With spirometry accreditation to be rolled out over the next couple of years, a practice nurse and a GP debate whether the scheme is worthwhile
Carol Stonham: A spirometry register is not a huge burden on primary care
Lung disease is the UK’s third biggest killer.1 But unlike other major disease areas, mortality rates haven’t decreased in more than a decade. One in five people in the UK lives with asthma, COPD or other respiratory disease – nearly 13 million people – and respiratory conditions are a major part of the gap in life expectancy between the poorest and the wealthiest.1
The journey to better care starts at the beginning – the diagnosis. Diagnostic spirometry is being performed in primary care but evidence tells us that we are not doing it well enough. COPD is diagnosed on an accurate history of symptoms but relies on quality assured diagnostic spirometry to confirm the diagnosis.2 The results of The National COPD Audit in Wales3 (now operating as The National Asthma and COPD Programme [NACAP]) found that only 54.3% of newly diagnosed patients had a FEV1/FVC ratio coded in their records, only 11.1% were coded as post bronchodilator FEV1/FVC ratio, and of those, only 8.5% had a result consistent with obstructive disease.
This demonstrates a number of potential factors – poor performance, poor interpretation of the test results and poor ability to consider spirometry in the clinical context. Consider the effect on morbidity, mortality, cost to patients through scripts and impact on lifestyle, impact on healthcare systems in use of (often repeated) unscheduled care and cost of treatments that are ineffective if diagnosis is incorrect.
The picture in asthma diagnosis is similar. The evidence tells us that overdiagnosis is problematic4 and we know that people with symptoms of asthma may not always reach a timely diagnosis. Although spirometry may not clarify a diagnosis of asthma, it can contribute to an inaccurate diagnosis or delay appropriate treatment if done poorly.
A Parliamentary review board met following the publication of the National Review of Asthma Deaths Report5 in 2015 to see what could be done better. One recommendation was the formation of a national register for those performing and interpreting diagnostic spirometry.
The NHS Long Term Plan6 is also working to improve the quality of diagnostic spirometry. It clearly states: ‘The NHS will do more to detect and diagnose respiratory problems earlier. Currently around a third of people with a first hospital admission for a COPD exacerbation have not been previously diagnosed. From 2019 we will build on the existing NHS RightCare programme to reduce variation in the quality of spirometry testing across the country. Primary care networks will support the diagnosis of respiratory conditions. More staff in primary care will be trained and accredited to provide the specialist input required to interpret results.’
The plan also describes the work of primary care networks. Working in this way means there may not need to be a qualified person in every practice if the patient is referred to a professional who has undergone training. Spirometry is a part of the diagnostic jigsaw. Demonstrating competence in diagnostic spirometry is a part of respiratory competence. Cervical cytology training was accepted as compulsory and the spirometry register could be going the same way.
Carol Stonham is an advanced nurse practitioner in Gloucestershire and member of the Primary Care Respiratory Society
1 Lung Disease in the UK. British Lung Foundation statistics.blf.org.uk/?_ ga=2.136267059.38826871 .1547811212-2010399124. 1536053665
2 NICE. NG115: COPD. London: NICE; 2018
3 Royal College of Physicians. Planning for Every Breath. rcplondon.ac.uk/projects/outputs/primary- care-audit-wales-2015-17-planning-every-breath
4 Pakhale S et al. Correcting misdiagnoses of asthma: a cost-effectiveness analysis. BMC Pulmon Med 2011;11:27
5 Royal College of Physicians. Why Asthma Still Kills. The National Review of Asthma Deaths. rcplondon.ac.uk/projects/outputs/why- asthma-still-kills
6 NHS England. NHS Long Term Plan. January 2019. england.nhs.uk/long-term-plan/
Dr John Cormack: Accreditation will as a barrier to practices performing spirometry
When the spirometry debate first raised its ugly head, I was alarmed as our nurses are competent and have a wealth of experience. They do a great job, and if I had my way, they’d continue to do so for the foreseeable future. None of them want to embark on a lengthy and arduous course – but if we stop providing the service because we do not have staff who are accredited, and they then become deskilled, we would refer everything on. We know from bitter experience that innovations ‘organised’ by NHS management tend to go badly wrong in the area where we work, so the likelihood was that there would not have been the requisite number of suitably trained staff available at the outset, and large waiting lists would have quickly built up.
We are lucky here in that, because of long-term underfunding (to an eye-watering degree), patients are prepared to pay for equipment so that we can provide extra services. This means that the quality of our equipment is better than you’d expect in a small practice – so that wasn’t an issue in the spirometry debate.
In other areas, some GPs take a different view. Where there is already a good service in secondary care, the doctors are happy to refer patients as it takes pressure off their practice nurses, and some feel more comfortable with the reports they get than they do with the ‘in-house’ reports.
The big disadvantage is that patients have to travel to hospital – and we conveniently forget to factor in the patient’s time. Another factor is taxpayers’ money – we do things in general practice far more cheaply than our hospital colleagues. If more practices are referring patients because of lack of accreditation, the cost to the NHS will rise.
Before deciding everybody needed accreditation, NHS England should have tried to assess what was available locally rather than mindlessly imposing a ‘one-size-fits-all’ policy. Practices that were and are providing a safe and satisfactory service and are happy to continue to do so (in this and many other fields) should be given encouragement rather than kicked in the teeth – if it ain’t broke, don’t fix it. Practices that do not have the wherewithal to do so, however, could have been offered whatever assistance they needed – and if that involves them referring all their patients to a local hospital, so be it.
As a general principle, I think the NHS in our area needs to do more to encourage GPs to provide more services locally, not put barriers in the way in the form of accreditation. A good example is when patients need to be fitted with a Holter monitor. We could send all our patients to the local hospital, but that is a long return journey (you effectively write off half a day if you are reliant on public transport). To collect your monitor, you have to get there at the start of the working day and you have to do the same thing the following day in order to make the monitor available to the next patient on the list. Compare that with the ease of having the same thing done at the practice. Fortunately, our patients’ generosity has made that possible, as there has been absolutely no support from elsewhere.
Dr John Cormack is a single-handed GP in Chelmsford, Essex