Suffolk & North East Essex Integrated Care System

Respiratory disease and air quality

WHY this is important for people in Suffolk and North East Essex

The best care and quality of life for people with respiratory disease and cleaner air are essential if everyone in Suffolk and North East Essex is to live well.

As an Integrated Care System we will ensure that:
  • People’s respiratory conditions are diagnosed early
  • People with respiratory conditions are supported to live well
  • People at higher risk of respiratory infections have access to high quality care
  • People have cleaner air


Chronic Obstructive Pulmonary Disease (COPD) is a common disabling condition with a high mortality. The most effective treatment is smoking cessation. There are two main forms of COPD: Chronic bronchitis and Emphysema. Most people with COPD have a combination of both conditions. Poor air quality is a significant public health issue, particulate matter has a significant contributory role in human all-cause mortality and in particular in cardiopulmonary mortality. We measure the annual concentration of human-made fine particulate matter at an area level, adjusted to account for population exposure. Fine particulate matter has a metric of micrograms per cubic metre (μg/m3).

MyCOPD is a web-based application for the self-management of chronic obstructive pulmonary disease (COPD). MyCOPD enables patients to manage their condition more effectively with a self-management plan and inhaler diary, online pulmonary rehabilitation program, online education tutorials, weather, pollution, and symptom reporting. myCOPD empowers patients to take more control of their own care.

In 2018 2,678 MyCOPD licenses were allocated to our system, funded by NHS England through the Innovation and Technology Tariff. Since then providers and commissioners have worked in collaboration to offer free licenses to suitable people with COPD. Initially starting with community and acute care providers, clinicians offered licences to suitable patients within a range of setting, in some areas further incentivised by for example local CQUINs (in North East Essex) or as part of a 100-day challenge (in West Suffolk). So far approximately 700 licenses have been taken up by patients. Although we were initially limited to offering the free licenses to severe COPD patients only, we have more recently also started implementing the MyCOPD licenses in Primary Care. So far approximately 100 licenses have been given to patients.

Although there is a comprehensive evaluation plan in place to measure the impact of MyCOPD on our health care system (including admissions and uptake of referrals) it is yet to early to draw conclusions. However, we have already identified some important learning. Time and resource need to be dedicated to the change in clinician and patient behaviours to best implement this type of technology. We need to plan for implementation before applying for licences to ensure a positive patient impact and return on investment. A whole pathway approach is key to achieving good clinician engagement. Finally, we believe information governance sign off, technology infrastructure, stakeholder engagement, pathway mapping, and training are all important factors to success.

A national Asthma UK survey of people with severe asthma found:
  • 68% say it holds them back in work and school
  • 71% say it affects their social life and 54% say it holds them back from going on holiday
  • 66% say it has made them (or their child) anxious and 55% say it has made them (or their child) depressed
  • 55% say it has affected their confidence, and a similar number say it affects family life
  • 75% say they’ve been to A&E more than three times (for themselves or their child) because of an asthma attack
  • 45% say they’ve been to A&E more than 10 times (for themselves or their child) because of an asthma attack
    • For more information see


The British Lung Foundation highlights that:
  • Lung disease is one of the top three killer diseases in the UK
  • 115,000 people a year die from lung disease – 1 person every 5 minutes
  • Mortality figures are roughly the same as 10 years ago, yet heart disease has fallen 15%
  • 1 in 5 people in the UK have been diagnosed with a lung disease
  • Every day, 1,500 new people are diagnosed with a lung disease

For more information see

LTA 16

What do we know about people’s local experiences?

A study of people with Chronic Obstructive Pulmonary Disease (COPD) in Cambridge found:

  • “I want to stay independent forever – not being a burden and doing things for oneself.”
  • “I want to stay in my own home – maintaining independence.“
  • “I want to be mobile – being able to see relatives and being mobile around the house.”
  • “I need help to stay confident – finding an interest and meeting other people.”
  • “I would like to stay as healthy as possible to achieve my aspirations – continuing to work, seeing grandchildren grow up and living as long as possible.”
  • “I value family support and I want to be able to maintain my social network – the importance of family and friends.”

