© 2019 by The Grumpy Old Nurse

"Hello

Is that the Grumpy Old Nurse's National Spirometry Register Help Line?

I'd like to report a nervous breakdown"

"That's 56 this week Kim, ... and it's only Tuesday"

A WOMAN ON THE EDGE

I have to say that there have been few things in almost 40 years of nursing that has managed to wind me up more than the WAY in which the proposed National Spirometry Register has been FORCED upon General Practice

Please can I make it clear that any frustration that might come through in this post has nothing to do with the call for health care professionals involved in performing spirometry, and/or interpreting spirometry test results, to be trained and assessed as being competent ... that goes without saying ... my issue is with the way in which proposed register has been set up, promoted and advertised 

I am being contacted on an almost daily basis by Practice Nurses, Nurse Managers, Practice Managers, GPs, CCG Managers, asking me whether or not the National Spirometry Register is mandatory

From those conversations it would seem that nurses are afraid of losing their NMC registration, CCGs are afraid of NHS England, Practice Managers are afraid of the CQC and as for me .... well, I am afraid of answering the phone in case I am asked, for the 300th time, if I have been regulated by the ARTP!  

I have had nurses call me in tears because they have been failed on a 'technicality' 

I have nurses sending me screenshots of the spirometry tracing that they are being asked to interpret as part of the assessment process because they have no idea whatsoever as to what is being asked of them

I had a call from a CCG nurse training manager asking me if there was any other way that they could train nurses other than via the ARTP because two nurses had gone off sick due to stress and anxiety related to the ARTP portfolio submission and assessment

I THINK IT IS SAFE TO SAY

There are a lot of people out there confused and afraid and, having examined the content of the ARTP website, I can understand why!

I have emailed and spoken to the ARTP on multiple occasions asking them to change and to clarify the wording on their website and have explained all of the above but the website remains misleading, inaccurate and out of date and I am still being contacted on a daily basis so I have decided to tell you what I know about the proposed National Spirometry Register

INFORMED DECISION MAKING

'A decision based on facts or information'

FACTS AND INFORMATION TO HELP YOU WITH YOUR DECISION MAKING

Who is the ARTP?

ARTP stands for the Association of Respiratory Technology and Physiology and their website states that they are a limited company and registered charity

Is the ARTP a Regulatory body for the Department of Health, NHS England or NHS Health Education England?

No

Does the ARTP have any power and/or authority over any other providers of spirometry training?

No

Does the ARTP have any power and/or authority over nurses?

No

Is the ARTP a formal educational accreditation unit? 

No

Is being on the National Spirometry Register a mandatory requirement for nurses or doctors?

No

I have sat and thought really long and hard about how I should tackle this next bit.  My first draft was too angry and, if I am being honest, it was a bit brutal and I don't want to be like that but I DO want for those of you who are reading this to know ALL of the facts (warts n all) as I do believe that the content of the ARTP website is misleading and inaccurate.  

So, I am going to write it as an open letter to the ARTP as this will keep me on the straight and narrow and, as they would say in Transactional Analysis circles, it will keep me 'in adult', but don't worry, I'm not going all millenial on you, I will still go for the jugular but just in a nice way.  

A note about the National Spirometry Quality Scrutiny Board (NSGSB)

The NSQSB is made up of a wide range of stakeholders (including patient representatives) involved in, and with expertise and interest in respiratory teaching, learning and assessment.


The current chair of the NSQSB is Professor Mike Morgan who is also the national clinical director for respiratory services at NHS England.


The role of the NSQSB is to provide external quality assurance to the processes underpinning training, assessment and the practice of spirometry. 


The NSQSB will be hosted by, but independent of, the ARTP.


Its two main aims will be to provide governance and oversight of the certification process for quality-assured diagnostic spirometry and to advise the ARTP on continuous quality improvement and best practice with respect to diagnostic spirometry, the certification process and the national register.


The minutes of each meeting of the NSQSB are publically available on the ARTP website. 

Now,  before we start, you might want to go and get yourself a gin and tonic as this might take a while ...

Dear ARTP, 

Every day I am contacted by various health care professionals asking me questions about the National Spirometry Register and I would like to draw your attention to a recent call from a practice nurse asking me if it was mandatory for her to be on the register.  I suggested that she visit your website and she told me that she had already done that but was still not sure and really didn't want to get into trouble with the NMC as she was only 3 years off retiring and didn't want to tarnish her career and felt that it might be best if she just didn't so spirometry at all.  She said the information on your website had scared her off spirometry for good!  

