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Health: Asthma

The noble Viscount, Lord Simon, has done us a great service by tabling this debate on a subject of which, sadly for him, he has first-hand experience. I congratulate him on a trenchant speech. It highlighted the main problem with asthma as a chronic condition, which is that in current NHS priorities it still ranks relatively low in many areas, despite its high prevalence and the fact that it is responsible for a high level of hospital admissions and more than 1,000 deaths a year. The rate of childhood asthma is higher in England than almost anywhere else in the world. We can and should draw attention to the prevalence statistics, but it is perhaps even more important to talk about the reality of living with asthma, which the noble Viscount was perhaps too stoical to refer to in any graphic detail, but which, as many of us will know from our families and friends, can be truly miserable and often an extremely frightening part of daily living. Service provision is, I fear, a lottery; Asthma UK has published unequivocal data to demonstrate that. One of the main markers of that lottery is hospital admissions, where we see a vast disparity between different regions of the country, not least where it comes to children. The chances of a child being hospitalised for asthma as an emergency admission is more than twice as high in the north-west than it is in the east of England. In the east Midlands, on the other hand, the rate is 21 per cent below the average. Those disparities cannot simply be attributed to socio-economic factors; they must also reflect differences in service provision. Quite rightly, Asthma UK has been urging the Government and the NHS to do something about that. Part of the problem—in fact, a major part, as the noble Viscount mentioned—is the absence of national standards. Without such standards, patients are missing out in a big way, but the NHS is also missing out on millions of pounds in potential savings. Asthma UK tells me that asthma-related emergency hospital admissions cost the NHS £61 million a year and that three-quarters of those admissions are avoidable. Even if it has exaggerated the scope for financial saving—I do not think that it has—we are still talking about tens of millions of pounds of unnecessary cost. Once someone has a serious asthma attack, the cost of looking after him is three and a half times more than if the attack had been prevented. As we have heard, there are 4.5 million people with asthma in England. More than two-thirds of asthmatics who were surveyed by Asthma UK said that their symptoms were not under control. An NSF or national clinical strategy would benefit an awful lot of people. I understand that we are the only western or developed country that has nothing of that nature. The last that we heard in a Lords Parliamentary Answer was that an NSF was not even in development. Why is that? Wales, Scotland and Northern Ireland have their own guidelines and the British Thoracic Society has issued guidelines, so it should not be too big a step to produce a national clinical strategy for England. As a start, we need to look at basic things such as personal asthma action plans. We know that where someone has one of those plans, setting out what treatment regime is appropriate to them and exactly when they should seek help, they are four times less likely to be admitted to hospital as an emergency case. However, as the noble Baroness, Lady Tonge, told us, only about a quarter of asthma patients have such a plan. The scope to improve asthma care is clearly considerable. It is clear that existing guidelines are just not doing the job. There are particular difficulties with people who have severe asthma or asthma that is difficult to control. Acute trusts have told Asthma UK that they find it hard to identify patients who have been admitted to hospital on a frequent basis, which seems extraordinary. They also find it difficult to follow those people up after they have been to hospital. I would be glad if the Minister could say something about specialist training in asthma for GPs and nurses. For many patients, access to an asthma specialist is difficult to achieve. Only 13 per cent of people with asthma have been offered the name of a GP specialising in asthma in their area. Asthma UK tells me that it is particularly concerned that many healthcare professionals who treat asthma have not had adequate training. The noble Baroness, Lady Greengross, referred to the 2006 study by Education for Health and Edinburgh University, which found that 20 per cent of asthma nurses have not had any accredited training. Again, that seems most surprising. On top of that, there has been a decline in their numbers, which, not surprisingly, patients say has affected the quality of care that they receive. That is also something that an NSF could address. Last year, as we heard from my noble friend, your Lordships’ Science and Technology Committee reported on the topic of allergy. Its approach to the subject was a general one but it made a number of recommendations on issues that directly relate to asthma. One was that there should be at least one allergy centre led by a full-time allergy specialist in each strategic health authority. It would be the job of the allergy centre to diagnose a patient’s allergy and to develop a treatment plan. Once that had happened, the patient’s condition would be managed back in the primary care setting. In reply, the Government promised to consider establishing a lead SHA and, in August this year, the north-west was approved as the first SHA to have an allergy centre. That is good news, but will the Minister confirm that, provided that the centre proves its worth, we can expect more of the same in other parts of the country? A number of the public health messages on asthma have a marked similarity to those on obesity. Of course, it is not uncommon for the two conditions to coexist in one individual. Taking exercise and eating plenty of fruit and vegetables both improve lung function. Smoking is a universally bad thing to do if you are asthmatic and if there are others in your house who suffer from asthma, especially children. For me, this is one of the big arguments in favour of banning smoking in public places. Smoking in the presence of a child or while pregnant increases the chances of the child developing asthma. The same applies to stress during pregnancy and allowing children to swim in chlorinated swimming pools. There is some tentative evidence that children should not be given paracetamol in the first year of life; it has been associated with a 46 per cent increase in the risk of asthma symptoms at age six to seven. We should be hearing more of those kinds of public health messages coming from the NHS. It should not only be Asthma UK that is left to promulgate them. There can be some serious asthma hazards in the workplace. A whole range of respiratory sensitisers that can trigger asthma are found in a number of working environments. The Health and Safety Executive has been active in promoting good practice in factories and other places of work but, as my noble friend said, the key to the successful management of asthma, as with any chronic condition, is the informed patient. I read an article in the Lancet the other day that set out three unanswered questions about asthma. What is asthma? Who gets asthma and why? Which factors enable us to predict how badly you will get asthma and how you will react to treatment? Those questions are more or less the only ones that matter. Beyond a certain very basic point, we do not know the answers. A good deal of research is going on in the UK and internationally to try to get closer to those issues, but we surely need to do more. We are still a long way from being able to prevent asthma and just as far away from being able to cure it. How can we better identify patients at an early stage who are at risk of a disease progression? On some of the specifics, can we do a randomised controlled trial to test the hypothesis of a link between paracetamol and asthma, or between eating nuts during pregnancy and giving birth to a child who becomes asthmatic? Can any sort of finger be pointed at domestic cleaning products? I wonder, incidentally, whether the Minister has seen recent reports in the press that appear to cast suspicion on the triple inoculation against diphtheria, tetanus and whooping cough as being a trigger for childhood asthma. It appears that researchers at the Manitoba Institute of Child Health found that, if the initial dose of the jab is delayed to when a child is at least four months old, the chance of the child developing asthma by the age of seven is less than half what it would be otherwise. That is a pretty dramatic finding. It would be helpful if the Minister could say whether the department is looking at it. The UK has the highest prevalence of asthma in children aged 13 and 14 in the world. We need to establish why that is. If the DTP inoculation looks as though it might be a contributory factor, I suggest that we need to confront the data head on. In general, progress in understanding asthma and how it works is slow. We cannot, and should not, be satisfied with that against the backdrop of facts and figures that the noble Viscount has cited. I hope that the Minister’s reply will give us a sense of how importantly asthma is taken by the Government, in terms of service delivery as well as research, and that we can leave this debate with at least some measure of encouragement.