significant impact on respiratory health30. Some of the health effects of

obesity on respiratory system include diseases such as:

Exertion dyspnoea – severe breathlessness as a result of only minor physical activity.

Obstructive sleep apnoea syndrome (OSA) – This leads to closing or narrowing of the

airways during sleep leading to snoring, repeated waking and lack of adequate sleep

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.

In Hillingdon 62% of the adult population are overweight or obese which is lower than the

England average of 64.8% but higher than the London average of 58.8%. In children the

obesity rate is 21.1% which is higher than the England average of 19.8% but lower than the

London average of 23.2%18.

6.1.10 Early development

Low-birth weight (LBW) has been associated with increased risk of respiratory infections and

greater susceptibility to air pollution due to an underdeveloped respiratory system31. Timely

access to antenatal care with focus on smoking cessation and adequate nutrition is

important to minimise the rates of LBW babies. 3.1% of babies born in Hillingdon are of low

birth weight which is comparable to the London average of 3% and marginally higher than

the England average of 2.8%. The proportion of women who smoke at the time of delivery is

7.1% as compared to 5% in London and 10.6% in England18.

Numerous studies have shown that exclusive breast feeding in the first 6 months of life

protects against respiratory infections in infancy and reduces hospitalisation from

respiratory disease well into adulthood32. A continued effort to encourage mothers to

breastfeed will reduce the incidence of respiratory disease. In Hillingdon the percentage of

mothers who breastfeed at 4-6 weeks is estimated as 65.2% in comparison to the England

average of 43.2%18. The admission rate for respiratory diseases in children aged up to 4

years of age is substantially lower in Hillingdon than the London and England average18:

Figure 10: Hospital admissions for respiratory disease 2014/15 (admissions/10,000 pop)18

264

53 9

312

60 20

522

67 20

Under 1 1 year 2,3,4 years

Hillingdon London England

17

6.1.11 Socio-economic factors

People in the lowest socioeconomic groups are up to 14 times more likely to suffer from a

respiratory disease than those in the highest group33. The picture in Hillingdon (figure 11)

shows the same relationship with more deprived wards having higher rates of hospital

admission for respiratory disease.

Fig 11: Age-standardised rate of hospital admissions for respiratory disease by deprivation rank in

Hillingdon 2013-2016 (Hospital Episode Statistics)

This is due to a higher proportion of deprived populations being exposed to a number of

key risk factors which can include33:

Smoking: Smoking is more common amongst the most deprived communities

o 26.5% of routine/manual workers smoke, compared to 11.7% of managerial workers.

o 23% of those earning under £10,000 smoke, compared with 11% earning £40,000+

o People who are homeless are more likely to smoke.

Outdoor air pollution: There is an established link between the prevalence and impact of

outdoor air pollution and socioeconomic deprivation:

o 66% of man-made carcinogens are emitted from the 10% most deprived city wards.

o Deprived communities may have less access to green spaces, and receive four times

less spending on transport needs than the richest 10%.

Housing:

o 24% of people in the lowest income quintile live in a privately rented home, of which

28% do not meet the decent homes standard.

o People in the most acute housing need are particularly at risk. Homeless people are

likely to have very poor respiratory health

R² = 0.4699

0

5

10

15

20

25

30

1 2 3 4 5 6 7 8 9 10

Ad

mis

sio

ns

pe

r 1

00

0

Deprivation decile (1 = most deprived)

18

6.1.12 Ethnicity

The Department of Health’s ‘Outcomes Strategy for Chronic Obstructive Pulmonary Disease

and Asthma in England4 – Assessment of the Impact on Equalities’ highlights the fact that a

patients' ethnicity can play a major factor in how well their respiratory condition is

understood and in how compliant a patient may be with respect to self-management.

Numerous studies have demonstrated the association between respiratory disease

incidence and management. This includes higher rates of hospital admission for minority

groups, difficulty in access to primary care and benefit from education due to a variety of

language and cultural factors34.

There are also differences in risk behaviours with certain ethnic groups more likely to smoke

than others. Smoking is comparatively prevalent amongst Black Caribbean (37%) and

Bangladeshi (36%) men and White English women (26%)33.

The incidence of TB is significantly greater in non-white ethnic groups, particularly in the

Black and South Asian populations. This is due to non-UK born residents migrating from

areas of high TB prevalence as well as transmission within these communities in the UK35.

Fig 12: TB notifications by place of birth and ethnic group, England 201534

19

6.2 Mortality

Fig 13: Mortality from respiratory disease (2009-2015)18

In Hillingdon the mortality from respiratory disease has fluctuated over the past 7 years but

mostly remained below the average of its comparable peersii. However there has been an

increase in mortality in the last 2 years that has meant respiratory mortality in Hillingdon is

now comparable to the peer average. There is also significant variation in the mortality rate

from respiratory disease by ward (figure 14).