I would like to draw your attention to the page on your website that she, and many others, have been particularly unsettled by and have also been quite offended by its tone and have found it, in parts, threatening, condescending, patronising and disrespectful, especially the reference to nurses ignoring guidance and I have to say that I agree with them.

The page in question is the one entitled ARTP Spirometry Register and starts with you explaining that it is held by your partner provider, The Institute of Clinical Science and Technology (ICS&T) but you don't mention that the register is owned by you.  On from that, you showcase the question, 'Is it Mandatory to be on the Spirometry National Register by 2021?' and you provide the following information in answer to that question:

'The NHS England Document "Improving the Quality of Diagnostic Spirometry in Adults" which discusses the National Register for Spirometry is a best practice recommendation but performing diagnostic spirometry without evidence of competence after 2021 may lead to issues with professional bodies. Best practice guidance is used throughout healthcare and certain organisations may check adherence to these guidelines.

The Nursing Medical Council could potentially be involved if nurses ignore guidance recommendations and perform diagnostic spirometry after 2021 when they have not been deemed competent. Also, the Medical Defence Union, who provide indemnity insurance within general practice would not cover a nurse who acted outside their competence.

The recommendations are therefore not mandatory because there is no policing mechanism, but it is an issue of clinical governance'

I believe that the answer you have given is inaccurate, out of date and misleading and I would like to explain what has led me to form these opinions.

I would like to start with the first paragraph.

 

'The NHS England Document "Improving the Quality of Diagnostic Spirometry in Adults" which discusses the National Register for Spirometry is a best practice recommendation'

I have noticed that you reference the "Improving the Quality of Diagnostic Spirometry in Adults" document on a number of occasions on your website so I thought it best to download it and go through it in detail.  The first thing I noticed was that you refer to it as 'The NHS England Document' and, indeed, the document does have the NHS England logo on the front which led me, and many others, to believe that, well, it was an NHS England document.  However, I also downloaded the minutes of the National Spirometry Quality Board (NSQSB) Meetings, which are freely available on your website, and confess to being a little bit confused by a reference to the said document in a minute (3.0/2018) listed in the June 14th 2018  'Matters Arising' by the chair Professor Mike Morgan who, I understand, is the National Clinical Director for Respiratory Clinical Services for NHS England, which stated:

 

“MM (Chairman) clarified that the document was published by the Primary Care Commission and does not have the authority of NHS England, who do not own the document and cannot implement the document”

I also noted that there were 4 members of the ARTP at that meeting and that meeting took place in June 2018 yet your website still references the document as being "The NHS England Document".   Please would it be possible to clarify this discrepancy and amend the wording on the website accordingly.

 

On from that, the document was produced in 2016 which was before the formation of the NSQSB.  Since then there have been many changes to the way in which spirometry training and assessment is carried out across the UK and, again, I draw your attention to another minute from the June 14th meeting

"CS (PCRS) commented that there is a perceived view that there is only one accredited training process. JS (ARTP) advised that this was not the case and that all other training is acceptable. Members from stakeholder organisations were unanimous in their concerns that, at present, the ARTP website presents information about training courses which suggests that a monopoly of training provision exists and that only those courses organised by ARTP are suitable for certification. Moreover, it also appears from the current information on the ARTP website that there is a monopoly on the assessment process, which was not desirable.  JS (ARTP) confirmed that neither was the case and that the wording on the website would be amended accordingly.

MM (Chair) confirmed that it was the intention of the document which led to the establishment of this process that there would not be a single mandatory provider. Any qualified trainer can provide the training’

Whilst the wording relating to training provision has been amended the wording relating to the assessment process is still misleading and I quote: 

 

"The ARTP Spirometry certification process can be undertaken through ICS&T (who host it on behalf of ARTP) either as a stand-alone process or as part of a training and certification package. 
This is currently the only official assessment route for Spirometry certification and entry on to the National Spirometry Register which ensures consistency and quality standards"

 

Once again, this is very confusing, as you state quite clearly on your website that the only official assessment route for spirometry certification and entry onto the national register is via the ARTP certification process yet JS (ARTP) confirmed at the NSQSB meeting on the 14th June 2018 that this was not the case and that the wording would be amended accordingly. 

