Respiratory Conditions

‘Respiratory conditions’ is the general term for disorders that include; airway, lung tissue, and lung circulation diseases, some of which may lead to respiratory failure, reduced quality of life, and increased mortality and morbidity. Respiratory disease affects one in five people and is the third biggest cause of death in England (after cancer and cardiovascular disease). Lung cancer, pneumonia  and chronic obstructive pulmonary disease (COPD) are the leading causes of death (NHS England). 

The most common respiratory diseases are asthma, COPD, bronchitis, and pneumonia. Some of these diseases, such as COPD, are progressive meaning that symptoms will generally worsen, especially if not addressed or treated. Some treatments help to dilate major air passages, improving shortness of breath, and so help control symptoms, increasing quality of life.  

In England, one third of all deaths from respiratory disorders are attributable to cigarette smoking (including second-hand smoke), but other risk factors for chronic respiratory diseases include; air pollution, allergens, occupational risks, poor housing, and frequent lower respiratory infections during childhood. Outdoor, and indoor air pollution (often caused by cooking with solid fuels) are also common causes (World Health Organisation). 

Hospital admissions for lung disease are rising, are generally non-elective, and contribute significantly to winter pressures faced by the NHS. The annual economic burden to the NHS for asthma is estimated at £3 billion, and £1.9 billion for COPD. In total, all lung conditions (including lung cancer) directly cost the NHS in the UK £11billion annually (NHS England).  

• NICE provides clinical guidance for respiratory conditions 
• The NHS Long Term Plan includes four main areas for people affected by lung disease; Improved diagnosis; improved pulmonary rehabilitation; medication reviews; and support for self-care. The plan emphasises prevention; committing more money to help people in hospital quit smoking; and promises to reduce air pollution caused by NHS processes. 
• The Quality and Outcome Framework (QOF) financially rewards general practices for providing quality care, helping to standardise improvements. COPD is one clinical domain in the Framework, measured by a range of indicators (e.g. people with COPD who have had influenza immunisation).  
• The NHS RightCare (Respiratory) resources provide support to commissioners and providers in achieving improved health outcomes for populations 
• The Core20PLUS5 approach to reducing health inequalities identifies chronic respiratory disease as one of five clinical areas for improvement, particularly for vaccination uptake. 
• Lincolnshire’s Joint Health and Wellbeing Strategy focusses on prevention – supporting people to improve their own health and wellbeing. 

Mortality rates and hospital admission figures for respiratory conditions in Lincolnshire are broadly in line with national averages. However, risk factors such as obesity, lack of physical activity, and smoking in pregnancy, are higher in Lincolnshire and this may contribute to a higher incidence of respiratory conditions in the future. This is clearly seen in Boston, East Lindsey, South Holland and Lincoln. It is reasonable to expect an increase in cases of respiratory viruses now infection prevention and control measures have relaxed following the worst of the Covid-19 pandemic. Lincolnshire residents experiencing symptoms of Post-COVID Syndrome are being supported by Lincolnshire Community Health Services (LCHS) Post-COVID Rehabilitation Service. 

Incidence of Lung cancer and COPD are considerably higher in the most deprived communities. Incidence and mortality rates from respiratory disease are higher in disadvantaged groups and in areas of social deprivation. Inequalities see the gap widening, leading to lower health outcomes. The most deprived communities have a higher incidence of smoking, exposure to higher levels of air pollution, poorer housing conditions, and greater exposure to occupational hazards (NHS England). Less wealthy people have limited access to a healthy diet containing antioxidant nutrients which protect against the harmful effects of air pollution (RCP London). 

Lincolnshire has a high proportion of routine manual labour which often correlates with higher smoking rates and higher exposure to occupational risks. Asthma+Lung UK found 80% of mesothelioma cases occur in men (mesothelioma is a tumour of the lining of the lungs, heart, or abdomen). Those most at risk have been exposed to asbestos while working in heavy industry or the armed forces. COPD is also more common in men but, in recent years, prevalence has plateaued for men but increased for women. 