Fig 14: Mortality from respiratory disease by ward 20151

Key: (Green-lower, Yellow-similar, Red-Higher than the England average)

6.2.1 Excess winter deaths

Respiratory disease contributes to a significant part of excess winter deaths every year. In

England in 2015/16 deaths from respiratory disease in winter were 39% higher than other

months25. In Hillingdon it is estimated that there were 170 excess winter deaths in 2015/16

representing an excess of 26.8% compared to other months. Younger adults (16-65) are the

only age group where excess deaths have increased in comparison to recent years and it is

thought be due to an increase in influenza-type illness in this group36.

ii Hillingdon's peers were those identified by NHS England and Public Health England who used a combination of demographic and socio-economic factors to find areas with the most similar populations.

00.20.40.60.8

11.21.41.61.8

2

Hillingdon

Peer average

30

40

50

60

70

80

90

100

110

120

2009 2010 2011 2012 2013 2014 2015

De

ath

s p

er

10

0,0

00

20

Fig 15: Excess winter deaths in England by main cause (2012-2016) (Office of National Statistics)

6.3 COPD

The estimated number of people with COPD in Hillingdon is based on a model derived from

Health Survey England in addition to taking local

population factors into consideration37. In Hillingdon

there are estimated to be 8534 residents who have

COPD. This represents 2.8% of the total population

(3.5% of adults).

Based on the number diagnosed in primary care, it is

estimated that only 42% of people with COPD living in

Hillingdon are known to health services. Given the

overwhelming evidence of the benefits of early

diagnosis of COPD, this represents a sizeable

opportunity to increase the identification of early

disease to improve health outcomes in this population and reduce demand for health services.

COPD predominantly affects older age groups with 82% of all admissions in those over 60.

While emergency COPD admissions have remained stable over time, they are significantly

higher than Hillingdon's peers (fig 19) and show significant variation by ward (fig 18).

Fig 16: COPD admissions by age 2014-2016 (HES)

0

10

20

30

40

50

60

70

80

90

2012/13 2013/14 2014/15 2015/16

Respiratory diseases

Dementia and Alzheimer'sdisease

Circulatory diseases

Injury and poisoning

-

50

100

150

200

250

300

Diagnosed42%Not

diagnosed58%

21

Fig 17: COPD admissions by month 2014-2016 (HES)

Fig 18: Age-adjusted COPD admissions by ward 2014-2016 (HES)

Variation in COPD admissions are stark (fig 18) even taking account of differences in age,

and will relate to differences in smoking prevalence, indoor and outdoor air quality. A

considerable portion of the difference is preventable through behavioural interventions

such as smoking cessation support as well as local policy and planning work to improve the

local environment. While monitoring and review measures in primary care are comparable

to peers. Hillingdon lags behind for referral to pulmonary rehabilitation and non-elective

admissions (fig 19).

Fig 19: Care for COPD in Hillingdon in comparison to peers 2015/1618,38

-

10

20

30

40

50

60

70

80A

pri

l

May

Jun

e

July

Au

gust

Sep

tem

ber

Oct

ob

er

No

vem

ber

Dec

em

ber

Jan

uar

y

Feb

ruar

y

Mar

ch

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

ber

Oct

ob

er

No

vem

ber

Dec

em

ber

Jan

uar

y

Feb

ruar

y

Mar

ch

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

ber

Oct

ob

er

No

vem

ber

Dec

em

ber

Jan

uar

y

Feb

ruar

y

Mar

ch

0

2

4

6

8

10

12

14

22

6.4 Asthma It is estimated that only 54% of asthma is currently diagnosed in Hillingdon18. Asthma affected a

wide distribution of age groups. Admissions to hospital have decreased slightly in recent years but

exhibit a wide variation by locality even after adjustment for age (figure 22).

Fig 20: Non-elective admissions for asthma by age 2014-2016 (Hospital Episode Statistics)

Fig 21: Asthma admissions by month 2014-2016 (Hospital Episode Statistics)

Fig 22: Age-adjusted Asthma admissions by ward 2014-2016 (Hospital Episode Statistics)

-

20

40

60

80

100

120

140

160

-

10

20

30

40

50

60

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

ber

Oct

ob

er

No

vem

ber

Dec

em

ber

Jan

uar

y

Feb

ruar

y

Mar

ch

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

ber

Oct

ob

er

No

vem

ber

Dec

em

ber

Jan

uar

y

Feb

ruar

y

Mar

ch

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

ber

Oct

ob

er

No

vem

ber

Dec

em

ber

Jan

uar

y

Feb

ruar

y

0

1

2

3

4

5

6

7

23

While asthma mortality is comparable to peers, the years of life lost due to the disease is

significantly higher, suggesting that a greater proportion of deaths in Hillingdon are in younger age

groups. Monitoring of asthma in primary care is comparable to peers with recording of smoking

status being better in Hillingdon than our peers.