For more information see Early, F, et all (2019) ‘What matters to people with COPD: outputs from Working Together fro Change’ Primary Care Respiratory Medicine vol29, Article 11 (2019) available at

HOW we plan to make a difference 

    1.1 People living with breathing problems will have their respiratory problems detected and diagnosed earlier. We will enable this by:

  • Implementing the Spirometry Competency Framework and expanding quality assured spirometry training so that more staff are trained and competent to perform and interpret spirometry, beginning in 2019. This will include all our primary care services having GPs and practice nurses by 2020 accredited for interpreting spirometry. Currently one third of people with a first hospital admission for COPD exacerbation have not been previously diagnosed. Primary Care Networks will support the early diagnosis of respiratory conditions.
  • Educating health and care staff to recognise the symptoms and signs of respiratory conditions. Earlier detection and diagnosis will enable people to access to the respiratory care pathway promptly, have support to manage their conditions, and help avoid unnecessary hospital admissions.
  • Case finding in primary care, to increase the number of people diagnosed with respiratory conditions early.
  • Staff supporting people to recognise early signs of lung cancer, and attend screening and testing where needed. Our system aims to become an early adopter for lung cancer screening. Earlier referral will help detect more early lung cancer and approve lung cancer survival.

    2.1 People with respiratory conditions will receive the right medication to manage their condition.

  • Healthcare professionals will follow national and local prescribing guidelines and will teach people the correct inhaler technique. 90% of NHS spend on asthma goes on medicines but incorrect use can contribute to poorer health outcomes, increased risk of exacerbation and hospital admission. Integrated working will help improve equality of access and health outcomes. This will build on our existing thriving system-wide respiratory network, GP Educational Events, and we will establish a Respiratory Nurse Forum and introduce new COPD Health Coaching Services.
  • Community pharmacists will review medication; educate on use of inhalers; support people to switch from short acting bronchodilators to dry powder inhalers or smart inhalers where clinically appropriate. Annual reviews are particularly important; it is estimated fewer than half of people with COPD have an annual review that covers medication and inhaler technique. In our ICS we will continue to roll out Pharmacy Rescue Packs to support patients in urgent need of specific medication.

    2.2 People with respiratory disease will be better able to manage their condition through high quality support. We will enable this by:

  • Integrating skilled health and care services providing personalised care. Integrating primary and secondary care, mental health and physical health, and health and social care services will help improve health outcomes and enable better patient experiences. We have launched Early Supported Discharge for COPD so patients can be discharged more quickly and be supported locally in their home. We are trialling virtual multidisciplinary meetings with the hospitals and with wider community staff, to improve care coordination.
  • Providing mental health support and coaching. We are focussing on improved access to Psychological Therapies for all Long Term Conditions. This will include how therapy can be integrated into existing pathways and services for respiratory patients in all three of our local acute hospitals and community services.
  • Improving access to approved specialist treatments where appropriate. Evidence-based treatments include biologics for severe asthma, anti-fibrotic therapy for pulmonary fibrosis, lung volume reduction for COPD, and Improved Access to Integrated Therapies for people with long term conditions.
  • Ensuring people with mental health problems, who are at greater risk of lung disease, have equal access to care.
  • Developing COPD and Asthma primary care nursing support. This will provide more community-based support for people living with these conditions.
  • Initiating MyCOPD App in primary care by GPs as well as hospital consultants, widening access for people to self-manage their own condition.

    2.3 People with respiratory disease will be better able to manage their condition through high quality rehabilitation.

  • We will expand awareness of, and access to pulmonary rehabilitation services, by 2029. Pulmonary rehabilitation will be provided for all people with COPD with an MRC score of three or above; we will also consider extending the threshold to people with an MRC breathlessness score of grade 2 and above. Greater ease of access to services, for example extending hours, or making services available in locations that are easier for people to travel to, could help people obtain support earlier and therefore improve health outcomes.
  • New models of rehabilitation will support people with mild COPD including digital tools.
  • People with COPD will be referred to pulmonary rehabilitation through the COPD Discharge Bundle.
  • We will develop generic collaborative pulmonary and cardiac programme of education and rehabilitation for people with heart and lung disease. Such rehabilitation programmes can improve exercise capacity and quality of life in up to 90% of patients.

    2.4 People receive community-based respiratory care based on best practice.

  • Primary Care Networks will improve access to care pathways and draw on expertise to develop services. Improved pathways and systems enables people to have a better experience of care and improved health outcomes. These networks will be well placed to support our initiatives such as Home Oxygen Assessment and Review Service, where the aim is to ensure that home oxygen is appropriately prescribed to those people who clinically need it so provision is evidence-based, clinically-led and continually strives to improve outcomes.
  • We will use population health in primary care to find eligible patients with COPD and refer them to rehabilitation.

