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GPs forced to undergo spirometry training under proposed rules from NHS England

Exclusive GPs and practice nurses will have to undergo specialist training in order to continue using spirometry in their practices, under new rules being developed for NHS England to improve the diagnosis of COPD.

Pulse has learnt that a working party is looking at compelling practices to ensure that all members of staff carrying out spirometry testing are ‘quality assured’, in a move that experts say could cause ‘gridlock’ as practices decide to refer more patients with COPD for spirometry.

A member of the working party said they were looking at the idea due to evidence of ‘sub-standard’ spirometry being conducted in some GP surgeries, that was leading to patients being misdiagnosed.

An audit by the now-defunct NHS Improvement found that a high proportion of patients who had not received quality-assured spirometry as part of their COPD diagnosis, with 44% recorded on the COPD register with an FEV1/FVC ratio ≥ 0.7 suggesting the patient may have been misdiagnosed.

The working party, which is overseen by NHS England, will make recommendations early in the New Year, but members of the party have told Pulse it is looking to implement an ‘accreditation’ system for the service, and is considering potential organisations to be chosen as accreditation bodies.

A similar accreditation system was recommended by NICE for skin cancer in 2009, causing a furore as GPs who had conducted minor surgery for years were forced to stop providing the service.

Dr Stephen Gaduzo, chair of the Primary Care Respiratory Society and a member of the NHS England working party, as well as a GP in Stockport, told Pulse the group was looking at how practice staff could become accredited to ensure they could carry out spirometry accurately.

He said: ‘We are considering accrediting GP practices and we are examining options for who could carry out the quality assurance and what form it could take. The introduction of a register of accredited individuals or organisations has been discussed. This may involve people practising spirometry having to attend half day or full day courses.

‘I know there are some GPs who will object to national quality assurance because they have been doing spirometry for years. There are some excellent services, but we do know there are substandard ones in GP surgeries.’

The working party – which includes members from organisations such as Education for Health, the British Thoracic Society and the Primary Care Respiratory Society – is examining options for who could carry out the quality assurance and what form it could take, Dr Gaduzo said. 

An NHS England spokesperson confirmed to Pulse that it is looking at the possibility of introducing measures of competency in the service.

The NHS England spokesperson said: ‘Patients throughout the UK have treatment on the basis of spirometry measures, so tests of course need to be good-quality. We are working with stakeholders to set out training, education and competency measures that can be adopted across the system with appropriate support.’

‘The measures will be designed to give a flexible approach that ensures high quality while allowing responsiveness to local circumstances and need. We expect to roll out these new standards from the start of the new financial year.’

But GPs are required to carrry out post-bronchodilator spirometry between three months before and 12 months after entering patients on to the COPD QOF register, and some are concerned that if the accreditation process is too onerous then GPs will give up providing spirometry altogether.

Dr Iain Small, a respiratory GPSI in Peterhead, Scotland, and former chair of the Primary Care Respiratory Society, said: ‘If you start to make things to complex and difficult then generalists will say that spirometry has become a specialist skill, and may not do it anymore.

‘They may think it has become too onerous or costly to train staff and provide cover for them. Then they will refer patients on to places that could do these specialist investigations. But that could cause a gridlock in the system.’

Dr Tarek Bakht, a respiratory GPSI in Bolton and an executive member of the PCRS, said it was important that spirometry was done accurately, but questioned whether there were the resources for practices to support them to re-train.

He said: ‘To make sure all spirometry is quality assured is good, and anyone who does spirometry should be competent to do so. However, the issue is how do we do this? We need resources and funding. What standards do we use? The number of spirometry is done in smaller practices is small - is this enough to keep that person skilled up? Do we do spirometry in practice or centrally?’

But Dr Daryl Freeman, a respiratory GPSI in Norfolk, said that basic mistakes are sometimes made in administering spirometry, and that in principle quality assurance could improve patient care.

She said: ‘If it means that everybody doing spirometry would need basic training, then that has to be a good thing. It could mean that 99% of spirometry is done well instead of 75%.’

Readers' comments (10)

  • It's not like it makes a difference anyway, main treatment is telling people not to smoke.

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  • The simple solution to this is not to retrain anyone. We'll just refer them into the hospital. IIRC performing spirometry is not a core GMS service.

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  • I agree with anonymous just refer them- simples

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  • ''Patients throughout the uk have treatment based on spirometry measures' '- Treatment should not be based on spirometry measures alone! spirometry confirms airflow limitation and is only part of the diagnostic process. 1/ patients with established COPD struggle to perform reproducible 'quality results' even when stable 2/ You can have a patient with an FEV1/FVC of say 36% who is an ex smoker physically active with minimal flare up / or a patient with fev1/fvc 68% who has frequent exacerbations poor quality of life/ and poor lung health. It would be more beneficial for GPSI to support and train practice nurses undertaking spirometry to be aware of differential diagnoses/ and to consider multiple comorbidities/ LVF etc ( practice nurse)

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  • So junior hospital doctors can make a diagnosis of "acute execerbation of COPD" in a patient with a chest infection, but GPs can't?
    Sounds logical - if you want to transfer work from primary to secondary care and, in the process, destroy general practice records - the only electronic medical records patients are likely to have for a very long time based on previous secondary care performance!
    Provide training - could be organised by CCGs - might be a good idea: accreditation by centrally licensed specialist agencies only and actively prevent early diagnosis?
    Late diagnosis isn't a problem - with or without spirometry!

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  • Spiromtery is performed badly.I have lost track of the number of patients with suspected COPD coming up as restrictive defects due to poor patient technique.There are alot of caveats with spirometry and it is as much an art as a science to get the patient to do it right.We have now set up a local community respiratory team which offers diagnostic spirometry.It makes far more sense to have one node of expertise rather than have every GP practice maintain and update their spirometry equipment and go on periodic spirometry courses.

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  • This is an excellent idea if backed up by sufficient training - primary care spirometry is variable. Variable as in often crap.

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  • GP services in the UK are so efficient compared to hospital services, because they are dynamic agile and flexible - just like me ;-) It is that efficiency that keeps the cost of health so low.

    However the never ending tick boxes which have for years ramped up the cost of secondary care are threatening to destroy the efficiency of General Practice and in turn the NHS as a whole.

    Assurance for cutting of a skin tag, the right type of curtains, the emphasis on diagnosing untreatable dementia and now this; all add costs to primary care and have saved the square root of zero lives.

    If you think it will save lives, please conduct a study to demonstrate that. If it does not save lives £"%£^(£&"%&("$%. (insert own comment).

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  • personally I think its time the primary care recognises these deficiencies--people are still using picometers to diagnose COPD--and why not if the QOF has paid all that money and to prove that we are following good medical practice then all should train and retrain
    we have to accumulate CPD points so why spirometry training should not be mandatory

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  • Medvivo telehealth services are available for patients with COPD across Surrey; this is providing beneficial additional support for patients through daily remote monitoring, by specialist nurse, of patient provided data. One of the larger Surrey CCGs is considering providing training for practitioners in telehealth alongside spirometry to encourage a joined up approach to diagnosis and treatment.

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