Fig 23: Care for Asthma in Hillingdon in comparison to peers 2015/1618,38

6.5 Pneumonia Pneumonia predominantly affects the very young and older age groups. Admissions for pneumonia

have increased over time in Hillingdon (figure 25) with some variation by locality (figure 26).

Fig 24: Pneumonia admissions by age 2014-2016 (HES)

Fig 25: Pneumonia admissions over time 2014-2016 (HES)

-

100

200

300

400

500

600

20

40

60

80

100

120

140

160

180

200

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

ber

Oct

ob

er

No

vem

ber

Dec

em

ber

Jan

uar

y

Feb

ruar

y

Mar

ch

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

ber

Oct

ob

er

No

vem

ber

Dec

em

ber

Jan

uar

y

Feb

ruar

y

Mar

ch

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

ber

Oct

ob

er

No

vem

ber

Dec

em

ber

Jan

uar

y

Feb

ruar

y

24

Fig 26: Pneumonia admissions by ward 2014-2016 (HES)

6.6 Tuberculosis (TB) TB incidence in Hillingdon has declined by a quarter since 2012 with 36.5 people diagnosed with TB

per 100,000 in 2015/1618. This has mirrored the trend in London and is thought to be due to a

decline in TB diagnosed in migrants as well as evidence of reduced transmission in the UK.

Fig 27: TB incidence compared to England 2000-201518

Despite this decline, TB incidence remains high in Hillingdon and London as compared to the rest of

England. Public Health England recently launched a new strategy aimed at reducing TB incidence

through closer and more effective collaboration39. The main objectives include improving access to

diagnostics and treatment, especially for underserved populations, and improving contact tracing

and other preventative measures. The majority of this work is being coordinated through nine TB

control boards across the country. In Hillingdon, while access to treatment is better than peers,

services lag behind others in relation to diagnostics and completion of treatment.

0

5

10

15

20

25

0

10

20

30

40

50

60

Inci

de

nce

(ca

ses

pe

r 1

00

,00

0 Hillingdon

England

25

Fig 28: Care for Asthma in Hillingdon in comparison to peers 2015/1618

7. Future need

7.1 Future prevalence of COPD

Based on a PHE prevalence model34 and taking into account the expected growth and

changes to the make-up of the population, the number of people with COPD will increase

steadily from approximately 8534 in 2017 to 10720 in 2030.

Year COPD prevalence Prevalence rate

2017 8534 2.8%

2020 8950 2.8%

2025 9799 3.2%

2030 10720 3.0%

To estimate the impact of smoking cessation or prevention on the future prevalence of

COPD, a Markov model was produced based on Hillingdon's population projection as well as

data from the literature. The diagram below displays the COPD model where individuals

within the population transition between states according to their smoking status.

Fig 29: Schematic of the transition states of the COPD prevalence model

Po

pu

lati

on

Gro

wth

26

Currently Hillingdon smoking cessation is responsible for approximately 400 sustained quits

a year. This equates to 1% of the smoking population in Hillingdon. If further optimisation of

the service can deliver quit rates comparable to other regions (2-3%) then the COPD

prevalence may reduce further in the medium to long-term.

Fig 30: Projected prevalence of COPD by scenario

7.2 Future prevalence of asthma

While recent years have seen a reduction in the incidence of asthma particularly in pre-

school children, the prevalence of asthma continues to grow as better care ensures longer

survival. If this trend continues it is likely that the actual prevalence of asthma will gradually

reduce in the future however given the absence of suitable forecast studies we will assume

a stable prevalence rate for Hillingdon in the coming years:

Year Asthma prevalence Prevalence rate

2017 28,211 9.13%

2020 29,526 9.13%

2025 31,389 9.13%

2030 33,041 9.13%

7000

8000

9000

10000

11000

12000

13000

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

CO

PD

pre

vale

nce

Years

Projected COPD prevalence 2017 to 2047

Current smoking quit rate 1% Quit rate at 2%

Quit rate at 2% + smoking Initiation reduced by 1%

27

In contrast to COPD, the exact causes of asthma remain unknown. However there are

environmental triggers known to cause acute exacerbations in those with asthma. Poor

indoor and outdoor air quality is known to increase the risk of exacerbation and thus work

to mitigate against these will help limit acute admissions and use of healthcare services.

28

8. Respiratory services in Hillingdon

8.1 Prevention: Smoking cessation

While the Hillingdon stop smoking quit rate is comparable to peer and national averages

(47% vs. 53% and 49% respectively)18 the proportion of smokers setting a quit date is less

than half of those in London and our peers. The relatively lower numbers of smokers

accessing stop smoking services suggests an opportunity for increased referral and may be

achieved through more effective pathways and partnerships with providers as well as

increasing awareness of the service amongst the population.

