Cross-Party Group on Lung Health
Grŵp Trawsbleidiol ar Iechyd yr Ysgyfaint
Minutes from 28 November 2023
MSs
John Griffiths MS (supported by Andrew Bettridge)
Non MSs (19)
Joseph Carter
Ben Coates - Asthma + Lung UK Cymru (Secretariat)
Josephine Cock
Andrew Cumella
Henry Davies
Ryland Doyle
Ann Francis
Crissie Gallimore
Lyn Lording-Jones
Georgina Marsh
Julie Mayes
Emma Clitheroe
Georgie Marsh
Joanne Allen
Jonathan Morgan
Meg Lewis
Pam Lloyd
Philip Webb
Val Maidment
1. John Griffiths MS - Welcome and introductions
John Griffiths MS started the meeting and thanked everyone for attending. He asked if any MSs or support staff wanted to introduce themselves. No other MSs were present at the point this question
John Griffiths MS informed attendees that there would be two presenters today, Andrew Cumella Asthma + Lung UK and Dr Simon Barry, Health Implementation Group. He encouraged people to put any questions they had in the chat.
2. John Griffiths MS – Apologies
The following MSs have sent their apologies:
Rhun ap Iorwerth MS
Rhys ab Owen MS
Jane Dodds MS
Heledd Fychan MS
Llyr Gruffydd MS
Mike Hedges MS
Vikki Howells
Altaf Hussain MS
Mark Isherwood MS
Rhianon Passmore MS
Buffy Williams MS
3. John Griffiths MS – Minutes of the last meeting
John Griffiths was the only MS present at the last meeting. Joseph Carter and Ben Coates will liaise with John Griffith’s office for final confirmation that these minutes are a true and accurate record of proceedings.
Action: Joseph Carter/Ben Coates to liaise with John Griffiths MS to sign off the minutes – Completed
4. Joseph Carter – Matters arising
There were no matters arising from September’s meeting.
5. Andrew Cumella, Senior Analyst, Asthma + Lung UK – Saving Your Breath: How better lung health benefits all of us in Wales
John Griffiths MS introduced Andrew Cumella and thanked him for presenting.
Andrew opened the presentation by providing an outline of the Saving Your Breath reports scope and aims. The report modelled the impact of two key scenario themes in respiratory care:
· Improved access to diagnostic tools:
o Increased FeNO and increased spirometry
· Improving care to enable better self-management
o Increased use of patient refill data
o Increasing access to pulmonary rehabilitation
o Access to biologic drug treatments for severe asthma patients
The presentation identified the key barriers to making progress on improving respiratory care and health in Wales. These included: low awareness of lung conditions and their impact among both patients and healthcare professionals; underinvestment has led to a limited set of treatment options, with implementation of NICE best practice also being poor; lung conditions are strongly associated with deprivation and its associated factors; and that lung conditions often develop alongside other conditions, which exacerbates the impact of lung disease, whilst also increasing the likelihood of lung diseases going undiagnosed.
The costs of lung disease in Wales were discussed, based on the data found within the report. These costs were broken down by the following categories: NHS Costs; lost life quality costs; lost productivity costs; and total indirect costs.
Access to effective diagnostics was shown to be a significant hurdle, with half of COPD cases undiagnosed or misdiagnosed. The report examined the impact of two diagnostic interventions: increasing use of FeNO testing and increasing the use of spirometry. The report showed that if these interventions were made by the NHS in Wales, this would lead to fewer people misdiagnosed with asthma; more personalised treatment plans, lowering maintenance costs; a better quality and quantity of diagnoses; in addition a reduction in exacerbations and hospitalisations. Improving diagnosis, in the manner the report examined, would result in 3,420 bed days a year, with 1,163 of these coming over the winter period.
The next recommendation of the report the presentation looked at was the diagnosis of lung condition diseases early and accurately. The report called for a restarting of spirometry across Wales and improved access to better training and the necessary equipment to perform spirometry testing.
The presentation also showed that a lot of respiratory hospital admissions are preventable through better care. Asthma + Lung UK’s latest patient survey showing that only 24% of those with asthma and 8% of those with COPD received best practice care.
In the area of improving self-management, the intervention modelled by the report was around the increased usage of patient refill data. The modelled impact of encouraging GPs to look at patient refill data and using it to routinely monitor and improve inhaler use showed a reduction in the number of uncontrolled asthma patients by 45% through better inhaler use; a 70% reduction in hospital bed days; a reduced number of unscheduled visits to GPs and hospitals. To achieve these outcomes the report called for: the introduction of annual reviews for all lung conditions; using patient data to improve treatment adherence; and effective data and monitoring on such annual reviews and medication checks.
The next subject of the presentation looked at increasing access to the right treatments, specifically, the expansion of pulmonary rehabilitation (PR). Data from the 2021 Wales primary care clinical audit showed that only 5.6% of adults with COPD had been referred to PR in the past 3 years. The intervention discussed was the increase of access to PR to all those who are eligible. The modelled impact of increasing referral rates to 80% (currently 14%) and completion rates within the referred population to 50% (currently 31%) resulted in reduces usage of healthcare due to improved life quality with COPD; productivity savings as people were able to be more economically active; and 30,000 be completing PR courses, resulting in 15,000 fewer exacerbations.
In order to implement this expansion of PR, the report called for: every PR service to have access to a full multi-disciplinary team; for Wales to join the Pulmonary Rehabilitation Services Accreditation Scheme; the PR pathway to be adopted; and for eligible patients to have a direct referral on an opt-out basis, rather than an offer.
