In 2015 the Department of Health published the Services Framework for Respiratory Health and Wellbeing, outlining 56 standards to improve respiratory services over a three-year period. The framework was a bold document, but without funding and leadership, services did not improve.
We have identified five lung conditions where improvements in the delivery of care can result in high-impact improvements to people’s lung health. These are asthma; chronic obstructive pulmonary disease (COPD), bronchiectasis, interstitial lung disease (in particular IPF) and Long COVID.
The right treatment at the right time Using medication properly is key to controlling symptoms so people diagnosed with a lung condition can live their lives as they wish. Inhalers are a vital part of treating COPD and asthma but there are significant problems with their use. A systematic review in errors of inhaler use suggests that three-quarters of people make errors using their inhaler devices and that this has not changed in over 40 years.
Overuse of reliever inhalers in asthma care has been linked to increased risk of hospital admission and even death. It is vital that all relevant healthcare professionals are trained in inhaler use and technique to do this effectively. Biologic treatments can improve symptoms and reduce attacks in people with severe asthma by helping to stop the body processes that cause lung inflammation. NICE and Department of Health have approved some of these drugs for severe asthma treatment but just 26% of people with severe asthma in Northern Ireland are currently eligible for treatment, and of those, two thirds have not yet received access. This means many people are still reliant on toxic oral steroids, which can cause diabetes, cataracts, and osteoporosis.
Two anti-fibrotic drugs, pirfenidone and nintedanib, are available for IPF, which can slow down disease progression, helping to improve quality of life. But under NICE guidelines they are only available to patients with lung function between 50% and 80%, meaning patients in the early stages of their condition and more advanced stages are not eligible.
Asthma
Asthma is a condition that affects 1 in 10 people in Northern Ireland of any age. It is a key factor in repeated respiratory infections in children and causes breathlessness in adults. If undiagnosed or inadequately treated, it can lead in the short-term to asthma attacks and in the long term to irreversible damage to the airways. Once a diagnosis of asthma has been achieved, information about asthma which is relevant, easy to understand and in an accessible format should be provided. Everyone with asthma should get basic care, which includes an annual review, an inhaler technique check and a written asthma action plan. Unfortunately, we know 53% of people with asthma in Northern Ireland miss the basic level of asthma care.
Chronic obstructive pulmonary disease (COPD)
COPD is a chronic progressive disease of the airways associated with high morbidity and mortality. 43,000 people in Northern Ireland are registered as living with COPD, however the total, including those undiagnosed, may be over 55,000. COPD is largely managed in primary care but exacerbations often result in admission to hospital. Regular inhaler and symptom reviews in primary care, smoking cessation support, self-management initiatives, long-term oxygen therapy and pulmonary rehabilitation programmes can all improve quality of life and reduce hospital admissions. As the condition progresses, accessing palliative care services can improve the quality of life of patients. The 2021 Annual COPD survey showed that only 13.5% of those diagnosed with COPD in Northern Ireland receive the NICE-recommended five fundamentals of COPD care that they need and only 62% were confident of what to do if their COPD flared up.
Bronchiectasis
Bronchiectasis is a condition characterised by chronic sputum production and frequent lung infections, often requiring hospital admission affecting 1 in every 1000 people in Northern Ireland. Physiotherapy has a significant role in Bronchiectasis management, helping to reduce infections and hospital admissions.
Interstitial Lung Diseases
ILDs comprise over 150 diverse conditions which primarily affect the lung’s smallest airways and alveolar air sacs. Whilst the cause of some ILDs is unknown, there is an overlap with occupational and environmental lung conditions such as coal and slate workers’ pneumoconiosis, asbestosis, and farmer’s lung. It is known that some ILDs are caused by cigarette smoke and others may occur as a reaction to medication. Yet others occur in association with conditions such as rheumatoid arthritis. Idiopathic pulmonary fibrosis (IPF), the most common ILD, has increased in prevalence over the past 20 years affecting over 1,200 people in Northern Ireland, the highest IPF prevalence rate in the UK. The median survival for IPF is just three years, a prognosis that is worse than many cancers.
Long COVID
Long COVID describes signs and symptoms that last for longer than 4 weeks after getting COVID-19. It is estimated to affect 10% of people who have had COVID and can affect your whole body. Common Long COVID symptoms include extreme tiredness (fatigue), shortness of breath (which is the second most reported symptom), chest pain or tightness and problems with memory and concentration (“brain fog”). Symptoms can change and come and go over time. It is important that people who present with Long COVID symptoms in primary care are supported in receiving timely referrals to specialist support.
Seasonal Flu and Pneumonia
Too many people die from short-term respiratory illnesses such as flu and pneumonia. Over 25 died in Northern Ireland due to influenza in 2019 and over 620 with pneumonia. Some cases could be prevented by better uptake of the flu/pneumococcal vaccination, one of the most cost-effective ways of treating someone with a pre-existing lung condition and it saves lives.
Asthma + Lung UK Northern Ireland is calling for:
- The urgent development of a new Lung Health Strategy, to restart, rebuild and transform respiratory services in primary and secondary care.
- A dedicated Centre of Excellence for Respiratory Medicine for Northern Ireland bringing together health care professionals, academia, and researchers to treat rarer lung conditions and improve standards
- Investment in an integrated respiratory service as recommended in the Bengoa Report, increasing numbers of community-based respiratory specialist nurses and allied healthcare professionals. Additional funding to expand Long COVID care centres and hubs in Northern Ireland to ensure people get the right treatment for their different symptoms.
- A review of GP services contract to reverse the fall in the number of annual reviews and spirometry tests for people with asthma and COPD.
- The development of regional databases of those living ILDs, whose treatment would largely be secondary care focussed.
- The inclusion of a dedicated respiratory chapter in all future Northern Ireland Health Surveys to build a more complete picture of lung conditions.
- All eligible patients to have equitable access to biologic and anti-fibrotic medications.
- The expansion of flu/pneumococcal vaccination uptake through out-of-hours delivery/delivery in non-healthcare venues (leisure centres, sports clubs, supermarkets, shopping centres, etc.).
Read next: How we can live better with lung conditions in Northern Ireland