Nick Hopkinson: The burden of asthma—how to frame it and what needs to be done?

nick_hopkinsonA study this week from the Asthma UK Centre for Applied Research at the University of Edinburgh, widely reported in the media, estimates that asthma costs the UK £1.1 billion/year in direct healthcare and disability allowance payments. News reports focused on the scale of these costs and the suggestion that 1100 people are dying “needlessly” each year.

Some of these deaths do arise from poor care—the Royal College of Physicians report Why asthma still kills contains examples. Yet the finding that many deaths are preventable with optimal long term treatment, self-management, and emergency care does not mean that their prevention is straightforward, or that this is merely a healthcare story. Missing the political aspects of the burden of asthma risks doing a disservice to people with this condition and to those at risk of developing it in the future.

Effective self-management of any long term condition takes time to learn and requires repeated reinforcement and support. Primary care is key, and it is timely that this week also saw a call from the BMA for GP consultations to be lengthened from 10 to 15 minutes. This will need resources, principally staff time. The delivery of this extra support to fix asthma is improbable in the context of current government policy, which is predicted to lead to the NHS being underfunded by £20 billion per year by 2020.

Exposure to air pollution both increases the risk of developing asthma and the risk of asthma attacks. The UK government has been found to be in breach of EU air quality regulations and is being taken to court again for its failure to remedy this. Moreover, the UK government actively and successfully lobbied for these regulations to be watered down. Action on asthma requires political will that takes citizens’ right to breathe clean air seriously.

The political choice to pursue austerity policies has impacted disproportionately on the most vulnerable in society. Asthma is a manifestation of this, with poorer asthma outcomes a feature of child poverty. There are several mechanisms that explain this association.

Firstly, fuel poverty means that many of the poorest people in the UK are living in cold damp homes with visible mould, which drives asthma symptoms and increases the risk of severe attacks. Also, coping with any long term condition is more difficult for people with disorganised lives. The withdrawal of social support exacerbates this. Thirdly, exposure to smoke, both actively and passively, is associated with poorer outcomes in asthma. Smoking rates are higher in more disadvantaged groups, but smoking cessation services are being cut and decommissioned as austerity bites into council budgets.

Although the problem of asthma indisputably requires solutions that incorporate healthcare, these will be insufficient without the political decisions that are harming people with asthma also being reversed. Action on air quality and poverty reduction is needed, or else concern about asthma is just so much hot air.

Nicholas Hopkinson @COPDdoc, reader in respiratory medicine, Imperial College, London.

Competing interests: None declared.

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