Improving asthma outcomes in the UK

What is asthma?

Asthma is a common, chronic, noncommunicable disease found in both adults and children. It affects the airways (the trachea, bronchi, and bronchioles), which carry air in and out of the lungs. In asthmatics, the airways can become narrow, due to a tightening of the muscles around the small airways, and inflamed, which can lead to serious breathing difficulties.[1]

The National Institute for Health and Care Excellence (NICE) reports that, every day, “185 people in the UK are admitted to hospital with an asthma attack, and 5.4 million people are using treatments for asthma”.[2] The most recent figures for England indicate that, in 2020/21, there were 41,150 hospital admissions where the primary diagnosis was asthma, with an average age of 41, while in 2019/20 it was estimated that 6.5% of GP patients in England (one in fifteen) had asthma and had been prescribed asthma-related drugs within the past year.[3] In some instances asthma can be fatal; in 2020 there were 1,335 deaths registered in England and Wales where the underlying cause was recorded as asthma. Of these, 61% were among people aged 80 or above.[4]

The Commons Library’s health conditions interactive dashboard contains constituency-level data and maps on this and other health conditions. This is based on NHS Digital data.

Common symptoms of asthma

Common symptoms of asthma include:

• a whistling sound when breathing (wheezing);
• breathlessness;
• a tight chest, which may feel like a band is tightening around it;
• [5]

The NHS emphasises that other conditions can cause the same symptoms as asthma. The pattern of symptoms in people who do have asthma, however, tend to display some of the following characteristics:

• They start or get worse with viral infections, such as a cold.
• They are triggered by exercise, allergies, cold air, or hyperventilation from laughing or crying.
• They are worse at night or in the morning.[6]
• They happen often and keep coming back.[7]

Asthma can be very variable; some people may have mild symptoms while in others they be more severe and unrelenting. Equally, some people may experience the disease intermittently, for a limited period, and then have extended periods that are symptom-free.[8]

An asthma diagnosis is based on a person’s medical history, symptoms and diagnostic tests. More detailed information can be found in the NICE’s guideline on Asthma: diagnosis, monitoring and chronic asthma management (last updated in March 2021). NICE reports that over 8 million people in the UK – approximately 12% of the population – have been diagnosed with asthma (though some may have since ‘grown out’ of the condition).[9]

Currently, there is no cure for asthma but it is possible to manage the condition so that the symptoms remain under control. Patients typically rely on inhalers, though the exact medicines prescribed will depend on multiple factors, including the type and severity of symptoms. The World Health Organization (WHO) notes that there are two main types of inhaler:

• bronchodilators (such as salbutamol), that open the air passages and relieve symptoms; and
• steroids (such as beclometasone), that reduce inflammation in the air passages. This improves asthma symptoms and reduces the risk of severe asthma attacks and death.[10]

Causes of asthma

The exact cause of asthma is not known; the National Heart, Lung and Blood Institute in the United States notes that “the causes may vary from person to person”.[11] There are, however, factors that can make a person more predisposed to asthma, including their environment, job, family history or genes, and other medical conditions, such as having an allergy-related condition like eczema or hay fever.[12]

Asthma symptoms can occur in response to a ‘trigger’, with common triggers including:

• Viral (but not bacterial) respiratory infections (common colds).
• Inhaled irritants (cigarette smoke, wood burning stoves and fireplaces, strong odours, chemical fumes).
• Inhaled allergens (pollens, dusts, moulds, animal danders – flecks of skin shed by pets).
• Cold air / sudden changes in the weather.
• Occasional ingested substances (aspirin, sulfite preservatives, specific foods).[13]

“Asthma attacks” describe an episode when symptoms get much worse and may be life threatening. This can take place very suddenly or over several days.[14]

Statistics

In 2019/20 it was estimated that 6.5% of GP patients in England (one in fifteen) had asthma and had been prescribed asthma-related drugs within the past year. The Library’s health conditions interactive dashboard contains constituency-level data and maps on this and other health conditions. This is based on NHS Digital data.