Figure 31: The number of smokers per 100,000 population setting a quite date and successfully

quitting Apr to Sep 201618

While pharmacies produce the most smoking quits they appear to be the least effective with

a 30% quit rate as compared to GP (62%) and community (68%) settings. This is in line with

studies suggesting more intensive programs have higher quit rates than less intensive

pharmacy-delivered ones40. Hospitals are effective at delivering smoking quits (58% quit

rate) but only contribute to 3% of all quits in Hillingdon18. Recent work between the Stop

Smoking service and Hillingdon Hospital has led to a greater number of referrals, but given

that smokers are estimated to represent 17% of all hospital admissions41, there remains

further opportunity to increase cessation activity in this setting.

Figure 32: The number of smokers per 100,000 population setting a quite date and successfully

quitting by type of setting Apr to Sep 201618

0

50

100

150

200

250

300

350

400

Community Hospital Pharmacy Generalpractice

Maternity Other

Setting a quit date

Successful quit

-

200

400

600

800

1,000

1,200

Hillingdon Peer London

Setting a quit date

Successful quits

29

Figure 33: The number of smokers per 100,000 population setting a quite date and successfully

quitting by method Apr to Sep 201618

Even though NICE and the National Centre for Smoking Cessation and Training favour the

use of combination NRT or varenicline40,42, single NRT is still the most utilised quit method in

Hillingdon. Success rate for single NRT was 40% as compared to combination NRT (49%) and

varenicline (67%). Furthermore closed-group sessions have been shown to be highly

effective and encouraged in the national guidance40 but only involve 1% of people who set a

quit date in Hillingdon.

Figure 34: The cost per quit for Hillingdon compared to other London boroughs Apr to Sep 201618

Without more detailed investigation, it is hard to identify why Hillingdon's cost per quit is

higher than the London average. However it may be related to the lower volumes of

smokers engaged in the programme that prevents some of the economies of scale seen in

other areas. A fuller review of the cost-effectiveness of Hillingdon's approach to smoking

cessation is recommended , taking into account habit changes such as the move toward

greater use of Vaping or e-cigarettes.

0

50

100

150

200

250

300

350

400

Single nicotineproduct

Combinationnicotine product

Varenicline No nictone ormedication

Unknown

Setting a quit date

Successful quit

0100200300400500600700800

Enfi

eld

Har

row

Wan

dsw

ort

h

Gre

en

wic

h

Wal

tham

Fo

rest

Bex

ley

Red

bri

dge

Ham

mer

smit

h a

nd

…

Sutt

on

Ealin

g

Mer

ton

Cam

den

Hav

erin

g

Bro

mle

y

Bar

ne

t

Ho

un

slo

w

Cro

ydo

n

Har

inge

y

Kin

gsto

n u

po

n T

ham

es

Bar

kin

g an

d D

agen

ham

Ken

sin

gto

n a

nd

Ch

else

a

Sou

thw

ark

Lam

bet

h

Hill

ingd

on

Wes

tmin

ster

Hac

kney

Bre

nt

Islin

gto

n

New

ham

Lew

ish

am

Ric

hm

on

d u

po

n…

Tow

er

Ham

lets

Cit

y o

f Lo

nd

on

Co

st p

er

qu

it

30

8.2 Prevention: Vaccination

8.2.1 Childhood pneumococcal vaccination (PCV at 12m)

Fig 35: Childhood pneumococcal vaccine uptake in Hillingdon and comparators 2014-201743

Immunisation remains one of the most effective ways to prevent pneumonia in younger

children and the community. The pneumococcal conjugate vaccine (PCV) protects against 13

strains of the disease and is given at 1 year of age followed by a booster at 2 years. In

Hillingdon immunisation rates in the past year have fallen below peer and London average.

8.2.2 Adult pneumococcal vaccination

Fig36: Adult pneumococcal vaccine uptake in Hillingdon and comparators 2014-1743

The pneumococcal polysaccharide vaccine (PPV) is given to people over 65 years and those

with long-term health conditions. Hillingdon's rate of PPV vaccine has steadily improved

over the past few years and is currently higher than the peer and regional average at 69.2%.

8.2.3 Influenza vaccination

Uptake of seasonal childhood influenza vaccination has steadily increased over the last few

years with an uptake of 51.1% in 2016 that is higher than the London average of 42.9% but

lower than the national average of 55%43. Seasonal adult influenza vaccination is routinely

given to individuals over the age of 65 or younger people with long-term conditions. The

uptake in Hillingdon in 2016 was 68% for over-65s (London average 65.1%) and 50.7%

(London average 45.1%) for those with long-term conditions.

