Quality statement for respiratory disease

One in twelve adults in Wales reports a longstanding respiratory illness and Wales has a higher rate of asthma prevalence than the European average. Prior to the COVID-19 pandemic, around 15-16% of all deaths were due to respiratory disease and in 2019 Wales had the highest avoidable mortality rate in the Great Britain for diseases of the respiratory system. Respiratory medicine costs the NHS in Wales more than £400 million per year.

The Respiratory Health Implementation Group was established in 2014 to support NHS bodies to improve the quality of services and deliver better patient outcomes. It has successfully focussed efforts on reducing variation in care through the introduction of national tools to standardise care across health boards. These have included national educational standards for all areas of respiratory medicine, national guidelines for chronic obstructive pulmonary disease (COPD) and asthma management, quality improvement tools and patient facing apps – all hosted on a single digital platform.

The 2020 COVID-19 pandemic required an unprecedented national response to a previously unknown disease characterised by severe pneumonitis. This brought into sharp focus the importance of respiratory disease services. The Respiratory Health Implementation Group responded to the pandemic by creating a suite of clinical guidance for the assessment and management of COVID-19 in hospitals settings and a framework for COVID-19 management in community care. This was augmented with a national data collection of COVID-19 ward-based care and a national framework for recovery from COVID-19 infection, including a patient app.

The pandemic has also had a significant impact on routine chronic lung condition management, particularly the delivery of annual reviews and spirometry. It is important NHS services recover quickly from the impact of the pandemic and re-establish routine care processes for people with chronic lung conditions. This will improve individual disease control, reduce complications, and avoid higher levels of healthcare demand.

The focus of this Quality Statement is the proper diagnosis, management, and treatment of respiratory disease in both adults and children and young people. It is complemented by other national strategy and policy related to the prevention and suppression of communicable diseases; as well as national plans for tobacco and obesity, the quality statement for cancer, and the UK-wide approach to rare disease, such as cystic fibrosis. Services design should ensure equity of access, including targeted approaches for hard to engage patient groups or groups that typically experience poorer respiratory outcomes.

Health boards – as integrated healthcare organisations – are responsible for the delivery of respiratory care services and will respond to this Quality Statement through the integrated medium term planning process. The successor to the Respiratory Health Implementation Group will support health boards to improve the quality, consistency, and value of healthcare delivery. It will do this by using the principles of implementation science to achieve local adoption of national digital guidelines, educational packages and patient apps. This will empower clinical services across primary, community, and secondary care to deliver excellent respiratory care.

The quality of respiratory disease care will be monitored through a suite of national dashboards and via the National Respiratory Audit Programme (NRAP).

Quality Attributes

Equitable

• The Respiratory Health Implementation Group develops national datasets to support clinical decision making and improve local planning of respiratory disease services for adults and children and young people.
• The Respiratory Health Implementation Group develops and maintains national guidance, pathways and tools (including PROMs) to support health boards deliver consistent and excellent respiratory disease care. 
• Health boards provide (or commission) specialist multi-professional teams, competent in the management of adult chronic respiratory disease (including tuberculosis, interstitial disease, COPD, asthma, sleep disordered breathing, and the delivery of oxygen therapy), that are appropriately resourced to meet the needs of their population.
• Health boards commission (or provide) regional specialist multi-professional teams competent in the management of chronic respiratory disease among children and young people.

Safe

• Health boards, as appropriate, admit patients with more severe single organ respiratory failure to a respiratory support unit (RSU), or intensive care unit, with staffing and equipment that meets national guidelines.
• Health boards provide (or commission) difficult-asthma services for people with severe or uncontrolled disease, which collaborate at national level to ensure consistency of provision and appropriate access to biologic therapy.
• Health boards take part in national clinical audit for respiratory disease and apply quality improvement methodology and national quality improvement resources in response to the findings.
• All patients considered for long-term oxygen therapy at home should have a standard assessment in line with British Thoracic Society guidance.

Effective

• Adults affected by chronic respiratory disease, where appropriate, receive routine care and review in primary and community care by a healthcare professional who is competent in the management of the patient’s respiratory condition.
• People with respiratory disease, and parents of children with respiratory disease, who use tobacco should be given brief cessation advice, offered Nicotine Replacement Therapy, and referred to smoking cessation services.
• People with chronic respiratory disease are offered their routine vaccinations to reduce their risk of exacerbation and hospitalisation.
• Health boards and trusts collaborate with academic and industry partners, such as Respiratory Innovation Wales, to accelerate research activity and innovation in respiratory medicine.
• Health boards have a nominated clinical and corporate lead for tuberculosis and a local plan for prevention and control, to ensure services can deal with complex case management and respond to any incidents or outbreaks.

Efficient

• People presenting multiple times to hospital with airways disease are supported by an appropriate member of a multi-professional team to improve disease control and reduce their risk of further unscheduled care admissions.
• New COPD patients, and those already on a COPD register, have coded evidence in the clinical record of spirometry, performed by an appropriately trained healthcare professional.
• New asthma patients, and those already on an asthma register, have coded evidence of disease according to the national guideline.
• Medicine usage reviews support individualised and appropriate changes in prescribing practice, increasing the prescribing of lower global warming potential inhalers as a percentage of total inhaler prescribing and reducing the use of SABA and long-term oral steroid prescribing.

Person-centred

• Spirometry should be available to patients over the age of 12 in primary or community care and results should be available to all relevant clinical teams through the Welsh Clinical Portal and independent contractor systems. 
• Patient apps are offered to all patients with asthma and COPD – or parents of children with asthma – as a digital patient self-management plan.
• Provide access to appropriate rehabilitation opportunities, including social prescribing, exercise referral and pulmonary rehabilitation services; and to peer-support groups, including from the third sector

Timely

• All patients admitted to hospital with a primary respiratory illness are seen by a respiratory specialist within 24 hours.
• All patients requiring non-invasive ventilation receive it within two hours of arrival at hospital and, as appropriate, are managed in a respiratory support unit or intensive care unit.
• Health boards and Trusts plan for seasonal variation in acute respiratory exacerbations and provide rapid access, community-based services, to avoid unnecessary admissions.

The following clinical management guidelines (icst.org.uk) are available for use in Wales:

• COPD Management and Prescribing Guideline
• Adult Asthma Management and Prescribing Guideline
• Admission Avoidance Guideline for COPD
• RSV Bronchiolitis pathways
• CYP Asthma Diagnosis, Management and Prescribing Guideline
• CYP Acute Asthma Pathway