Respiratory diagnostics service model review
Respiratory disease is a major NHS priority. Conditions such as asthma and chronic obstructive pulmonary disease (COPD) affect millions of people, place significant pressure on health services, and disproportionately impact disadvantaged communities.
NHS England and the London Respiratory Clinical Network commissioned the Health Innovation Network South London to review two respiratory diagnostic service models developed in London. The review explored how different approaches are supporting access to quality-assured respiratory testing, including spirometry, and what can be learned to support the further development and spread of best practice across London.
Introduction
Respiratory disease is a major NHS priority. Conditions such as asthma and chronic obstructive pulmonary disease (COPD) affect millions of people, place significant pressure on health services, and disproportionately impact disadvantaged communities. National initiatives have therefore focused on improving access to high quality, consistent and accessible respiratory investigations to support earlier and accurate diagnosis.
Respiratory diagnostic service models aim to deliver equitable access to quality assured diagnostic testing, including spirometry, in line with national spirometry commissioning standards. In the London region, systems can refer to the NHS England London service specification for respiratory diagnostic service models, published by the Regional Respiratory Clinical Network (1). The specification sets out co-produced recommendations for delivering accurate respiratory diagnosis for patients with breathlessness and other respiratory symptoms at a population level.
NHS England and the London Respiratory Clinical Network commissioned the Health Innovation Network South London to undertake a mixed methods review of two different respiratory diagnostic service models, which were developed in London, informed by the regional service specification. A case study approach was adopted to understand the delivery, utility and effectiveness of these different models, to support the further development and scaling of best practice across London.
Findings
Across London, the respiratory diagnostic landscape is diverse, with two predominant service models in operation: specialist-led and primary care-led services. While both models can deliver quality assured spirometry and support accurate diagnosis in the community, they differ in delivery setting, scale, workforce configuration, and operational performance. The table below summarises the implementation and impact of two individual mature service models. Each model presents distinct trade-offs in terms of access, cost, workforce requirements and expertise, and sustainability.
| Domain | Specialist-led service | Primary care-led service |
|---|---|---|
| Model overview | • Launched in 2018, covers two London boroughs • Transitioned from five sites to acute trust based with two community clinics • Shift driven by GP room shortages, high patient did not attend (DNA) rates and ventilation requirements reducing patients seen • All essential diagnostics provided and extends beyond the basic model outlined in the London Respiratory Clinical Network specification | • Launched in 2022, covers one London borough • Delivered by a GP federation across two community sites • Largely consistent model since inception, although staffing has evolved overtime • Most essential diagnostics provided and extends beyond the basic model outlined in the London Respiratory Clinical Network specification |
| Workforce | • Five staff, all Association for Respiratory Technology & Physiology (ARTP) trained • Assistant physiologists deliver testing and admin, and specialist and principal physiologists provide quality assurance and clinical oversight • Access to a consultant respiratory physician for support and oversight | • 11 staff, mix of permanent and agency staff performing or interpreting spirometry, and substantial operational management and administration capacity • Multidisciplinary team (MDT) for clinical oversight |
Utilisation and efficiency | • 399 referrals per month on average • 249-day appointment wait on average • 1.13 referrals per available appointments – demand exceeds capacity • 72% attendance rate | • 112 referrals per month on average • 100% of accepted referrals offered an appointment within 20 working days • 85% attendance rate |
Implementation | Enablers: • Acute trust infrastructure and standards, and flexible specialist oversight support quality and implementation Barriers: • Long waits, primary care system integration and limited funding for clinical oversight and administration constrain delivery | Enablers: • Flexible MDT working, strong clinical input, and skilled administrative staff support delivery Barriers: • Workforce recruitment and primary care integration challenges delivery |
System integration | • Community diagnostic centre (CDC) not yet locally established | • No direct referrals into the local CDC |
Equity | • Equitable access across population groups • Higher did not attend rates among young adults and males | • Equitable access across population groups |
Impact | • 24% of results indicative of asthma and 8% COPD | • 25% of results indicative of asthma and 32% COPD |
| Cost | • The approximate annual cost of the service is £181,493 • Oncosts and overheads are not included | • The approximate annual cost of the service is £117,375 • No specific staff costings provided and oncosts included |
Sustainability | • Sustainability challenged by high demand, long waiting lists, and limited administrative support • Walk-in fractional exhaled nitric oxide testing is being explored to reduce wait times for asthma diagnostics | • A need to upskill GPs to use test results confidently for accurate diagnosis • Staff progressing towards ARTP qualifications |
At a system level, there was a strong sense of achievement in the scale and breadth of respiratory diagnostic services models established. There was also a shared recognition of the need to improve standardisation and alignment with the London Respiratory Clinical Network specification, while continuing to respond to the policy direction, system reform and emerging technologies. Strengthening governance, accountability, and collaboration was identified as critical to sustaining effective and high-quality respiratory diagnostic service models and pathways.
Recommendations
The review sets out eight recommendations to support the continued development, scale and spread of respiratory diagnostic service models.
Service level recommendations: Aimed at commissioners and providers, focusing on the practical and operational considerations required to design, implement, and oversee respiratory diagnostic service models.
System level recommendations: Aimed at system leaders, outlining the strategic opportunities to support consistency, integration, and collaboration across the wider system.
References
1. NHS England. London Respiratory Clinical Network specification for a population level respiratory diagnostic service for COPD, asthma and breathlessness. 2023.
Read the full report
Learn more about how the service models work in practice and explore the full set of recommendations.
Stay up to date
Our newsletter keeps you in the loop with the latest developments in health and care innovation.