Respiratory diagnosis – what next?
By Carol Stonham MBE, Respiratory Nurse NHS Gloucestershire CCG and Executive Chair, Primary Care Respiratory Society
The pandemic halted many things in healthcare. Patients stopped presenting with new symptoms for fear of picking up the virus and many diagnostic tests were considered risky to both the patient and the healthcare professional undertaking testing.
For people with respiratory symptoms spirometry in particular stopped and has been very slow to restart (if indeed it has restarted at all). There is talk of diagnostic hubs and spokes springing up, and of contractual negotiations to encourage a wider spirometry restart, but these may be limited in the short term whilst the backlog of people needing diagnostic spirometry continues to grow.
NHS Gloucestershire CCG is tackling respiratory diagnostics head on. We were successful in our bid to set up a community diagnostic hub. This will offer testing to complex patients and a full range of tests for breathless patients – such as full lung function, imaging and relevant cardiovascular investigations such as cardiac echo. Other disease areas will be included for diagnostic testing such as ophthalmology.
This is an exciting step on the journey to better diagnostic testing, however, the service will not have the capacity to offer spirometry to everyone presenting with a history and clinical examination suggestive of more common respiratory conditions such as asthma and COPD.
To address this problem, we are negotiating to be able to contract with practices (an integrated care system cannot currently contract with a primary care network (PCN) currently) and pay them for the respiratory diagnostics they perform. The general practice contract is and has always been open to interpretation in this matter – patients need diagnostic spirometry for the practice to be able to claim payment under the Quality and Objectives Framework (part of the way general practice is paid), but the contract does not state where that test should be carried out and by whom.
The way forward surely must be local diagnostic hubs for breathlessness at PCN level for people of all ages presenting with a likely diagnosis of asthma or COPD. Relevant tests need to be offered such as exhaled nitric oxide (FeNO), spirometry with reversibility if appropriate, and a trained competent clinician to undertake testing and interpret the results in the clinical context. Payment for performing a test alone will not drive a quality service.
To encourage collaborative working across the PCN and ensure that someone has the time, passion and drive to make this happen we are investing in Respiratory Champions. We are offering payment for this role – a day a week per PCN – to ensure the delegated person is freed up and backfilled from their current role.
The Respiratory Champion is likely to be a practice nurse. To deliver spirometry this person needs to be certified and registered with the Association for Respiratory Technologists and Physiologists (ARTP). Their role will not just be concerned with spirometry however – the Respiratory Champion will highlight any training needs within the PCN, cascade information, and inspire a passion to deliver excellent care to patients with respiratory conditions. In return we will offer support, open channels of communication and respiratory or leadership training to the Champion.
Children and young people have been considered in our plans and the PCN-based hubs will be set up for all ages. The majority of children and young people will receive their respiratory diagnosis at a PCN based hub which is appropriate – it will be local and more familiar. There will be some children and young people who have more complex conditions and will need onward referral to either a specialist, or into the complex diagnostic hub. There will be additional training needs which we will also address.
Will our model work? Time will tell but reflecting on the delivery of respiratory diagnostics and care pre-pandemic, this was not optimal – the data from the National Asthma and COPD Audit confirms that. We should and can do better and think we have a model to deliver a better service to people with respiratory conditions.
An accurate and timely diagnosis local to home and increased focus on routine and unscheduled care is what we are aspiring to. We will see if our blue sky thinking gets us there.
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