The last element of the model discussed in the presentation was that of severe asthma. Over half of those with severe asthma have uncontrolled symptoms, experience years of poor care before any progress toward controlling their symptoms. The report showed that whilst only 5% of those with asthma can be classified as having ‘severe’ asthma, this cohort accounts for half of asthma costs. To help improve care for those with severe asthma, the report called for increased access to biologic drug treatments for severe asthma and the commission of dedicated difficult asthma services.
Taking into account of all the interventions recommended within the report, the estimated economic impact of these would result in £19.5m in direct NHS savings, with a further £24.5m in wider economic benefits. In total, this would lead a total of £44m of savings per year.
Joseph Carter then provided an overview of the conclusions of the report and the current state of respiratory care in Wales. He noted that this report was published on 28 November 2023 to mark a year since the Welsh Government published its Quality Statement for Respiratory Disease, arguing that very little progress has been made.
Q&A Session following Andrew Cumella’s presentation
Phillip Webb noted a conversation he had recently with Asthma + Lung UK’s diagnostic innovation group in London, where there was discussion on the work required around prevention. He raised the importance of rolling out better systems for monitoring indoor air quality as part of this.
Meg Lewis highlighted that certain products used within the health system are known lung disease progressors, suggesting that this has received very little attention to date. She also asked, referring to the impact of expanding pulmonary rehabilitation (PR), whether the cost-savings shown as resulting from that also included the positive knock-on effects in helping people to live more active lives, such as reduced risk of diabetes or obesity. She also highlighted the key contribution that the dietetic advice within PR programmes is, as this advice is often not given immediately following diagnosis.
Lyn-Lording Jones asked about the staff costings required to implement the report’s recommendations. Additionally, she asked, should the Welsh Government take these recommendations on board, what the costs of promoting these practices among GPs would be, in order to deliver the outcomes required.
Andrew Cumella responded first to Meg Lewis’ question, where he confirmed that the potential for reducing risks of diabetes or obesity, as a consequence of PR, was not included within the model used. He explained that it was difficult to determine the ‘right’ boundaries of the model in these circumstances, also noting that sometimes the data you need to make these determinations isn’t always there.
Turning to Lyn-Lording Jones questions, Andrew confirmed that the costs of implementing the changes the report recommended were not included within the model. Joseph Carter noted that the report was based on modelling that included lower, median and higher estimates for the cost savings resulting from the interventions. In each case, Asthma + Lung UK Cymru opted to use the median cost-saving outcome. He agreed that there were significant issues around the recruitment of the NHS workforce, making the Welsh Government Workforce Plan of vital importance.
6. Dr Simon Barry – Preparing for Winter
Dr Simon Barry highlighted the work being done to help health practitioners and patients prepare for winter, coming in the form of six webinars, focusing on staying well and the management of their condition in order to stay out of hospital over the winter period.
He argued that the true paradigm shift required will be to help patients better understand and manage their conditions. This was identified as the key way into getting the solutions required to make meaningful improvements in respiratory health care. Dr Simon Barry went on to argue that Wales was much further ahead on this agenda when compared to the rest of the UK.
He noted that in the National Respiratory Audit, Wales was the only nation of the UK to include data derived from primary care. This data shows that there are some bad outcomes at the moment, with spirometry being in a particularly critical situation. The data shows that only 25% of patients with asthma have a self-management plan, but 100% of those using the NHS Wales AsthmaHub mobile app do have a self-management plan.
To demonstrate that Wales was further ahead on the self-management agenda, Dr Simon Barry presented some data emanating from patients using the NHS Wales AsthmaHub mobile app. App users are 19% less likely to go to A&E and 36% less likely to attend their GPs. Therefore, he argued, use of the app is helping reduce pressure on frontline services over the winter period. Additionally, use of the app is helping patients to have better asthma control and reduce blue inhaler usage. He also demonstrated how the apps are increasing the uptake of switching to green inhalers.
Following this presentation, John Griffiths MS had to leave the meeting. Joseph Carter took over as Chair.
Q&A Session following Dr Simon Barry’s presentation
Lyn-Lording Jones disputed the 100% effectiveness claim of the NHS Wales AsthmaHub apps providing self-management plans, as the app does not work for her specific condition. She recognised that her condition was rare, as she has a high peak-flow, but noted this can plummet, with the app not reflecting the reality of her condition. She suggested that the figure should perhaps be amended to 99.9% of those who use the apps.
Meg Lewis asked whether the apps could also be used to manage conditions beyond Asthma and COPD. Dr Simon Barry responded that there was an equivalent app targeted at the parents of those with asthma, he then confirmed that a Tracheostomy app was currently being developed. He agreed that equivalent apps should be made available to people with other conditions. However, he noted there were some complexities. For example, as a person gets older there are greater chances of them having further co-morbidities. The issue here is that there might need to be several separate apps dedicated to the management of specific conditions, raising the question of whether an app that deals with multiple conditions might be more appropriate. However, there are major questions over who exactly will invest in developing apps for further conditions moving forward. Dr Simon Barry reiterated that these apps are not the whole picture, as they require a full system behind them to enable them.
Responding to a question submitted via the chat function, which asked whether the switch from pMDI inhalers to Dry Powder Inhalers was having an impact on control [of asthma], Dr Simon Barry suggested that the app users were far ahead of the curve on switching to Dry Power Inhalers. These users can also be shown to have much better control over their asthma.
7. Joseph Carter – Next meeting and the work ahead
Joseph Carter then spoke about future meetings. He confirmed that the next meeting will be held at 9.30 on 6 February 2024, with the following meeting being held at 9.30 on 21 May 2024.
8. Joseph Carter - Any other business
Joseph Carter asked if anyone had any other business. They didn’t, so he thanked everyone for attending and brought the meeting to a close.