Why is it an issue?
Asthma affects the airways in the lungs. Symptoms include breathlessness, chest tightness, coughing and wheezing. For most people the condition is not curable. However, Occupational asthma, where the condition is caused by exposure to triggers in the workplace, can sometimes be cured, and so it is very important for any link to the workplace to be identified. Occupational factors account for approximately 1 in 6 cases of asthma in working age adults (British Occupational Health Research Foundation, 2010)
The goal of asthma management is for the person living with asthma to be free of symptoms and for the individual to lead a normal and active life. This can be achieved through the tailored use of medication (usually inhalers) and to some extent by avoiding things that the individual knows will make their symptoms worse (triggers) for example cigarette smoke. Those with asthma need to be able to recognise quickly when their symptoms are worsening and know what action to take if they do worsen. The use of asthma action plans, that explain what to do when your symptoms worsen, and educations have been shown to reduce admissions by 75%. (2) A review of your asthma when you are well and at least once a year has been shown to improve outcomes for people living with asthma.
5.4 million people in the UK have asthma (1 in 10 adults and 1 in 8 children) and sadly there are still approximately 1100 deaths a year in the UK, 90% of which are said to be preventable. (Department of Health, 2011) It is believed that poor knowledge of how medication works and how to use inhalers contributes significantly to these deaths (Asthma UK).
There are wide variations in outcomes for people living with Asthma. A 5 fold difference has been demonstrated between some areas in hospital admissions for adults with acute exacerbation of their asthma and as much as a 6 fold difference for children. The 2011 National asthma audit demonstrated suboptimal initial assessment in Emergency Departments, poor use of asthma action plans (only 41% of those admitted were given one at discharge) and 44% of children didn’t have their inhaler technique checked before discharge. Inadequate follow up has been shown to increase future risk of admissions, in the national audit only 68.6% had a review in hospital planned 4 weeks post discharge and 37.2% of patients were advised to attend primary care within 7 days.
What’s the local picture and how do we compare?
How do we compare?
What do things look like locally?
- In 2012 there were over 24,000(6.8%) people in Wakefield District receiving treatment for Asthma, higher than both Yorkshire and the Humber (6.2% and England (5.9%) (QOF, 2012).
- The geographic distribution is more diffuse than other long-term conditions, not necessarily following a deprivation pattern with the same strength as other conditions (relative slope index of just over 12%).
- In 2011/12 430 people were admitted to hospital with an acute exacerbation of their asthma, 128 of these were under 18 years old. Admissions have fallen steadily over the past few years in 2009/10 there were 590 admissions for acute exacerbation in Asthma, 219 of these were under 18 years old.
- 21% of people in Wakefield living with Asthma report they are currently smoking compared to a rate in the general population of 23%.
- 42% of people in NHS Wakefield have been provided with a written asthma action plan, nationally only 23% of people are recorded as having a written action plan.
- 28 day readmission rates have fallen from 16% (2010/11) to 12.5% (2011/12)
- In Wakefield Patients admitted to Mid Yorkshire Hospitals the introduction of a Care Quality Indicator and work done with NHS Improvement Lung has led to an improvement in recorded follow up plans with 93.3% provided with a 4 week follow up appointment and 68.4% of those attending the Emergency Department told to see their GP in 2 working days.
- Nearly 6,000 people living with asthma in Wakefield did not have an annual review with their Practice in 2011/12.
What’s the trend what can we predict?
- Wakefield has made significant improvements in patient outcomes over the past 5 years; however, we continue to face significant challenges over the coming years.
What are we doing and what can be done differently?
- The Public Health Respiratory Team has worked with the local Mid Yorkshire NHS Hospitals Trust Respiratory Team to support clinicians to make significant improvements to patient care reflected in improvements in patient outcomes, for example admission rates, inpatient care and readmission rates.
- The introduction of an Asthma Care Bundle to the Emergency Department (CQUIN) and a further care bundle for inpatient and discharge care at Mid Yorkshire Hospitals Trust by the Respiratory Team with the support of NHS improvement- Lung have resulted in improved recording of initial assessment and management in the emergency department and at discharge.
- In 2013 the NICE Asthma Quality Standards were published. Key areas to address in Wakefield are listed below:
- People with asthma must have a self-management plan, updated every year and supported by education
- Working with Practices to increase access through the Long Term Condition Care Planning work being undertaken
- Introduction of Wakefield, Kirklees and Calderdale Asthma guidelines and local action plans
- Implementation of the ‘Compare your Care’ initiative from Asthma UK to encourage patients to ask their health care professional for an action plans
- People with asthma have (at least) one annual review of their condition with an asthma specialist (for example, a practice nurse with an asthma qualification) with adequate time (at least 20 minutes)
- Working with Community Pharmacists to improve quality of tMURs and support closer working between Pharmacists and primary care
- ED asthma CQUIN continuing for 2013/14 with improved targets
- Developing telephone reviews for those patients who do not attend for their appointments for annual review
- Asthma template developed and in place to support structured review
- Education of volunteers to enable them to take part in patient reviews to increase access to advice and information
- Inhaler technique training and resources provided across the health care community
- Patients seen in A&E, out of hour’s services or admitted with acute exacerbation of asthma must be seen by their GP Practice within 2 working days of attendance
- Working with ED and Primary Care to develop processes and pathway to enable patients to be seen within 2 working days of unscheduled care in their GP practice