This document discusses approaches to addressing breathlessness from an integrated perspective across specialties and settings. It notes that breathlessness affects a large portion of the population but is underdiagnosed and inconsistently addressed. The working group recommends taking a systematic history, using various tests to assess underlying conditions, addressing mental health and obesity factors, and providing evidence-based treatments like rehabilitation and smoking cessation. Commissioners are urged to foster integration across specialties and providers to improve outcomes for those with breathlessness.

1. Breathlessness
Siân Williams, IMPRESS Programme Manager
July 2014

2. Why breathlessness?
• Looked at a disease - COPD, wanted to
start with usual presentation to GP:
symptom
• Address multi-morbidity
• Address physical and mental
health “parity of esteem”
• Improve consistency across specialities
and settings
• Integrate approaches locally
• Address cost, opportunity cost, value

3. Source: Mercer et al The Lancet 2012; 380:37-43 (DOI:10.1016/S0140-6736(12)60240-2)

4. Source: Mercer et al The Lancet 2012; 380:37-43 (DOI:10.1016/S0140-6736(12)60240-2)

5. Presents opportunity and opportunity cost
• Respiratory programme budget
over £4.69bn - up by 6% year
to 2012-13
• Cardiovascular programme budget
over £6.90bn (0.3% reduction)
• How do you serve local population
best with that resource?
• Look at what is most cost-effective
(effect on quality adjusted life
years) at
individual AND population
level and also at cost in
NHS
Respiratory

6. 35
Quality of
life
1
0
.8
A little more on QALYs (Quality-adjusted life years)
30*.5 = 15
QALYs
gained
65
.5
Age
QoL 0.8 drops dead age 35
Intervention  30 years QoL 0.5

7. Value for Money triangle & rectangle of population health
gain
costs
Value
X
X
X
Population
Health
Gain
Benefit
per person
e.g. QALYs
Numbers who benefit

8. Working party drawn from general practice, hospital, psychology, respiratory,
cardiology, obesity, mental health specialities
Dr Noel Baxter, GP, Southwark
Dr Angel Chater, Registered Health Psychologist and Sport and Exercise Psychologist, Lecturer in Behavioural Medicine UCL School of Pharmacy
Centre for Behavioural Medicine
Dr Mark Dancy, Consultant Cardiologist, North West London Hospitals Trust
Dr Sarah Elkin, Lead in Respiratory Medicine at Imperial College NHS Trust and Honorary Senior Lecturer at Imperial College London
Professor Ahmet Fuat, Professor of Primary Care Cardiology, Durham University, GP, GP Tutor and GPSI Cardiology, Darlington
Dr Steve Holmes, GP Shepton Mallet, Co-chair of IMPRESS
Professor Mike Kirby, Visiting Professor University of Hertfordshire, UK Editor Primary Care Cardiovascular Journal
Dr Basil Penney, GP, Darlington, GPSI Respiratory Medicine and GP Respiratory Lead, Darlington Clinical Commissioning Group
Dr Louise Restrick, Integrated Consultant Respiratory Physician, Whittington Health and Islington CCG, London Respiratory Network Lead
Sam Roberts, Director of Community Academic Partnerships, UCLPartners
Jane Scullion, Respiratory Nurse Consultant University Hospitals of Leicester NHS Trust, Respiratory Clinical Lead Midlands and East
Dr Shahrad Taheri, Bariatric physician and lead for weight management services and senior lecturer in Medicine, University of Birmingham,
Birmingham Heartlands Hospital and Royal College of Physicians Action on Obesity nominee
Writers:
Chiara De Poli, Department of Management, London School of Economics and Political Science
Siân Williams, IMPRESS Programme Manager
Original meeting facilitated by: Mara Airoldi, Department of Management, London School of Economics and Political Science

9. Additional contributions
Dr Suzanna Hardman, Consultant Cardiologist with an Interest in Community Cardiology, Whittington Health, Honorary
Senior Lecturer UCL
Dr David Kingdon, Professor of Mental Health Care Delivery University of Southampton, representing National Clinical
Director, Mental Health
Dr Mike Ward, Consultant Respiratory Physician, Co-chair IMPRESS
Dr Vince Mak, Integrated Care Consultant, North West London Hospitals Trust
Maria Buxton, Consultant Respiratory Physiotherapist, North West London Hospitals Trust and Ealing Hospital Trust,
Brent
Helen Marlow, Pharmaceutical Adviser NHS England (London)
Sandy Walmsley, Respiratory Nurse Specialist, Solihull Care Trust
Dr Rob Fowler, Consultant physician in respiratory, general and geriatric medicine, Barking Havering and Redbridge
University Hospitals NHS Trust
Dr Matt Kearney, Department of Health England
Leah Herridge, Redesign Manager (Long Term Conditions) Pathway Commissioning, NHS Southwark CCG
Mark da Rocha, Service Redesign & Primary Care Development; CVD Lead, NHS Lambeth & Southwark CCGs
Dr Eric Cajeat, NHS Lambeth CCG