I would now like to go back to the "Improving the Quality of Diagnostic Spirometry in Adults" document in which you cite the findings the All-Party Parliamentary Group (APPG) report 2014 on the inquiry into respiratory deaths (2014) as being the driving force behind the proposed national register stating that it 'called for a system to assess and certify the competence of all healthcare professionals undertaking and interpreting diagnostic spirometry' and indeed it did call for a 'system' to assess and certify competence but it did not directly call for a national register. 

 

The report made 21 separate recommendations and the one relating to spirometry was actually tagged onto a wider recommendation relating to respiratory care as referenced below (recommendation number 5)  from the APPG report:

"Health Education England (HEE) should work with professional bodies such as the Primary Care Respiratory Society UK (PCRS) and British Thoracic Society (BTS) to ensure high, consistent standards of training and competency assessment for all healthcare professionals treating people with respiratory conditions. This should include working with NHS England to establish a system to assess and certify the competence of all healthcare professionals undertaking and interpreting quality-assured diagnostic spirometry"

 

The report also called for the department of health to introduce free prescriptions for people with respiratory conditions.

 

I am concerned that you have taken one part of one recommendation and escalated it into a situation that is causing considerable stress and anxiety to nurses and I am seeing two main consequences of this:

  1. Nurses are simply refusing to do spirometry

  2. Nurses are so anxious about getting into trouble with the NMC if they are not on the spirometry register and are being pressurised into ARTP training courses by their CCGs (who seem to be are afraid of getting into trouble with NHS England/CQC) and the pursuit of spirometry certification becomes all-consuming due to the sheer amount of time, work and effort needed to pass the assessment process. 

I have spent 17 years working across the UK on large scale primary care respiratory projects all involving the assessment and management of people who had a history of repeated admissions and were considered high risk for further admission or death.  I have reviewed over 10,000 of these patients and mentored around 500 practice nurses and I feel that I have the experience to suggest that if the APPG report wanted to look at ways of reducing respiratory morbidity and mortality then a Practice Nurse's time would be better spent on the first part of the APPG (recommendation 5) which calls for consistent standards of training and competency assessment for all health care professionals TREATING people with respiratory conditions.   

Please note that diagnostics is not a Practice Nurse's responsibility! 

I would like to move onto this next statement:

 

'but performing diagnostic spirometry without evidence of competence after 2021 may lead to issues with professional bodies'

The statement says 'without evidence of competence', it does not say, 'without being on the national spirometry register' and there is a fundamental difference between the two and I would like to relate to you part of an email that I sent you previously, and of which I did not get a reply, which is as follows:

 

'Nurses are being led to believe that they may get reported to the NMC if they are not on the spirometry register but this is NOT what it says on your website … it says ‘without evidence of competence’ … lets say that a nurse is assessed as being competent by someone other than the ARTP but someone who has as much experience as any ARTP assessor in the use of spirometry in general practice and who assesses that person in line with the standards set out in the Guide to Performing Quality Assured Spirometry document supported by the ARTP and who then signs a competency document relating to that person … in effect this is evidence of competency so surely this must suffice?'

Again, clarity on this matter would be much appreciated.

The statement below is an interesting one:

 

'Best practice guidance is used throughout healthcare and certain organisations may check adherence to these guidelines'

Please, could you clarify what you mean by 'certain organisations'  and, with regards to adherence to best practice, what advice would you give to general practice when two sets of national guidelines make different recommendations as is the current case in asthma?  

I also note that there is a difference in best practice recommendations between the ARTP and the GOLD guidelines relating to the use of fixed ratio or LLN ratio as a diagnostic cut off point.  Now I fully understand and appreciate the reasoning behind both arguments but I have had the luxury of being able to focus on one disease area for the last 17 years, a luxury that a Practice Nurse does not have so what is he/she to do?

I would also like to draw your attention to the Quality and Outcomes Framework (QOF) and ask what the 'certain organisations' might make of the clinical indicators in QOF as these don't always adhere to national guidance and are, in fact, quite brazen about it at times as demonstrated in the CVD-PP Indicator which I have detailed verbatim below:

'NICE CG181 recommends offering atorvastatin 20 mg for the primary prevention of CVD to patients who have a 10% or greater 10-year risk of developing CVD however, the intervention threshold in this indicator has been pragmatically set at a 20% or greater 10-year risk'

I would like to reference the findings of the National Review into Asthma Deaths (NRAD) (2014):  