82

84

86

88

90

92

94

Q4 14/15 Q1 15/16 Q2 15/16 Q3 15/16 Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17

London

Peer

Hillingdon

62

63

64

65

66

67

68

69

70

2013 2014 2015 2016

London

Peer

Hillingdon

31

8.3 Prevention: COPD screening

Recent evidence has confirmed the long-standing view that early COPD diagnosis is one of

the most important and cost-effective interventions in COPD management. The Target

COPD trial involving 74,818 patients randomised to active case-finding, opportunistic case-

finding or routine care44. It found that an active targeted approach to case finding including

mailed screening questionnaires before spirometry is a more cost-effective than

opportunistic screening (£333 per case detected) and more effective than routine care (4%

diagnosed vs. 1% respectively) to identify undiagnosed patients. Another study in

community pharmacies demonstrated the cost-effectiveness of active case-finding and is

estimated to be a cost saving at £392 per patient screened45.

Over the last 2 years, 62 pharmacies in Hillingdon have taken part in a COPD screening

programme for individuals who access the stop smoking service. This involves lung-function

test using a portable device. If an individual is screened positive, a referral for formal

diagnosis by the GP is made. A total of 132 patients were screened from March 2015 to April

2017.

The proportion of those screened positive who were subsequently diagnosed with COPD is

unknown at present but will be indentified to assess the effectiveness of this service.

Screening activity over the last year has reduced as the numbers of smokers accessing

pharmacies as well as a lack of capacity to support them. Data suggests that only 16 out of

the 62 pharmacies have regularly screened service users. A renewed focus on encouraging

practices to screen as well as expanding those eligible to be screened is likely to improve the

effectiveness of the service.

32

8.4 Treatment: Respiratory care services

In line with what is happening nationally, Hillingdon is moving towards a more integrated

model of care. The Integrated Respiratory Service will target 2 main patient groups, Adult

Asthmatics and COPD patients. It will aim:

To ensure timely and accurate diagnosis of COPD and Asthma patients. This means that

patients are on the correct treatment and therefore receiving better management.

To reduce unnecessary Respiratory related attendances at A&E.

To reduce the number of unplanned admissions for Respiratory disease, particularly

short-stay admissions.

To improve the ability of patients to self-manage and support them when they

exacerbate, ensuring they access the most appropriate service timely and safely.

To ensure patients are managed holistically, linking into local services for their other

healthcare needs e.g. Falls, Swallowing and Continence problems.

To ensure that GP’s and practice nurses have the right training and specialist support to

manage all COPD and Asthma patients in line with national guidance without undue

referrals to secondary care.

To reduce variances in the care available to respiratory patients in Hillingdon.

To achieve this it is proposed that a consultant-led specialist integrated service be

established that spans primary and secondary care. This would enable more coordinated

and holistic care as well as improved specialist capacity in the community. This is expected

to improve diagnosis and management of COPD and asthma as well as reduce non-elective

admissions to secondary care.

Figure 37: Proposed Integrated Care Model (Hillingdon CCG)

New services

33

Evidence46,47 suggests that the effectiveness of an integrated system is dependent on:

The strategic role played by the respiratory specialist in providing medical leadership of

the multi-disciplinary team and a strategic role developing and evaluating new services.

Strong focus on staff development and education

Effective communication and sharing of data across settings to enhance coordination

Appropriately targeted financial incentives developed with commissioners.

Once implemented, a robust evaluation of the new model in Hillingdon is necessary to

ascertain whether it delivers the desired outcomes.

8.5 Rehabilitation: Pulmonary rehabilitation

There is strong evidence that pulmonary rehabilitation (PR) improves quality of life and

reduces the risk of exacerbation in people with COPD48. A recent Cochrane review of 20

studies found high quality evidence that PR improves quality of life and moderate quality

evidence that it reduces readmission to hospital. One important aspect of the review found

considerable variation in the way pulmonary rehabilitation was delivered and it is likely to

have an impact of effectiveness. It may be worth reviewing the way PR is delivered in

Hillingdon and compare this to high-functioning programmes elsewhere.

Fig 38: Rate of referral of COPD patients for pulmonary rehabilitation 2013-2015 (NHS Digital)

Despite the increase in the rate of referral for pulmonary rehabilitation in Hillingdon it still

lags behind its peers. Another aspect is the large proportion of people who fail to complete

the rehabilitation programme estimated as much as 60% nationally49. Work to increase

referral rates and improve completion will help improve health and reduce the burden of

COPD in Hillingdon.

0

2

4

6

8

10

12

14

16

18

20

2013/14 2014/15

%re

ferr

al r

ate

Hillingdon

Peer average

34

8.6 Cost of care The cost of respiratory care in Hillingdon is comparable to its peers. Though there is an opportunity

to reduce costs in line with the better-performing regions1

Fig 39: Cost of respiratory care 2015/161

Looking at spending versus outcomes (fig 40), Hillingdon's respiratory outcomes are comparable to

its peers but its spending on respiratory care is marginally higher.

