Before we look at another potential way of evidencing quality and consistency, I would just like to clear up a few points as to what the ARTP is and is not responsible for when it comes to spirometry training as there is a lot of misunderstanding out there.
The ARTP does NOT offer, provide, develop or deliver education and/or training in spirometry.
The ARTP, amongst other things, develop standards and operating procedures aimed at promoting the safe, effective and accurate delivery of quality assured diagnostic spirometry.
The ARTP also issues guidance to training providers, such as ourselves, which offers suggestions as to what we might want to include in our training courses.
The ARTP holds a list of spirometry training providers who approach the ARTP agree to meet the standards set out in section 2 of the ARTP Spirometry Standards document.
The ARTP does not endorse individual training providers listed in the directory and state that it is the candidates responsibility to ensure they choose an appropriate trainer to meet their training requirements.
The ARTP does not review and/or ‘accredit’ the content of spirometry training materials and/or courses of the training providers listed on their website.
The ARTP, as detailed on their website, administer an assessment process that, if successful, leads to certification and entry onto the national spirometry register. The ARTP compare this process to that of us gaining our driving license. We first find a driving instructor and when we feel ready, we book our driving test which is carried out by examiners at test centres and, if successful, we get our licence and our name is placed on a register held by the DVLA.
In this analogy, ARTP is the assessment and certification centre.
As it stands, the assessment and certification process takes 9 months from start to finish, during which time the learner must assemble a detailed portfolio of evidence and pass an OSCE and MCQ examination.
The assessment process costs £250 and there is an annual recertification cost of £40.
These costs are on top of the cost of training as this is delivered separately by a training provider.
The ARTP Standards document is an excellent resource and one which I refer to on a regular basis.
The need to ensure that those performing and reporting on spirometry follow ARTP Standards and are safe and competent goes without question.
It is the assessment process that needs to be addressed as it is this, plus the high time and financial costs, that is STOPPING general practice based nurses from using spirometry and this is a problem!
Much of the hoo-ha around establishing the national spirometry register has focused on the importance of ‘Quality Assured Diagnostic Spirometry’ and I am certainly not arguing about that as I have seen more than my fair share of inappropriate and missed diagnosis due to dodgy spirometry test results over the last 20 years.
Diagnostic spirometry hubs are now popping up but these are in their infancy, have enough teething problems of their own on top of very long waiting lists and strict referral criteria. I am sure that in time these hubs will prove to be very effective but there is more to using spirometry in general practice than just for diagnostics!
What about the use of spirometry during asthma patient reviews?
The UK has one of the highest asthma death rates across Europe.
The National Review into Asthma Deaths (NRAD) was brutal and laid bare the sorry state of asthma care.
I have been using spirometry in asthma patient reviews for as long as I can remember and one of the most alarming findings during this time has been the number of asthma patients whose PEFR’s were well within what would be considered a normal range YET their FEV/FVC ratio’s were less than their lower limit of normal. I know that had I not used spirometry in these patients I would have under-estimated the severity of their asthma and would have failed to make changes to their treatment regimes.
There is more to spirometry in general practice than diagnostics and setting up ‘Diagnostic Hubs’ will not facilitate the use of spirometry during asthma patient reviews.
Asthma is not like type 2 diabetes!
When a patient turns up for their asthma patient review we need to know what their lung function is like there and then, in the here and now. We can’t look at a lung function test result that might have been taken a month ago and use that as a true reflection of what might be going on inside their airways at the time of the review.
It is tempting to think, ‘Ahhh, but we use more than just lung function to assess asthma control’ and we do, but I have lost count of the number of asthma patients sitting there in front of me with no external signs and/or symptoms of uncontrolled asthma, scoring 25 on the Asthma Control Test but who are missing over 500mls off their FEV1, have FEV/FVC ratio’s well below their LLNs and FeNO test results up through the roof!
Using spirometry during an asthma patient review is not like using spirometry for the purpose of diagnostics. You do not need to carry out 3 RVCs, 3 FVC’s, administer short acting beta2 agonists, wait 20 minutes then repeat everything all over again. All that you need to do is record 3 FVC manoeuvres that meet the acceptability and repeatability criteria as per ARTP standards. That’s it! It takes no more than 5 minutes yet it is invaluable. How many times have you carried out an asthma patient review on a patient who is overusing their SABA inhaler, telling you that they are having symptoms yet their PEFR is reading 100% predicted, leaving you scratching your head and wondering what to believe, the clinical history or the PEFR?
