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NICE finalises guidance for hospitals to refer suspected COPD patients to their GP

NICE has signed off a new clinical guideline which will see hospitals referring patients with suspected chronic obstructive pulmonary disease (COPD) to their GP for spirometry testing.

The guidance recommends that primary care respiratory review and spirometry testing are considered for patients who are incidentally found to have signs of COPD on a chest X-ray or CT scan, including patients already under the care of general practice and those under secondary care. 

NICE argued that while this change will cause a small increase to GP workload, the additional spirometry referrals will have a ‘minimal resource impact’.

The recommendation forms part of the COPD in over 16s NICE guidance, published last week, and reported on in draft earlier this year.

The final guidelines said: ‘Consider primary care respiratory review and spirometry for people with emphysema or signs of chronic airways disease on a chest X-ray or CT scan.’

It added: ‘There may be a small number of additional referrals for spirometry, but this is expected to have a minimal resource impact.’

GPs previously argued that while GP-led spirometry is ‘reasonable’ if the patient was already under GP care, hospital specialists should arrange follow-ups themselves if the patient is already in secondary care.

Back in 2016, Pulse revealed that GPs would need to be certified and appear on a national register in order to perform spirometry, based on a new scheme implemented by NHS England.

But earlier this year, the BMA's GP Committee said that while spirometry appeared as an item within the QOF, it is not part of GMS core contractual services and therefore local commissioners are responsible for setting training requirements.

NICE also released the final guidance on antibiotic prescribing for COPD this month, which called for antibiotics to be restricted and for GPs to only prescribe them for severe exacerbations.

Other recommendations from the latest guidance includes reviewing the choice of antibiotic being prescribed when microbiological results from a sputum sample become available.

COPD in over 16s recommendations in full:

Consider primary care respiratory review and spirometry for people with emphysema or signs of chronic airways disease on a chest X-ray or CT scan. [2018]

If the person is a current smoker, their spirometry results are normal and they have no symptoms or signs of respiratory disease:

  • offer smoking cessation advice and treatment, and referral to specialist stop smoking services (see the NICE guideline on stop smoking interventions and services)
  • warn them that they are at higher risk of lung disease
  • advise them to return if they develop respiratory symptoms
  • be aware that the presence of emphysema on a CT scan is an independent risk factor for lung cancer. [2018]

If the person is not a current smoker, their spirometry is normal and they have no symptoms or signs of respiratory disease:

  • ask them if they have a personal or family history of lung or liver disease and consider alternative diagnoses, such as alpha-1 antitrypsin deficiency
  • reassure them that their emphysema or chronic airways disease is unlikely to get worse
  • advise them to return if they develop respiratory symptoms
  • be aware that the presence of emphysema on a CT scan is an independent risk factor for lung cancer. [2018]

Source: NICE

Readers' comments (8)

  • National Hopeless Service

    ‘There may be a small number of additional referrals for spirometry, but this is expected to have a minimal resource impact.’

    How about the the chest clinic do this for free..

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  • If there are a small number of additional referrals for spirometry, it would mean that a National Enhanced Service paying £100 or so for spirometry is fairly reasonable.

    Not GMS.

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  • if you are not paid for spirometry on a contract in primary care refer all spirometry to your local resp department till they complain to the ccg and then get a contract being paid to do it in primary care. this is what one practice i worked at did. then you get money to do it. simples

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  • spirometry referral must be paid for. pay either hospital or GP, your choice

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  • The national idiot collective of england are at it again...
    Hospitals to refer to GPs to refer back to hospitals again.
    Perhaps its a sign that they now realise they are disappearing up their own back passage.

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  • Also PSA testing, and diabetes, IHD, Asthma, HT and so on.
    If we accept an open Contract [and all LMCs have rejected an appointment based payment system] then hey presto, everything is cheaper if GPs do it, because it is all in the one payment for GMS per year.

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  • AlanAlmond

    I full expect a box on the discharge proforma that will be routinely ticked by anyone at the hospital who thinks a patient ‘might have COPD’ suggesting the GP perform spirometry. A similar routine note regarding memory issues suggesting ‘screening for dementia’ is already appended to just about anyone leaving hospital over the age of 65. Suggestions will come as a matter of routine from first year junior Drs and ward clarks (indeed anyone filling in the paperwork) ..which is NEVER completed by a senior member of the team, usually the most junior, who is deligated to filling in the dreary TTOs. Anyone believe that some bright spark will pass up the chance to make the suggestion that ‘this patient might have COPD..GP to check...just to make sure.’ Anyone going into hospital with so much as a cough, will come out with a helpful suggestion...GP please do spirometry. If you believe otherwise I’d suggest you don’t know much about how hospital discharges work. It’ll become so routine it will soon become meaningless, except for lawyers, who’ll retrospectively have an excuse to sue any GP who’s patient subsequently runs into difficulties with respiratory illness and once went into hospital...and the ‘stupid GP’ didn’t check spirometry as the genius hospital employee suggested. Nice idea but the implementation will lead to meaningless over investigation and legal risk for primary care. NICE exists in a parallel universe of good intentions a gift to lawyers and a curse to everyone else...principally patients who will receive increasingly confused and poorly focused investigation at the expense of their overall care.

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  • Vinci Ho

    It is an incentive to develop full primary care spirometry and even FeNO services( for asthma)
    But I am sorry , No Money , No Talk.

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