Fig 40: Respiratory spend versus outcomes for Hillingdon in comparison to peers 201551

0

5000

10000

15000

20000

25000

30000

35000

40000

Elective Non-elective Total spend

Co

st (

£)

Hillingdon

Peer average

Inf,HI,SC

Can,GI,SkinBlood,Hear

End

MH,Dent,Poi

LD

Neu

Vis,Resp,Mat

Circ

Musc,Trau

GU

Nn

Oth

-2.5

-2.0

-1.5

-1.0

-0.5

0.0

0.5

1.0

1.5

2.0

2.5

-2.5 -2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0 2.5

Outc

om

e Z

score

Spend per head Z score

Lower spend, Better outcome

Lower spend,Worse outcome

Higher spend,Worse outcome

Higher spend,Better outcome

35

9. Overview of best practice in respiratory care

A large number of guidance documents have been produced to help professionals deliver

more effective respiratory care (see section 10). Highlights of these include:

Prevention: smoking cessation

High intensity programs with combination NRT/medication work more effectively than

single NRT or only counselling (NICE)42.

Cessation programs delivered by dedicated stop smoking practitioners are most

effective (NICE)42.

By virtue of the interactions with smokers, hospital-based professionals have an

important role to play in terms of referral and cessation (NICE)42

Stop smoking services should offer support to people who are using e-cigarettes in a quit

attempt (PHE, RCP)11,12.

Case finding

Given the irreversible nature of COPD, one of the most important interventions to reduce

the burden of COPD is through early diagnosis. This can be achieved by case-finding.

A recent large randomised control trial found that the use of a mailed screening

questionnaire followed by post-bronchodilator spirometry identified COPD in 4% of the

eligible population compared to 1% in the routine care group. It was estimated to cost

£333 per COPD case identified44.

Another study involving 22 community pharmacies used a questionnaire to identify

those at most risk of COPD and subsequent spirometry testing44. Of the 238 people

screened, 135(57%) were identified at risk and offered smoking cessation support.

Figure 41: COPD value pyramid50 (modified to include a value estimate for COPD screening44,45)

The above graphic demonstrates the relative cost-effectiveness of interventions for COPD.

Of note is the high cost-effectiveness of preventative interventions in relation to established

treatment options.

Case-finding: From -£20 to £17/QALY

36

Monitoring and review

Asthma51

Every NHS hospital and general practice should have a designated, named clinical lead

for asthma, responsible for formal training in the management of acute asthma.

Patients with asthma must be referred to a specialist asthma service if they have

required more than two courses of systemic corticosteroids, oral or injected, in the

previous 12 months or require management using British Thoracic Society (BTS)

stepwise treatment 4 or 5 to achieve control.

People with asthma should have a structured review by a healthcare professional with

specialist training in asthma, at least annually. People at high risk of severe asthma

attacks should be monitored more closely, ensuring that their personal asthma action

plans (PAAPs) are reviewed and updated at each review.

Patient self-management should be encouraged to reflect their known triggers, e.g.

increasing medication before the start of the hay-fever season etc.

COPD

Patients with COPD should be reviewed at least once per year, or more frequently if

indicated, and the review should cover smoking status, lung function, effectiveness of

drug regimen, inhaler technique, need for pulmonary rehabilitation and need for

specialist input52.

Pulmonary rehabilitation should be made available to all appropriate people with COPD

including those who have had a recent hospitalisation for an acute exacerbation52.

Managing respiratory conditions in hospital

Asthma

Follow-up arrangements must be made after every attendance at an emergency

department or out-of-hours service for an asthma attack. Secondary care follow-up

should be arranged after every hospital admission for asthma, and for patients who have

attended the emergency department two or more times with an asthma attack in the

previous 12 months52.

COPD

Patients admitted with COPD exacerbation should receive a respiratory specialist

opinion within 24 hours, 7 days a week53.

Risk-stratification based management has been shown to ensure appropriate support

for patients in hospital as well as on discharge to other settings53.

COPD discharge bundles have been shown to reduce variation and improve care. A

‘bundle’ is a set of evidence-based interventions which should be delivered to all

patients. They include smoking cessation advice and treatment, an assessment for

pulmonary rehabilitation classes, self-management support, a review of inhaler use and

follow-up by a respiratory specialist within one month of discharge53.