There are over 8 million people diagnosed with asthma in the UK. Each one of them will need to have their asthma reviewed at least once a year, more if they are poorly controlled.
Almost ALL asthma care is delivered in primary care by general practice nurses who are also responsible for delivering care to people with CVD, Type 2 Diabetes, COPD and the list goes on and includes the complete UK Immunisation and Vaccination Programme which, I believe, provides us with a credible and alternative way of evidencing quality and consistency in spirometry!
Just over a year ago, we were asked by a large NHS organisation to write them a Immunisation and Vaccination course. As with spirometry, there are national standards that set out to training providers like ourselves, exactly what we need to include in our training courses.
The overall aim of these national standards for immunisation training is to describe the minimum training that should be given to all practitioners engaging in any aspect of immunisation so that they are able to confidently, competently, safely and effectively promote and administer vaccinations.
We developed our course and mapped it exactly to the recommendations set out within the national minimal standards document. We had the course accredited by the CPD Standards Office in London to ensure that it met those standards but we still needed a way of assessing competency and this is where the RCN Immunisation Knowledge and Skills Competence Assessment Tool came in. Eventually, we had a CPD Accredited Immunisation and Vaccination Course that met national standards set out by Public Health England and a way of assessing competency via a RCN developed assessment tool.
Not long after this we were contacted by another NHS organisation who wanted spirometry training for their staff but did not want to go down the ARTP route. They were adamant about this and were aware that being on the national register was not mandatory but they wanted some way of assessing competency.
Following the same method that we used for the Immunisation and Vaccination Course, we mapped the course content to ARTP Standards and then adapted the Immunisation and Vaccination Skills Competency Assessment Tool to the spirometry standards (plus ARTP recommendations for training providers) and sent it off to be externally validated and accredited by the CPD Standards Office in London.
And here lies my suggestion for an alternative option to the national register for providing evidence of quality and consistency in spirometry for the purposes of satisfying the CQC.
I don’t want to be dismissive of the national register as it has good intentions. My issue is with the assessment process itself which I believe is geared more towards technicians working in lung function labs rather than general practice nurses using simple spirometry for the purpose of asthma and COPD patient follow up reviews.
Delivering the UK Immunisation and Vaccination Schedule requires a health professional to have a huge breadth of knowledge and skills covering everything from injection techniques, anaphylaxis, cold chain, in-depth knowledge of multiple different infectious diseases and the vaccines that protect against them.
As someone who has worked in general practice for 35 years and who has been involved in delivering the immunisation and vaccination schedule and performing spirometry, I know which task generated the most stress and anxiety within me and it wasn’t obtaining 3 RVC or FVC manoeuvres!
As someone who has written courses in both Immunisation and Vaccination and Spirometry, I also know which course took me the longest to produce, and was by far the most complicated in terms of content, and again, this was definitely not teaching someone how to obtain 3 RVC or FVC manoeuvres in line with national standards.
I believe that the ARTP assessment process is disproportionate to the way in which spirometry is used within general practice for the purpose of obtaining lung function data during an asthma or COPD follow-up and/or annual review.
Do we really need to embark on a 9 month expensive assessment process to obtain 3 FVC manoeuvres?
As the CQC state, being on the national register is just one way of evidencing quality and consistency and using a knowledge and skills competency assessment tool is another way.
It is worth noting here that the UK Health and Security Agency endorses the use of the RCN Immunisation Knowledge and Skills Competency Assessment Tool as a way as evidencing competency.
If such an assessment tool is deemed appropriate for something as extensive and complex as administering vaccinations to the UK population, (and is endorsed by a government agency), then surely this is a method that could be used to evidence quality and consistency in obtaining 3 FVC manoeuvres.
At the time of writing this post I am awaiting a response from the CQC regarding general practice surgeries being able to use this as an alternative way of evidencing quality and consistency.
I have sent them a copy of the assessment tool that we have developed along with a detailed rationale for use.
Will keep you updated…