1. Direct Access Pathway: Developing an innovative direct access patient service
Kelly Backler
Lead Respiratory Physiologist, Hinchingbrooke Hospital
Trust Lead for HCS
Primary Care representative for ARTP

2. NHS Improvement (Lung) Pilot
To provide direct access for primary care referrals to Lung Function To increase diagnostic range for GP’s to aid accurate, early diagnosis of respiratory diseases. To reduce costs to NHS Cambridgeshire by reducing inappropriate referrals. 2

3. Pre pilot audit
Audit C+Book respiratory patients -3 months A proportion of these referrals resulted minor interventions by the consultant. These would have been suitable for management in primary care, if the diagnostic support were available. 30% of referrals were immediately discharged back to the GP
66 patients in audit
30% referrals discharged (estimated total saving of £10,000 a year). 3

4. Incentives for GP’s
The GP direct referral service offers a two week wait time vs eight week wait to Chest Consultation. Quality assured tests are performed with measures of not only Spirometry, but gas transfer and static lung volumes which are not currently available within primary care. 4

5. Incentives for GP’s
To reduce admissions by providing definitive diagnosis and therefore more appropriate treatment in Primary Care. Patients receive detailed information regarding their results and diagnosis from a specialist. Patient is able to have one to one conversations regarding any fears or concerns regarding their diagnosis. 5

6. Cost Savings
The approximate current outpatient charge for PFTS is £120 per patient. By contrast, the tariff for new patient Chest consultation is approximately £260 per patient This provides a saving of £140 per referral 6

7. Cost Savings
If chest clinic is not required and the patient is not subsequently referred
This results in a cost negative service
If Chest Clinic referral is required the cost of lung function is deducted from the Consultation tariff.
This results in a cost neutral service 7

8. Problems encountered
The GP’s at first were reluctant to refer. Unaware that the service was for PFTs rather than just Spirometry. Once the individual GP had used our service once they referred again to the service. Some patients were unable to travel
We found speaking to the GP’s directly, rather than sending flyers or newsletters resulted in increased referrals. 8

9. Conclusion No of Referrals in total – 108 patients
No of referrals needing Chest Clinic follow up – 22 (20%)
No of referrals discharged from Lung Function to GP with no need for Chest Clinic referral and managed in primary care– 86 (80%)
This is an estimated saving to Primary Care of £12,500. 9

10. Feedback Questionnaires
Both the GP’s and the patients were asked to complete a questionnaire after the PFT appointment. Patients were all very happy with the service. GP’s questionnaires showed high levels of satisfication with the referral process, waiting time, management plan given and outcome of plan.

11. Feedback Questionnaires
Patient comments
Quick appointment given
Very efficient service
Very good approach
Thank you very much
Staff very helpful
Clear explanation of tests given
GP comments
Excellent service, Thank you
Very useful service
Quick and efficient results

12. Clinical Physiology Department
Respiratory   
GP Direct Referral Diagnostics – Outcome sheet
PATIENT – DOB –  
HBH Hospital Number – GP SURGERY – 
For Admin use only:
Appt date for Pulmonary Function Tests 13/05/2011
Tests undertaken…Spirometry, static lung volumes and gas transfer
Results returned directly to referring GP to undertake patients treatment
 PHYSIOLOGIST COMMENTS                                                                              
BMI = 30.4 kg/m2
Ex-heavy smoker
Obese.
Spirometry shows FEV1 / VCmax = 2.32 / 3.54, ratio 66%, i.e. an obstructive defect, with further evidence on flow-volume loop of small airways obstruction. Elevated residual volume (RV = 151% predicted), but TLC normal and gas transfer normal.
These findings are in keeping with COPD, with some air trapping; normal TLC probably reflects obesity. FEV1 is 74% predicted, i.e. moderate COPD (NICE stage 2).
Recommendations:
He should be on the COPD register.
If dyspnoeic, consider prn salbutamol or long-acting anti-cholinergic inhaler.
Weight loss should be advised.
These results do not exclude other parenchymal lung diseases such as bronchiectasis, if there are clinical features to suggest this.
Forms given to patient:
“The Way Lungs Work”, “Exercise and the Lungs”
Name: Kelly Backler / Dr. Robert Buttery       
Designation: Lead Respiratory Physiologist / Consultant Respiratory Physician
Date:   12

13. Closer to home diagnostics
The next step will be reversing this process and going into practices To perform lung function in the community rather than the patient having to travel This is in conjunction with guidance that diagnostics should be available “closer to home”. 13

14. Closer to home diagnostics
Previously not possible due to lack of equipment Currently only one piece of equipment on the market that is suitable to provide PFT’s Leasing equipment and factoring in costs to any contract agreements for provision Use existing local services as a framework e.g. Community Echo clinics
Using Cardiac Echo service as an example which is well established
an example of hospital based tests being provided in the community 14