37

10. Guidelines and Resources

Asthma Quality standard: Asthma (QS25) NICE February 2013

BTS/SIGN Asthma Guideline 2016

National Outcomes Strategy for Asthma and COPD, DH, 2011

Designing and commissioning services for adults with asthma: A good practice guide, PCC 2012

Good practice guide for adults with asthma (Primary Care Commissioning) 2011

Good practice guide for children with asthma (Primary Care Commissioning) 2011

Why asthma still kills. The National Review of Asthma Deaths (NRAD), RCP May 2014

Bronchiectasis Non-CF bronchiectasis: BTS, July 2010

Cystic fibrosis Cystic fibrosis (GID-CGWAVE0736) Oct 2017 NICE guidelines (In development)

COPD Chronic obstructive pulmonary disease in over 16s: diagnosis and management (CG101) NICE June 2010 (update in development)

Quality standard (QS10) Chronic obstructive pulmonary disease in adults. NICE July 2011

National Outcomes Strategy for Asthma and COPD, DH, 2011

COPD: Who cares matters. National clinical audit report RCP/BTS February 2015

NHS Commissioning Toolkit for COPD pathway (2011)

British Thoracic Society. IMPRESS guide to Pulmonary Rehabilitation. 2011

Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease Cochrane Collaboration

Pneumonia Management of Community Acquired Pneumonia in Adults: BTS, 2009

Management of Community Acquired Pneumonia in Children: BTS, 2011

Pneumonia in adults: diagnosis and management (CG191) NICE, December 2014

Quality standard: Pneumonia in adults (GID-QSD115) NICE, January 2016

Bronchiolitis in children: diagnosis and management [NG9] NICE, June 2015

Respiratory tract infections (self-limiting): prescribing antibiotics [CG69] NICE, July 2008

Excess winter deaths

Excess winter deaths and illness and the health risks associated with cold homes [NG6] NICE, March 2015

Quality standard: Preventing excess winter deaths and illness associated with cold homes [QS117] NICE, March 2016

Other Stop smoking services Public health guideline [PH10] NICE, February 2008

The Department of Health (2012) NHS Companion Document for the Outcomes Strategy

NHS Improvement (2011) Prevention and Early Identification toolkit

38

11. References

1. NHS right Care, Commissioning for Value, Respiratory April 2016 NHS England

2. Estimating the economic burden of respiratory illness in the UK. British Lung Foundation 2017

3. Hillingdon Joint Strategic Needs Assessment 2016. http://www.hillingdon.gov.uk/jsna

4. An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in

England. Department of Health / Medical Directorate / Respiratory Team July 2011

5. NHS Five Year Forward View. NHS England 2014. https://www.england.nhs.uk/publication/nhs-

five-year-forward-view/

6. NW London Sustainability and Transformation Plan Oct 2016.

https://www.healthiernorthwestlondon.nhs.uk/sites/nhsnwlondon/files/documents/nwl_stp_oc

tober_submission_v01pub.pdf

7. Improving air quality in the UK: tackling nitrogen dioxide in our towns and cities Draft UK Air

Quality Plan for tackling nitrogen dioxide DEFRA, DFT May 2017.

https://consult.defra.gov.uk/airquality/air-quality-plan-for-tackling-nitrogen-

dioxide/supporting_documents/Draft%20Revised%20AQ%20Plan.pdf

8. Public Health Profiles, Public Health England. https://fingertips.phe.org.uk/

9. Chatterjee K, Alzghoul B, Innabi A, Meena N. Is vaping a gateway to smoking: a review of the

longitudinal studies. Int J Adolesc Med Health. 2016 Aug 9.

10. Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P. Electronic cigarettes for

smoking cessation (Review). Cochrane Database of Systematic Reviews 2016

11. E-cigarettes: an evidence update. A report commissioned by Public Health England, Aug 2015.

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/457102/Ecigar

ettes_an_evidence_update_A_report_commissioned_by_Public_Health_England_FINAL.pdf

12. Royal College of Physicians. Nicotine without smoke: tobacco harm reduction—a report by the

Tobacco Advisory Group of the Royal College of Physicians. Apr 2016.

www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction.

13. Adult smoking habits in Great Britain: 2014. Office of National Statistics

14. World Health Organization. The optimal duration of exclusive breastfeeding: report of the expert

consultation. Geneva: World Health Organization; March 28–30, 2001.

15. Public Health England (2016) ‘Surveillance of influenza and other respiratory viruses in the

United Kingdom: winter 2015 to 2016’, accessed on 08 November 2016.

16. The mortality effects of long-term exposure to particulate air pollution in the UK, Committee on

the Medical Effects of Air Pollution, Dept of Health, 2010

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/304641/COM

EAP_mortality_effects_of_long_term_exposure.pdf

17. Estimating Local Mortality Burdens associated with Particulate Air Pollution. PHE-CRCE-010.

Public Health England 2014

18. Airports Commission. Final report 2015

19. London Atmospheric Emissions Inventory. Greater London Authority 2013

20. Local Health, Public Health England http://localhealth.org.uk/#v=map11;l=en

21. High Speed Rail (LondonWest Midlands) Health impact assessment. November 2013

22. Health impact analysis for the draft Airports National Policy Statement, Dept. For Transport 2017

https://www.gov.uk/government/publications/health-impact-analysis-for-the-draft-airports-

national-policy-statement

39

23. DeVries R, Kriebel D, Sama S. Low level air pollution and exacerbation of existing copd: a case

crossover analysis. Environmental Health 2016

24. Shi L, Zanobetti A, Kloog I, Coull BA, Koutrakis P, Melly SJ, Schwartz JD. Low-Concentration PM2.5

and Mortality: Estimating Acute and Chronic Effects in a Population-Based Study. Environ Health

Perspect. 2016 Jan;124(1):46-52.