    2.5 People with respiratory conditions receive the best hospital and out-of-hospital care. We will enable this by:

  • Nurse-led supported discharge services in Emergency Departments. This measure will help to enable safe out-of-hospital care. Respiratory HOT clinics have been set for rapid assessment for patients suffering an acute exacerbation of their respiratory symptoms. This service will reduce the pressure on Emergency Departments and reduce avoidable admissions.
  • Structured hospital admission with prompt assessment by specialist teams and discharge using COPD/asthma Discharge Bundles. We will ensure all people with COPD are assessed for suitability for an Early Supported Discharge Scheme.

    2.6 Carers of people with respiratory conditions have support to stay well.

  • Carers will receive information and support. Supporting carers helps them in their role and also helps them maintain their own good health and wellbeing.

    3.1 People with respiratory conditions know how to prevent risk of worsening health. We will enable this by:

  • Improving public awareness of respiratory conditions. This helps people with respiratory conditions to self-care and for reasonable adjustments to be made.
  • Advising people to avoid areas and times of the day where air pollution is high. Almost 30% of preventable deaths in England are due to noncommunicable diseases attributed to air pollution.
  • Health and care staff recognising exacerbations in people’s conditions early. Identifying difficulties early enables access to robust pathways of care providing prompt treatment and support.
  • Risk assessing and risk scoring people vulnerable to pneumonia in winter through integrated working between community nurses, care homes, home care agencies and carers.
  • Community acquired pneumonia is a leading cause of admission to hospital, despite being avoidable in many cases. It disproportionally affects older people, and in cold weather demand for primary and hospital care increases.
  • Promoting flu vaccinations for staff in health and social care, care homes, domiciliary care and other community-based settings. Minimising the risk of infection helps avoid illness and longer-term deterioration in health.

    4.1 People can use methods of transport with low or no emissions. We will enable this by:

  • Encouraging people to walk or cycle for short journeys. Schemes such as pooling bikes and bus passes can help promote good practices.
  • Environmental planning that makes using walking, cycling and public transport easier. Walking or cycling is an alternative to using a vehicle reduces air pollution and helps promote good physical health.
  • Investing in low and no emission vehicles for staff. By 2028 the NHS will cut business mileages and fleet air pollutant emissions by 20% by 2023/24. At least 90% of the NHS fleet will use low emissions engines (25% Ultra Low Emissions).
  • Promoting ultra-low emissions zones, pedestrian zones and turning off idling engines. These measures will help cut the use of higher-emissions vehicles, and encourage use of lower-emissions vehicles.

    4.2 People can avoid travelling, to reduce their environmental impact.

  • We will reduce staff and patient traveling by e.g. planning meetings differently, flexible working, public transport. The NHS will cut business mileages by 20% by 2023/24. Greater connectivity will enable people to work locally or from home and communicate online.

    4.3 Heating our buildings has less environmental impact.

  • We will promote housing that uses the cleanest domestic fuels. Cleaner housing helps prevent respiratory ill-health.
  • We will reduce the use of fossil fuels in public buildings. In NHS sites, primary heating from coal and oil fuel will be fully phased out.

    4.4 People are not exposed to harmful emissions, based on best policy and practice.

  • We will implement national guidance on evidence, modelling, data and analytic tools to develop measures that reduce emissions at source. The interventions that will have the greatest impact on reducing harm to people’s health are those which reduce emissions of air pollution at source, and these should be the main focus of actions

We will know we are making a difference because we will see:

  • Lower under-75 mortality from respiratory disease considered preventable
  • Reduced prevalence of smoking
  • Fewer emergency respiratory admissions in children under 18
  • Fewer non-elective admissions for COPD, asthma and pneumonia
  • Improved air quality through implementation of local and national cleaner air guidance
  • Increased diagnosis confirmed by spirometry, by implementing the Spirometry Competency Framework and completion of training for staff
  • An increase in diagnosis using MRC dyspnoea score, and/or using FEV1 pulmonary function test
  • Increased uptake of flu and pneumonia vaccinations in people with respiratory disease including among groups with protected characteristics

Last Updated on December 10, 2020

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