Not enough is being done to provide access to good quality spirometry testing in England, GPs and respiratory specialists have warned.
There are huge gaps in provision around the country – a problem that has worsened since the pandemic – leaving COPD patients without the early intervention they need and likely increasing inequalities, experts and charities have told Pulse.
Asthma+Lung UK is working on a report due out in August which will include detailed data highlighting the patchy provision of testing which seems to have fallen into commissioning gap in many areas.
It follows a report last year which found almost a quarter of people wait five years or more for a diagnosis of COPD.
At the time the charity called for ‘an urgent increase in availability of quality assured spirometry across the system, to at least pre-pandemic levels’, but while there are some pockets of progress, there are still significant barriers to testing across the country, they added.
It has been estimated that 50,000 people missed out on a COPD diagnosis in the first year of the pandemic and it is likely this pattern has continued says GP and Asthma+Lung UK clinical lead Dr Andy Whittamore.
He said while GP practices used to do more spirometry testing it was never funded and several barriers around the cost and upkeep of machine, staff training and certification meant many did not start again after the pandemic.
Alternative funding streams for quality-assured testing need to be found, he added. It has been further complicated by announcements that Community Diagnostic Centres would be doing spirometry ‘so we getting this information that someone else is going to do it’, he said.
‘During the pandemic spirometry stopped and we had a big shift in the respiratory nurse workforce who dropped out of primary care. Now with ICBs struggling for money I can’t see them throwing a lot of money into this.’
There are models of good practice, he added. In his practice they have trained healthcare assistants to do it and have an experienced respiratory nurse to do the interpretation. In Gloucestershire they have set up a locally enhanced service.
‘But there are patients who are just not getting a test. They might be getting the wrong treatment or not getting treatment because they haven’t got the right diagnosis,’ he added. ‘We do need things to change and proper funding streams.’
Dr Rammya Mathew, a GP in London, said lack of access to spirometry is ‘widespread’.
‘We have had no access in our borough for months now. Specialist services won’t see our patients without a diagnosis which need spirometry.’
She added where PCNs had tried to set up services they had struggled to recruit.
‘The fact that this situation has gone on now for so long is nothing short of a scandal and there needs to be accountability going forward.’
Dr Vincent Mak, consultant physician in respiratory integrated care at Imperial College Healthcare NHS Trusts said the pandemic had provided the opportunity to ensure high quality spirometry services that were sustainable were set up.
The Primary Care Respiratory Society had put out a service specification based on providing spirometry to a PCN-sized population which they have used in North West London with all PCNs either have a hub up and running or are proposing to do so, he added.
But in other areas of London, it is not yet in place.
‘It’s taken ages to get the ball rolling because there are so many different barriers put in place, including funding,’ he says.
Dr Irem Patel, London joint clinical director for respiratory, NHS England and consultant at King’s College Hospital NHS Foundation Trust, said has been working on a similar programme in South London: ‘We know at least half of all our patients with COPD are probably undiagnosed. [Nationally] We’re in a terrible place, much worse than we were before Covid but we were very keen to use that as a positive disrupter to do this in a better way.’
She added: ‘There’s much more we need to be doing and its really variable. This isn’t happening systematically enough, fast enough, at scale and it’s nowhere near addressing health inequalities.’
In May NHS England published a tool to reduce variation in care in patients presenting with breathlessness.
An NHS England spokesperson said: ‘We recognise the importance of early and accurate diagnosis of respiratory disease through quality-assured spirometry. The pandemic inevitably had an impact on the delivery of spirometry in community settings, but we are working hard to support the restoration of services to above pre-pandemic levels and expand access in community settings, including by offering spirometry in community diagnostic hubs.’
“The best is the enemy of the good”
A classic problem in healthcare.
Practices used to provide, at their own expense, a reasonably “good” spirometry service.
Then someone in an ivory tower decided spirometry could be made “the best” by insisting on new training and certification.
Result: practices declining to jump through further hoops at their own expense = no service
Spot on DS 9/12 month waiting list locally.
Dylan Summers sums it up perfectly. a reasonable test for all or a gold standard test for few if any. Basic hand held spirometry can be a useful screen on screen out test but even that now not done as some practices still have covid policies that also have stopped peak flow testing
Whilst on gold standard Fraction NO testing for asthma also not available and even where it is misdiagnosis either in or out 20% of asthmatics (neutrophil rather then eosinophilic asthma).
Other have written how guidelines are not tramlines and perhaps we need to be more patient friendly as the things that help (Inhaled steroids in asthma and stopping smoking in copd) can be tried without a ”gold standard test that has to wait years to be done
As commented by Dylan. A problem completely generated by managers and self appointed Respiratory leads. Decimated excellent Primary care spirometry by scare mongering about risks but especially insisting ARTP accreditation.
The result is the precise opposite of what is intended with thousands of patients suffering and getting inadequate or the wrong treatment. Inundated secondary care and in our area NO secondary care Spirometry. Thank god some practices like mine did the accreditation and continue to do the procedures however we may also need to stop if the powers that be insist we cover ALL the PCN patients which we do not have capacity for. or just do our own patients for no payment…
To weed out a few dodgy providers the vast majority get penalised. Does that sound familiar ?
Experienced Clinicians will find a way but the newer GPs will never gain the skills or have interest and could be too timid to stand up to directives that harm patients like these
Next of course we will need accreditation to use and ecg, use an otoscope etc
This is yet another example that shows that the power that be do not and did not understand the versatility and value of primary care.
You’ll miss us when we’re gone AND it will cost you a lot more.
Oh God—when will it all end—–no trainers to be a G.P.——no trainers for Respiratory services——-no trainers for Sleep Apnoea—-we’re doomed
Artp needs to be rowed back on and stopped. It is unaffordable from a healthcare system point of view.
The situation will only be compounded if there is no change.
I think that this would be a great research question. It could be turned around very quickly.
I look forward to the report and thank them for their efforts.
We need to collaborate together on this from a population health point of view.
I feel ARTP has a lot to answer for I am afraid. They managed to persuade CQC that accreditation (by them) was necessary, and that it added something -but in fact has made provision of services unsustainable when costs and backfill time not covered.
I think using terms like gold standard with Spirometry are oversell. Any test that requires averaging the best of 3 isn’t a great scientific test. Sens and specificity are low. Its a useful guide only in my view, used in conjunction with history exam and other tests.