25. Excess winter mortality in England and Wales Statistical bulletins, Office of National Statistics.

https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bu

lletins/excesswintermortalityinenglandandwales/previousReleases

26. The impact of housing conditions on excess winter deaths, Joseph Rowntree Foundation 2001

27. English Housing Survey Headline Report 2014-15

28. Royal College of Physicians (2010) Passive smoking and children

29. Laumbach R, Meng Q, Kipen H. What can individuals do to reduce personal health risks from air

pollution? J Thorac Dis 2015;7(1):96-107

30. Zammit C, Liddicoat H, I Moonsie, H Makker. Obesity and respiratory diseases. International

Journal of General Medicine 2010:3 335–343

31. Walter EC, Ehlenbach WJ, Hotchkin DL, Chien JW, Koepsell TD. Low birth weight and respiratory

disease in adulthood: a population-based case-control study. Am J Respir Crit Care Med. 2009 Jul

15;180(2):176-80.

32. Tromp I, Kiefte-de Jong J, Raat H, Jaddoe V, Franco O, Hofman A, et al. (2017) Breastfeeding and

the risk of respiratory tract infections after infancy: The Generation R Study. PLoS ONE 12(2)

33. Briefing: health inequalities and lung disease. British Lung Foundation 2017

34. Respiratory disease: does ethnicity matter? Primary Care Respiratory Journal (2004) 13, 63—64

35. Tuberculosis in England, 2016 report. Public Health England

36. Public Health England (2016) ‘Surveillance of influenza and other respiratory viruses in the

United Kingdom: winter 2015 to 2016’, accessed on 08 November 2016.

37. Nacul LC, Soljak M, and Meade T. Model for estimating the population prevalence of chronic

obstructive pulmonary disease: cross sectional data from the Health Survey for England. Popul

Health Metr. 2007; 5:8

38. NHS Digital Indicator Portal, NHS Digital. https://indicators.hscic.gov.uk/webview/

39. Collaborative Tuberculosis Strategy for England 2015 to 2020, Public Health England 2015

40. Local Stop Smoking Services, Service and delivery guidance NCSCT 2014

41. Szatkowski L, Murray R, Hubbard R, et al Prevalence of smoking among patients treated in NHS

hospitals in England in 2010/2011: a national audit Thorax November 2014.

42. Stop smoking services Public health guideline [PH10] Published date: February 2008

43. Cover of vaccination evaluated rapidly (COVER) programme, Public Health England.

https://www.gov.uk/government/collections/vaccine-uptake

44. Jordan RE, Adab P, Sitch A, Enocson A, Blissett D, Jowett S, Marsh J, Riley RD, Miller MR, Cooper

BG, Turner AM, Jolly K, Ayres JG, Haroon S, Stockley R, Greenfield S, Siebert S, Daley AJ, Cheng

KK, Fitzmaurice D. Targeted case finding for chronic obstructive pulmonary disease versus

routine practice in primary care (TargetCOPD): a cluster-randomised controlled trial. Lancet

Respir Med. 2016 Sep;4(9):720-30.

45. Wright D, Twigg M and Thornley T. Chronic obstructive pulmonary disease case finding by

community pharmacists: a potential cost-effective public health intervention. International

Journal of Pharmacy Practice 2015, 23, pp. 83–85

40

46. R Partridge MR and Baxter N. Integrated care: respiratory medicine ready and waiting. Future

Hospital Journal 2016 Vol 3, No 1: 37–9

47. Specialists in out-of-hospital settings: Findings from six case studies. The King's Fund 2014

48. Puhan MA, Gimeno-Santos E, Cates CJ, Troosters T. Pulmonary rehabilitation following

exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016 8;12

49. Boutou AK, Tanner RJ, Lord VM, et al. An evaluation of factors associated with completion and

benefit from pulmonary rehabilitation in COPD. BMJ Open Respir Res. 2014;1:e000051

50. The pyramid of value for COPD interventions developed by the London Respiratory Network

2014

51. Why asthma still kills. The National Review of Asthma Deaths (NRAD). Confidential Enquiry

report (May 2014)

52. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Clinical

guideline CG101. National Institute of Clinical excellence, June 2010

53. National COPD Audit Programme: Clinical audit of COPD exacerbations admitted to acute units

in England and Wales 2014.