Improving asthma outcomes

As noted by the All Party Parliamentary Group for Respiratory Health, chaired by Jim Shannon, there are several asthma guidelines used throughout the UK.[15] These include the guidelines created by the British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN) and the National Institute for Health and Care Excellence (NICE)[16], as well as locally-developed guidelines. NICE, SIGN and BTS have begun work to develop a joint guideline relating to asthma care, with a likely publication date is 2023. The APPG has noted the widespread welcome for the planned UK-wide guidelines, and other moves being made to rationalise the various guidelines.[17] The APPG commended the positive steps taken to improve asthma outcomes but noted that UK Government plans often included asthma in wider respiratory health policy rather than as stand-alone initiatives. The APPG have also commented that there “…is little, if any, differentiation between asthma and severe asthma within the government’s policies and initiatives.”[18]

In England, the NHS Long Term Plan (January 2019) included respiratory disease as a national clinical priority, with the overarching objective of improving outcomes for people with respiratory disease, including asthma.[19]  The Long Term Plan included commitments to:

• Earlier detection and diagnosis for respiratory problems like asthma, providing the opportunity for better management, and to help prevent exacerbations and avoidable emergency admissions to hospital.
• Support those with respiratory disease to receive and use the right medication. The Plan noted that 90% of NHS spend on asthma goes on medicines, but “…incorrect use of medication can also contribute to poorer health outcomes and increased risk of exacerbations, or even admission.”[20]

The NHS Long Term Plan provided the following on how the NHS would support the best use of inhalers:

Pharmacists in primary care networks will undertake a range of medicine reviews, including educating patients on the correct use of inhalers and contributing to multidisciplinary working. As part of this work, they can also support patients to reduce the use of short acting bronchodilator inhalers and switch to dry powder inhalers where clinically appropriate, which use significantly less fluorinated gases than traditional metered dose inhalers. Pharmacists can also support uptake of new smart inhalers, as clinically indicated.[21]

A response to a Parliamentary Question in the Lords in January 2021 set out some recent steps being taken to improve asthma outcomes:

NHS England and NHS Improvement have established 13 respiratory clinical networks across the country, to provide clinical leadership of respiratory services. One of their objectives focuses on improving clinical pathways for asthma. The Quality Outcomes Framework (QOF) ensures all general practitioner (GP) practices establish and maintain a register of patients with an asthma diagnosis in accordance with the National Institute for Health and Clinical Excellence’s guidance. An update to the GP Contract for 2020/21-2023/24 to be implemented in 2021 includes an improved QOF asthma domain. The content of the asthma review has been amended to incorporate aspects of care positively associated with better patient outcomes and self-management, including a review of inhaler technique and record of exacerbations.[22]

The National Institute for Health and Care Excellence provides further information on Indicators from the Quality and Outcomes Framework (QOF) for asthma in the General Medical Services (GMS) contract.[23]

In January 2021 Professor Andrew Menzies-Gow, NHS England's National Clinical Director for Respiratory wrote a blog on the progress of the NHS Long Term Plan in 2020, which explained how the NHS has been working to help those with lung disease through the pandemic.[24]

The Royal College of Physician’s website provides information on the National Asthma and COPD Audit Programme (NACAP) for England and Wales, which aims to improve the quality of care, services and clinical outcomes for patients with asthma and chronic obstructive pulmonary disease (COPD).[25]

In 2020 the Taskforce for Lung Health produced an update on their 2018 national plan to improve the nation’s lung health.[26]

In November 2020 the APPG for Respiratory Health produced a report on improving asthma outcomes in the UK.[27] The report was the result of a six month inquiry into “why improvements in asthma outcomes are stagnating in the UK” and to recommend policy solutions for the NHS “…to reverse the upward trend in asthma mortality.” The APPG made a number of recommendations to improve the lives and treatment of asthma patients. These included that the guideline discussions between NICE, BTS and SIGN should consider elements of the BTS “care bundle” and “other patient-centric best practice”, with a view to incorporating these into routine clinical practice.[28] Other recommendations included the following:

• We recommend that when clinically agreed thresholds have been reached on repeat prescriptions and on the use of relief inhalers and courses of OCS [systemic oral corticosteroids], health records should be used as an automatic trigger for reviews, follow up appointments and referrals.
• We recommend that QOF should be used to incentivise high quality outcomes for asthma, both in terms of improved quality of life as well as reduced asthma attacks, admissions and deaths.
• We recommend that the Government looks more fully into the possibilities of NHS data being made more widely available and allowing them to be interpreted by clinicians to improve asthma outcomes in clinical practice.
• We recommend that the Government adopts a consistent and practical electronic health record for asthma, which can be shared across primary and secondary care, including urgent care. We also recommend that the NHS undertakes a specific assessment of innovative technologies that may be of most help to asthma patients.
• We recommend that the clinical bodies responsible for the upcoming revised guidelines take into account the need for greater awareness for patients on the correct use of inhalers and that the government and its executive agencies… run an information campaign designed to remind patients on the appropriate use of inhalers…
• We recommend that the government drives and monitors greater uniformity and consistency in the asthma guidelines and that they undertake a 12 monthly review of the new revised guidelines which are expected from the NICE/BTS/SIGN discussions in 2021…
• We recommend that an appropriate clinical code needs to be created for severe asthma, to give certainty to patients and clinicians.
• We recommend that the Government puts in place the necessary steps for the creation and roll out of diagnostic hubs for respiratory illnesses, including asthma, throughout primary care.
• We recommend that clinicians be supported in their choice to prescribe biologics to severe asthma patients with adequate funding to support biologics services and wider education on the benefits of this form of treatment.[29]

Asthma UK publish an annual Asthma Survey, the reports of which are available on its website. Based on the experience of over 12,000 people with asthma, the two most recent reports have considered the impact of the coronavirus pandemic, and geographical and socio-economic inequalities, on care:

• The Annual Asthma Survey 2019, The Great Asthma Divide
• The Annual Asthma Survey 2020, Asthma Care In Crisis

[1] World Health Organization, Fact sheet: Asthma, 3 May 2021

[2] NICE, Asthma: diagnosis, monitoring and chronic asthma management, NICE guideline [NG80], Information for the public, Last updated: 22 March 2021

[3] NHS Digital, Hospital Admitted Patient Care Activity

[4] NOMIS, Mortality Statistics

[5] NHS, Overview: asthma, 19 April 2021

[6] US National Heart, Lung and Blood Institute, Asthma - Signs, Symptoms, and Complications, 3 December 2020

[7] NHS, Symptoms-Asthma, 19 April 2021

[8] University of Iowa Children’s Hospital, Overview of asthma, not dated

[9] NICE, Asthma: What is the prevalence of asthma? Last revised May 2021

[10] World Health Organization, Fact sheet: Asthma, 3 May 2021

[11] US National Heart, Lung and Blood Institute, Asthma - causes, 3 December 2020

[12] World Health Organization, Fact sheet: Asthma, 3 May 2021;

[13] University of Iowa Children’s Hospital, Overview of asthma, not dated

[14] Asthma UK, Asthma attacks, not dated; NHS, Asthma attacks, 19 April 2021

[15] APPG for Respiratory Health, Improving Asthma Outcomes In The UK (2.4MB, PDF) (November 2020), p31

[16] BTS/SIGN/NICE, British Guideline on the Management of Asthma: Quick Reference Guide (July 2019). See also NICE [NG80], Asthma: Diagnosis, Monitoring and Chronic Asthma Management: NICE Guideline (November 2017, updated February 2020)

[17] APPG for Respiratory Health, Improving Asthma Outcomes In The UK(2.4MB, PDF) (November 2020), p31

[18] Ibid, p15

[19] NHS Long Term Plan: Respiratory disease (January 2019)

[20] Ibid

[21] Ibid

[22] PQ 11648, 15 January 2021

[23] NICE Clinical Knowledge Summaries, QOF indicators: Goals and outcome measures: Asthma

[24] British Lung Foundation, blog on the progress of the NHS Long Term Plan in 2020 by Professor Andrew Menzies-Gow, NHS England National Clinical Director for Respiratory (January 2021)

[25] RCP London, National Asthma and COPD Audit Programme (NACAP)

[26] Taskforce for Lung Health national plan: two years on (2020). The Taskforce for Lung Health is comprised of its members, with a website hosted and managed on their behalf by the Asthma UK and British Lung Foundation Partnership, which provides the secretariat to the Taskforce.

[27] APPG for Respiratory Health, Improving Asthma Outcomes In The UK (2.4MB, PDF) (November 2020)

[28] Ibid, p5

[29] Ibid, pp5-8