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Annual Report Respiratory ACTasONE RESPIRATORY PROGRAMME ANNUAL REPORT APRIL 2020!MARCH 2021 CONTENTS Foreword ............................................................................3 Background ........................................................................5 COVID-19 ...........................................................................8 Post COVID syndrome service ..............................................11 Flu .....................................................................................13 Next steps ..........................................................................16 Acknowledgements .............................................................18 ACT AS ONE RESPIRATORY PROGRAMME ANNUAL REPORT 2 FOREWORD ACT AS ONE RESPIRATORY PROGRAMME ANNUAL REPORT 3 FOREWORD In a year like no other where we have had to respond quickly to the threats and challenges posed by a global pandemic, we have really demonstrated how we Act as One in our respiratory programmes. In a normal year there are seasonal pressures which we can plan for, with the odd exception, but COVID-19 has been unparalleled and has had an impact on all our lives. Among the tragic stories of personal loss, there have been reasons for optimism as our communities worked together to collectively respond to the pandemic and we have seen partnership working at a scale which would have been barely imaginable just over a year ago from the time of writing. We are particularly impressed with how we have worked across services, teams and organisational boundaries in response to COVID-19. This included setting up long COVID care pathways, which were featured nationally by Channel 4’s Despatches programme. We have also established the COVID@Home service – you can read more about this in our annual report. While we have been dealing with the impact of COVID-19 on our health and care services, we have continued to make progress in our Act as One Respiratory Programme. We had our most successful flu vaccination programme with more than 25,000 additional people taking up the offer of a flu jab this year compared to 2019. But hidden in this data is the continuing challenge of varying uptake across our place, with lower uptake in areas that are economically challenged. This low uptake of the flu vaccine in some parts of our place highlights the need for us to really understand and respond to health inequalities that have been further widened since the pandemic began. Our focus will be on continuing to innovate but we are committed to understanding our communities and ensuring we can respond to their needs. This means we will be person and not service led throughout our programme, supported by the relationships we have through our voluntary and community sector organisations. This has been an extraordinary year, we cannot forget the human impact of the pandemic yet we must also hold on to the rapid transformation that is helping our communities and making best use of our people to improve outcomes. Karen Dawber SRO for the Act as One Respiratory Programme ACT AS ONE RESPIRATORY PROGRAMME ANNUAL REPORT 4 BACKGROUND ACT AS ONE RESPIRATORY PROGRAMME ANNUAL REPORT 5 BACKGROUND Respiratory diseases are diseases that affect the air passages, including the nasal passages, the bronchi and the lungs. They range from acute infections, such as pneumonia and bronchitis, to chronic conditions such as asthma and chronic obstructive pulmonary disease (COPD). With some of the greatest ill health locally associated with asthma and COPD, these respiratory conditions contribute to health inequalities, ill health and premature death. ‘Lung conditions, including lung cancer, are estimated to cost wider society around £9.9 billion each year. Respiratory disease affects one in five people in England, and is the third biggest cause of death. Hospital admissions for lung disease have risen over the past seven years at three times the rate of all admissions generally and remain a major factor in the winter pressures faced by the NHS. Over the next ten years we will be targeting investment in improved treatment and support for those with respiratory disease, with an ambition to transform our outcomes to equal, or better, our international counterparts.’ NHS Long Term Plan Our Joint Strategic Needs Assessment highlights the following: More than people die from respiratory disease every year in the district. An estimated 25% of these deaths are preventable. With rates of early death (before the age of 75) from respiratory disease in Bradford District amongst the highest in England and the second highest in Yorkshire and Humber, respiratory disease is a leading cause of dying early in Bradford District. deaths (on average) per year due to respiratory disease in the under 75s. The main 180 causes of death are COPD and pneumonia. y t Mortality rates in Bradford i District and Craven have l shown an increase since a Bradford t 2011, whereas rates for District and r respiratory disease in Craven o England and Yorkshire and Humber have shown m a steady decline. ACT AS ONE RESPIRATORY PROGRAMME ANNUAL REPORT 6 There is a strong association of Bradford’s neighbourhoods fall between mortality and deprivation, 34% within the 10% most deprived in with the most deprived parts of the England, an additional three district having the highest neighbourhoods since 2015 (2019 premature mortality rates. Indices of Deprivation). 21st most deprived out of 317 local authorities of the population are from Black, Asian 33% and Minority Ethnic backgrounds, with 27% from Asian/Asian British backgrounds. Air pollution is associated with a number of adverse health impacts. It particularly affects the most vulnerable in society: children and older people, and those with heart and lung conditions. There is also often a strong correlation with equalities issues, because areas with poor air quality are also often the less affluent areas. 13,362 asthma higher prevalence 43,613 COPD than England average These numbers are likely to be an underestimate of the actual number as many people remain undiagnosed. The proportion of people undiagnosed varies between GP practices. Whilst some degree of variation is expected, the variation described suggests that some GP practices are better than others at detecting COPD, and that there is capacity for improvement. Disease rates for COPD are lower in parts of Bradford City, in part, a reflection of the younger age structure of the population. As the number of older people increases, the number of people with COPD is expected to increase. One of the main challenges in managing COPD and asthma is that many people are unaware that they have the condition and aren’t diagnosed until the disease is at an advanced stage. Late diagnosis has a substantial impact on symptom control, quality of life, outcomes, and cost. ACT AS ONE RESPIRATORY PROGRAMME ANNUAL REPORT 7 COVIDF19 ACT AS ONE RESPIRATORY PROGRAMME ANNUAL REPORT 8 COVIDF19 We know that people living in deprived areas and people from Black, Asian and Minority Ethnic backgrounds are at considerably increased risk of COVID-19 infection and mortality. Some of the reasons for this include people working in key worker roles and in densely populated areas, making exposure more likely. There are also high rates of conditions that we know put people at increased risk of COVID-19, e.g. diabetes. Data from the Quality and Outcomes Framework (QOF) suggests that diabetes prevalence is 8.7% in the former NHS Bradford districts CCG area and 11.1% in the former Bradford City area, compared to an average of 7.1% in England. Our work has predominately been shaped by our response to the pandemic. COVID-19 struck us hard in our population. We needed to react quickly, effectively and efficiently to develop pathways to safely support both patients with COVID-19, and those who needed non-COVID care and treatment. Some of our services developed within the pandemic will become routinely commissioned and we will be engaging with our system and our local people to understand what worked well and how we can develop services further. COVID@Home service At the beginning of January 2021, the COVID@Home service went live in the Digital Care Hub (DCH). A virtual ward was set up to which people with suspected/proven COVID-19, had access to support and oximetry for a 14-day period. Patients on the virtual ward are supported 24/7 by the DCH clinical team. Patients report their oximetry readings and any symptoms using the Luscii App or a daily paper diary and the DCH clinical team review those who deteriorate. The service was initially set up to provide support for people identified in the community and/or emergency department (ED) with COVID-19, who are safe to be cared for at home with the aim of reducing complications as a result of silent hypoxia. This was quickly expanded to those in hospital who could be discharged early, also with remote monitoring and support at home. The referral criteria consisted of all adults over 65 testing positive or with COVID-19 symptoms, or under 65 and from the Clinically Extremely Vulnerable (CEV) groups who do not require hospital inpatient treatment. This included those who had pre-existing hypoxia (e.g. COPD patients) but not those for whom escalation of care to hospital would be inappropriate (e.g. end of life). All GPs and ED teams were provided with pulse oximeters and clear guidelines for referral. All patients were asked for feedback on discharge and comments encouraged throughout their time on the caseload. Outlined below are two examples
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