Chronic obstructive pulmonary disease causes significantly more mortality and morbidity than other causes of airflow limitation in adults1 but is underdiagnosed and under-recognised. The World Health Organization estimates that chronic obstructive pulmonary disease is the fourth leading cause of death worldwide, with 2.74 million deaths in 2000, and this burden is growing rapidly.2 The main cause is cigarette smoking, and the United Kingdom is now experiencing the ravages of a past high prevalence of smoking in its ageing population. Costs for 1996-7 showed that the NHS spent more than £818m ($1.3bn; €1.2bn) on the disease.3

In the United Kingdom chronic obstructive pulmonary disease accounts for as many as one in eight medical admissions.1 Emergency admissions for chronic obstructive pulmonary disease have recently risen dramatically, contributing notably to the hospital bed crisis.4 Annual admissions peak in early January, due, in part, to increased respiratory illness, acute exacerbations, and reduced primary care support over the holidays.5 6

The prevalence of chronic obstructive pulmonary disease is greatest in socioeconomically deprived people; the differential effect between higher and lower social groups is perhaps greater for chronic obstructive pulmonary …