Introduction

Grouped together the many different lung conditions are the third largest killer in the UK. The direct cost of lung conditions to the NHS was estimated to be £9.6 billion in 2019, with £1.7 billion attributable to primary care, £6.3 billion to secondary care and £1.7 billion to prescription charges and insured expenditure (Asthma and Lung UK 2023).

Spirometry measures lung function by asking the patient to blow into a machine and empty their lungs. Although the test is simple to perform, when performed poorly or interpreted incorrectly, it can lead to missed or the wrong diagnoses as well as incorrect and delayed treatment (Jones RCM; Price D; Ryan D; Sims EJ; von Ziegenweidt J; Mascarenhas L et al 2014)

Spirometry services were halted at the start of the covid-19 pandemic for safety reasons. Restarting spirometry has proved challenging in many areas as services needed to be redesigned to protect patients and staff.

Restoration of spirometry within clinical pathways is essential for the diagnosis of people living with lung disease, particularly asthma and chronic obstructive pulmonary disease. Without this, timely treatment such as delivery of vaccination (a Core20PLUS5 indicator), appropriate inhaler therapy and pulmonary rehabilitation cannot be achieved. Support for the restoration and provision of spirometry services is available on the FutureNHS platform (login required).

The NHS England 2024/25 priorities and operational planning guidance highlights the importance of timely access to diagnostics including spirometry and using new diagnostic capacity in the community to commission these tests. Delivering spirometry in the community, closer to home, will also help reduce unnecessary referrals into secondary care and unnecessary acute admissions. A lack of diagnostic access is placing unnecessary additional pressure on emergency departments, especially during winter when respiratory admissions are 80% higher than during the summer (Allen 2021).

The commissioning standards are as follows:

1. Understanding local population needs

Using data and other intelligence, systems should work to identify the needs of their local population. This should include approaches such as active patient finding that address the under-diagnosis of respiratory disease in underserved populations.

1.1 A lack of diagnosis is a foundational driver of the health inequalities that exist in respiratory disease. Chronic respiratory disease is 1 of the 5 areas of focus in NHS England’s Core20PLUS5 approach to reducing health inequalities. Commissioners must work to understand population needs and use data to develop tailored offers of delivery.

1.2 Systems should understand the value delivered through early and accurate diagnosis of respiratory disease and take a joined-up and collaborative approach to narrowing health inequalities in access, experience and outcomes. Their approach may include using data, health equity audits and contacts to identify population groups that need support to access services. This will enable better delivery of interventions proven to improve outcomes and appropriate resourcing of integrated respiratory pathways to reduce health inequalities.

Resources

• Data (smoking prevalence)
• Data (health inequalities)
• Information on trend analysis (on the FutureNHS platform – login required)
• Tackling health inequalities – optimal integrated respiratory care pathway, pages 34 and 35 (on the FutureNHS platform – login required)
• Core20PLUS5 – an approach to reducing healthcare inequalities
• The healthcare inequalities improvement dashboard
• Saving your breath (asthmaandlung.org.uk)
• Adult breathlessness pathway (pre-diagnosis): diagnostic pathway support tool

2. Planning service capacity

Spirometry testing capacity should align to the identified levels of population need. This includes having an appropriately trained workforce to deliver locality-based spirometry for all ages (see standard 4 for more information around children and young people).

Integrated care boards and primary care networks should work together to ensure their local models for access to spirometry serve their population, including by reviewing current activity for spirometry in light of intelligence on those potentially waiting for tests.

Resources

• Core spirometry narrative (on the FutureNHS platform – login required)
• Association for Respiratory Technology and Physiology register
• NHS RightCare chronic obstructive pulmonary disease pathway
• Provision and accessibility gap analysis example (on the FutureNHS platform – login required)

3. Ensuring access to quality assured testing

All patients should receive spirometry from appropriately trained individuals. Those individuals should be supported to achieve accreditation in delivery of quality assured spirometry.

Spirometry results should be interpreted and reported by a trained, competent healthcare professional, taking into consideration the clinical history and examination.

Systems should have in place a mechanism to allow the interpretation and reporting of the tests.

Resources

• Association for Respiratory Technology and Physiology (ARTP) spirometry certification
• ARTP statement on pulmonary function testing 2020
• Care Quality Commission guidance on spirometry in general practice
• ARTP statement on pulmonary function testing 2020 – BMJ open respiratory research

4. Provision for children and young people

A large proportion of those with asthma are diagnosed as children, emphasising the importance of access to good quality diagnostics from an early age. Although different models of diagnostic pathways exist, provision for children and young people from age 6 should be included in any model to ensure equitable access.

There will be specific considerations when developing diagnostic pathways that include children and young people, to ensure services are suitable for this age group. For example, safeguarding requirements, equipment and time.

Resources

• Core 20PLUS5 for children and young people
• Children and young people asthma dashboards (admissions and primary care dispensing)
• Diagnosing asthma in children and young people. Age specific considerations when developing diagnostic models. (coming soon 2024)
• Community diagnostic centres: guidance for planning, design and implementation (coming soon 2024)

5. Delivering community-based testing

Access to spirometry pathways in the community is key and the models for this will depend on the prevalence of respiratory problems, rurality and accessibility needs of the population.

5.1 A variety of provision is needed to meet the population need for spirometry testing; to bring it closer to people’s homes and deliver services in a cost-effective way. Models range from provision in an individual GP surgery, through to groups of GPs, to a service in a community setting such as a community hospital or in secondary care either in the community or at a local hospital, and more recently in community diagnostic centres (CDCs). Even with the additional capacity for quality assured spirometry provided by CDCs, systems still need to commission primary care-based respiratory diagnostic testing. Spirometry can be done on a per test/service basis and costs will vary depending on the model (see annex A).

5.2 Service design should be co-created with the community and include the patient voice.

5.3 Testing in the community, close to people’s homes, is likely to give a better patient experience when confirming or excluding airways obstruction, making a diagnosis, and determining the level of severity of illness. It will also be more cost-effective. For those presenting with chronic persistent breathlessness who may need a number of tests and investigations, referral to a CDC is likely to be better for patients and more cost-effective.

5.4 Referral of patients with unexplained symptoms of breathlessness, especially in the setting of normal spirometry, into the breathlessness pathway for further advice and management should be considered.

Resources

• Diagnosing the problem: right test, right time (asthmaandlung.org.uk)
• Resource pack: case studies, templates, specifications (on the FutureNHS platform – login required)
• General practice direct access guidance
• Community diagnostic centres (on the FutureNHS platform – login required)
• Case studies and models of delivery (on the FutureNHS platform – login required)
• Adult breathlessness pathway (pre-diagnosis): diagnostic pathway support tool

Annex A: estimated cost per test to conduct spirometry with bronchodilator assessment in England 2024/25 (year 1 and year 2 scenarios)

Fixed costs

[1] An average agreed estimated time allocated for preparation of equipment and decontamination once testing has been completed.

[2] Excludes cleaning solution costs, expected to be < £20/annum.

[3] Spirometer £5,000, capitalised – 5 years useful life.

1 test per day costings year 1

6 tests per day costings year 1

14 tests per day costings year 1

1 test per day costings year 2

6 test per day costings year 2

14 tests per day costings year 2

Publication reference: PRN01255