10. Breathlessness: population
Breathlessness affects:
• Up to 10% of adult population
• 30% of older people
• Major cause of attendance at ER but
• Only 1% of recorded GP consultations
• 2/3 is cardio-pulmonary
• Affects 50% obese + 70% obese elderly
• Assume all patients anxious to some extent
– how much and why?

11. Breathlessness: population
• Underdiagnosis of single
conditions: COPD, heart
failure, depression and anxiety
• Only 18% of people with COPD
just have COPD….so one
diagnosis may not be enough

12. • The system not sufficiently effective at
diagnosing single conditions
• The scale is large
• Solutions will need to:
– Segment the population
– Take notice of mental health and obesity
– Find synergies and build on them
– Empower everyone in the system
– Avoid expensive solutions such as multidisciplinary
clinics except for those at greatest need
So what does this mean for services?

13. Breathlessness assessment conclusions about (cost)
effectiveness
• Huge gaps in the literature
• Little history of sharing evidence across specialities
therefore consensus needed
• Identify those who need acute care
• Take a good history in a systematic way
• It may take more than one consultation: diagnosis isn’t
easy; early diagnosis really isn’t easy
• Specifically ask about smoking in an evidence-based
way but don’t ignore non-smokers
• Use tests: pulse oximetry, peak flow, spirometry, ECG,
BNP, echocardiography, PHQ4, GPPAQ
• Use measurement BMI, waist and neck circumference
• Keep the end in sight because intervention success
affected by the assessment process

16. Breathlessness treatments: (cost) effectiveness
• Strong evidence for treatments for single
conditions, much weaker for multiple
• But need more flu vaccination, stop smoking as
treatment, support to increase physical activity,
referral to programmes of rehabilitation, weight
management, NICE-pharmacotherapy
• Locally sensitive: demography, relationships,
knowledge, service

17. IMPRESS breathlessness: resources
• Algorithm and notes to accompany algorithm
• Breathlessness IMPRESS Tips (BITs) for:
– Clinicians
– Patients
– Commissioners
– Researchers
• Prevalence modelling for breathlessness by condition
– How many people with [COPD, HF, anxiety etc] are
breathless
– How many breathless people have [COPD, HF, anxiety etc]

18. So what do we need to do differently when planning?
•Be guided by a right care framework
•Involve many stakeholders
•Foster integration across specialties
Check how local provision matches the IMPRESS algorithm
• What do you have in place already
• How might you streamline this for every adult with long term
breathlessness?
• How does the current system identify and support the
population at risk of poor health outcomes and use of
unscheduled care
• Does your analysis highlight gaps that require change? If so,
what?

19. So what do we need to do differently when commissioning?
• Check that primary care has the right: equipment, training, specialist behavioural change
services to refer to, time, coding templates
• Provide sufficient programmed rehabilitation
• Ensure equal access by patients with breathlessness, no matter the underlying condition, to
high quality end of life care
• Look for opportunities to integrate existing teams and services
• Consider the best allocation of resources to improve your population’s health outcomes
• When specifying breathlessness services, talk to providers about the organisational model and
new or extended professional roles and their feasibility and sustainability
Enhance the use of IAPT services
• Apply lateral thinking when activating local resources for breathless people

20. So what do we need to do differently as clinicians?
• Be as specific and evidence-based with your
language as your spirometry/BNP…
• Even if you’ve made a diagnosis, think is that
all/only explanation eg intermittent
breathlessness….asthma/arrhythmia?
• Discuss with colleagues how to integrate
questions into the consultation
• Check how you use well-known tools such as
MRC….

21. MRC example: Grade 3 and 4 (threshold for PR referral)
Is the patient unable to keep up with normal
men on the level, but able to walk about a mile
or more at his own speed?”
Fletcher 1959
Grade 3: Walks slower than contemporaries
on level ground because of breathlessness, or
has to stop for breath when walking at own
pace
Grade 4: Stops for breath after walking about
100m or after a few minutes on level ground
RCP today

22. What else?
• Test the algorithm, adapt it, use it
• Review rehabilitation programmes eligibility
criteria
• Understand how interpretation of tests is
offered: spirometry, echocardiography, BNP in
the community and in hospital

23. www.impressresp.com
Impressions 31 breathlessness