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

Concerningly, hospital admission and mortality rates from COPD in Lincoln have tended to be considerably worse than the England average. Evidence from the Asthma+Lung Association (BLF) shows outdoor air pollution is generally higher in deprived urban areas, such as Lincoln, which worsens symptoms of lung disease, and can cause lung disease to develop. 66% of man-made carcinogens are emitted in the 10% most deprived English city wards, and deprived communities have less access to green spaces (PHE, 2016). 

Lincolnshire has recorded increasing numbers of infants and severely disabled children having frequent and prolonged hospital admissions for respiratory tract infections. Once in hospital, discharge is often delayed by the need for chest physiotherapy after an acute illness. This has led to the introduction of specialist community services. 

One You Lincolnshire provides smoking cessation support as part of an Integrated Lifestyle Service. Inpatient and maternity smoking cessation services are being developed by Lincolnshire Integrated Care System (ICS). Lincolnshire’s Tobacco Control Steering Group deliver their enforcement and legislative responsibilities, helping reduce smoking and access to uncontrolled, harmful/illicit substances. 

A 5-year programme for Lincolnshire is being developed to improve access to pulmonary rehabilitation and community-based Spirometry, a key diagnostic tool. 

Lincolnshire Community Health Services (LCHS) provide the community based Children’s Rapid Response Service supporting children with complex physical disabilities that have additional respiratory problems. 

General practices maintain a register of people with COPD, linked to the QOF. These patients are supported to manage their condition by specialist services for people with intermediate and complex COPD issues. These services include: 

• Acute Respiratory Assessment Service (ARAS), provided by Respiratory Nurse Specialists in partnership with hospital staff, community nursing teams, GPs, and social services. For patients experiencing an acute exacerbation (‘flare up’) and supports patients and their carers in their own home, preventing admission to hospital. 
• Early Assisted Discharge service involves the community respiratory team providing specialist treatment and support at home to facilitate early discharge from hospital 
• A countywide respiratory service of Pulmonary Rehabilitation is provided by LCHS for COPD patients. This involves education and exercises to improve; physical fitness, exercise tolerance, breathlessness management, quality of life and mood. 
• Respiratory Physiotherapy to assess, treat and educate patients in managing breathlessness and sputum clearance 
• Several patient self-support groups are established across the county 

Healthwatch are commissioned to ensure the public can engage with and feedback on all health services, including respiratory services. One You Lincolnshire also gather service user feedback. 

NICE provide guidance on excess winter deaths and illnesses associated with cold, poorly maintained properties with damp or mould. However greater awareness is needed to ensure the pathway and recommendations are embedded within housing protocols and good practice models. 

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

Research is needed into the risks of exposure and incidents of workplace hazards in Lincolnshire, focussing on industries pertinent to Lincolnshire such as agriculture, quarrying, plastics manufacturing, and the food industry. 

• Increase referrals to the Lincolnshire Integrated Lifestyle Service  
• Inpatient and maternity smoking cessation services to be developed by Lincolnshire Integrated Care System (ICS)  
• Working in partnership with local communities, health and care colleagues will come together via Primary Care Networks to develop community services that reflect the needs of the local population and seek to address the issues that create health inequalities. These developments will build on the initiatives developed by Neighbourhood Teams to support proactive care and enable patients to better manage their own conditions. Opportunities to utilise telemedicine and enhanced support via health coaches will contribute to the wider provision of services aimed at reducing unplanned hospital admissions. 
• Develop Lincolnshire’s Joint Research Agenda: a collaboration between Lincoln Institute for Health and Lincolnshire NHS Trusts, to explore respiratory priorities, identify key stakeholders, and explore funding opportunities to develop the network and their projects. 
• Increase the number of frontline healthcare staff trained to deliver respiratory advice. 
• Increase screening appointments to ensure early diagnosis. 
• Deliver more structured support for patients with COPD outside of hospitals 
• Explore recommendations of the Asthma + Lung UK Strategy to 2027.