'The expert panels identified factors that could have avoided death in relation to the health professional’s implementation of asthma guidelines in 89 (46%) of the 195 deaths, including lack of specific asthma expertise in 34 (17%) and lack of knowledge of the UK asthma guidelines in 48 (25%)'

NRAD investigated the deaths of 195 people and found that lack of adherence to national asthma guidelines was a major factor in these deaths.  What have the 'certain organisations' done about the findings of NRAD in terms of failure to follow adherence to guidelines?  Did the MDU refuse to indemnify any of those health care professionals involved in the care of the people who died?  These are serious and valid questions because if the organisations you cite are not acting on the findings of NRAD then are they really likely to spend time on checking whether or not the 16,000 Practice Nurses across the UK are performing spirometry without being on a non-mandatory register?  

And finally, I would have to say that this next statement has been the one that has caused the most offence amongst the many nurses that have contacted me regarding the register:

'The Nursing Medical Council could potentially be involved if nurses ignore guidance recommendations and perform diagnostic spirometry after 2021 when they have not been deemed competent'

 

To begin with, there is no such thing as the Nursing Medical Council, the regulatory body for nurses is called the Nursing and Midwifery Council but it is the implication that nurses would overtly ignore guidance recommendations that have caused the most offence.  

Having spent the best part of the last 17 years mentoring Practice Nurses in their places of work I can quite categorically state that they do not overtly ignore guidance recommendations.  I would like to draw your attention to the wording in the

APPG report:

'assess and certify the competence of all healthcare professionals undertaking and interpreting quality-assured diagnostic spirometry'

 

The APPG does not single out nurses, they call for all healthcare professionals to be assessed and certified yet on your website you single out nurses.  Now I accept and appreciate that nurses perform spirometry so I have no issue with that but, as mentioned earlier, diagnostics is not a Practice Nurse responsibility but what has stopped you advising doctors that the GMC could potentially involved if they ignore guidance recommendations and interpret spirometry results when they have not been  'deemed competent' ?  

Certain organisations could perceive the singling out of nurses as being discriminatory as the APPG report was quite clear that it was all healthcare professionals who should be assessed yet you changed that wording to focus on nurses even though diagnostics is not a practice nurse responsibility. 

It did get me wondering as to how a GP would react if the word 'nurse' was replaced with 'GP' in the statements being discussed here so I asked my husband, who is a GP and a Deputy Dean for GP Education, and he replied by saying that the BMA would not put up with that ... and neither should Practice Nurses, which leads me onto my final point ... 

 

Who deemed the content of the ARTP assessment process as being fit for purpose and relevant to the use of spirometry in general practice?

I have heard reports of relatively high failure and drop out rates related to the assessment process.  I acknowledge that these are only reports and may not be accurate, however,  if there is a high failure and drop out rate, how is this being evaluated and who/what is it that is failing, the nurse or the training and assessment process?

 

The reason we ask these questions of you is related to the part of the portfolio that deals with the calibration process as it uses different submission criteria for syringe calibration v physiological control.

With regards to the portfolio of evidence, it asks for the following:

  • Calibration log (20 syringe calibrations)

  • Physiological control values (10 spirometry measurements with mean and +/- 5% calculated)

 

We have some questions regarding the above:

  1. Why do you ask for 20 examples of syringe calibration and only 10 examples of physiological control? 

  2. If you are able to assess competency on 10 examples of physiological control, why do you need 20 examples of syringe calibration?  

  3. How did you decide that it would take 20 examples of syringe calibration to prove competency? 

  4. How did you decide that it would take 10 examples of physiological control to prove competency? 

  5. Would you fail a nurse who produced a portfolio of evidence that contained 17 perfect examples of syringe calibration given the fact that you are happy to accept only 10 physiological examples?  

I am struggling to reconcile that fact that on the one hand, your organisation is very strict and forthright and, it could be said, unforgiving when it comes to the standards that you set for nurses, yet on the other hand, some of the content of your website (and some of the documents you cite) is out of date, littered with supposition and inaccuracies.   You also alternate between calling the register, the ARTP register or the National register and this is confusing.  A true National Register would be totally independent of one training company as is the case with Nursing and Midwifery Register.  

If I may would like to direct one last question to the National Spirometry Quality Scrutiny Board.

How can an organisation with such vested business interests in a national register, which is currently owned by themselves, have such a central and pivotal role in regulating a self-promoting national policy?

True independent policy setting and regulation is required!

Kindest Regards

The Grumpy Old Nurse