England and Wales have seen the highest death rate from asthma in the past decade, with 12 700 people dying from asthma in the past 10 years – an increase of 33% according to an Asthma UK analysis of data from the Office for National Statistics (ONS) (2019) (The Pharmaceutical Journal, 2019). Asthma UK is now calling on the NHS to take urgent action on a situation it describes as ‘a lack of basic asthma care’ – this comes only 5 years after the National Review of Asthma Deaths (NRAD) highlighted that two-thirds of asthma deaths in the UK could have been prevented with better basic care (Levy et al, 2014; The Pharmaceutical Journal, 2019).
Asthma care
The basic care in the UK referred to by Asthma UK consists of the prescription and use of preventer, reliever and combination inhalers, as well as tablets, injections, surgery and other novel treatments for more severe cases (Foster, 2018; NHS, 2018). However, whether the patient is taught proper inhaler technique, whether they have an asthma action plan to help them manage their condition, and whether they have an annual asthma review with their nurse or GP, is highly variable.
The NRAD had made 19 recommendations for improved care to decrease preventable deaths in 2014; however, only one of these has been partially implemented 5 years later (Levy et al, 2018). Demonstrating the consequences of this inaction, asthma deaths increased by 8% from 2017–2018 to 1400 people (The Pharmaceutical Journal, 2019). Asthma UK have estimated that 60% of people living with asthma in England and Wales – about 2.9 million – are not receiving the basic care recommended by national guidelines (The Pharmaceutical Journal, 2019).
So what reasons lie behind the lack of basic care and what needs to change in order to ensure this new standard is met?
Asthma action plan
People with a written asthma action plan are four times less likely to be admitted to hospital for their asthma (Adams et al, 2000). Although the research demonstrating this was published 19 years ago, there are still not enough people using asthma plans.
Asthma action plans not only specify a patient's asthma triggers, but also their daily routine, what their asthma should look like when it is under control, how to know if it isn't, and what specific steps to follow as well as who to contact if this is the case. Patients should be taught to check-in regularly with their action plan, even keeping a copy of it on their phone and/or on their fridge, for example, so it remains top of mind and easy to access.
Patient empowerment
Another interesting point highlighted in this research was that people who do not use an avoidance coping style also fare better (Adams et al, 2000). This supports the current movement to empower patients, arm them with knowledge and relevant tools about their condition, and encourage them to self-manage their condition. This increases personal responsibility, daily action and, importantly, a sense of control over their health.
Complacent culture
Asthma is extremely common, affecting about 5.4 million people in the UK (Asthma UK, 2018). This may contribute to the misperception that is not a serious condition and lead to its suboptimal management. However, every 10 seconds, someone has a potentially life-threatening asthma attack in the UK – a statistic which is less often quoted (Asthma UK, 2018).
Unfortunately, despite asthma being a life-threatening condition, there is a great deal of complacency surrounding its management, both among health professionals and patients (Levy et al, 2014; Marsh, 2018). I would suggest that patients mostly take their lead from their health professionals and the complacency surrounding asthma is entrenched in the larger healthcare and societal cultures. We all know people who have asthma and it is not usually perceived as a very serious condition. In fact, the NRAD demonstrated that both patients and health professionals had poor perceptions of asthma, and its risk of death in particular (Levy et al, 2014; Marsh, 2018).
The culture surrounding asthma needs to be shifted gradually, and from multiple directions. Examples include a larger and more robust evidence-base; a wider dissemination of this evidence both medical and healthcare journals and in the mainstream media; and an increased understanding of asthma, and resulting action on the part of healthcare organisations, individual health professionals and patients and their families.
Your role in this picture
As well as prescribing an appropriate treatment to patients living with asthma, health professionals and prescribers have a significant role and duty to support patients' understanding of how they can achieve and maintain control of their condition (Marsh, 2018). Discussions about asthma; its symptoms; the role of treatments, their side effects and costs; as well as any concerns the patient is having should be taking place in order to improve patient adherence to their medications (Marsh, 2018).
Furthermore, while guidance from the National Institute for Health and Care Excellence (NICE) (2017) recommended use of a short-acting beta2 agonist (SABA) alone for people with newly diagnosed asthma, overuse of SABAs indicates poor asthma control. NRAD note that poor adherence with regular inhaled corticosteroids (ICSs) is a major risk factor for asthma death (Marsh, 2018). Therefore, ICSs remain the most fundamental treatment, and the aims of asthma management should be to maintain control on the lowest possible level of medication (British Thoracic Society and Scottish Intercollegiate Guideline Network, 2016).
In addition to being prescribed appropriate treatment formulations and dosages, with regular review, a patient should be taught to control their own asthma in between consultations. They should understand how to correctly use their inhalers, as well as what signs to be aware of, so that they are the foremost experts on their asthma, its management, and the achievement and maintenance of their optimal overall health and wellbeing.
Conclusion
The asthma death rate in the UK had been stagnant at around 1200 people for many years. Of these deaths, 90% were acknowledged to involve preventable factors. NRAD, commissioned by the Healthcare Quality Improvement Partnership on behalf of NHS England, systematically reviewed deaths from asthma over a 12-month period from 1 February 2012, and subjected them to an in-depth and confidential enquiry involving multiple disciplines (Royal College of Physicians, 2014). It investigated the individual circumstances surrounding these deaths, with the aim to decrease this death rate.
However, more than 5 years after its publication, not only is the asthma death rate not declining, it is on the rise. Despite having more information and more robust evidence than we did before the NRAD on what can be done to prevent deaths from asthma, little action has been taken.
Inhaler prescriptions must be accompanied by discussions about proper technique, the establishment of an asthma action plan and a structured annual review by a health professional with specialist training in asthma (with closer monitoring of people at high risk of a severe asthma attack). The notion that individual health professionals cannot make a difference on their own is a dangerous one, and the proactive action of each prescriber will be necessary in order to shift the care culture, and the perception of asthma and its management in the UK.