Posted on November 14, 2022

The FeNO testing programme aims to improve the speed and accuracy of asthma diagnosis and prescribing, therefore reducing the risks of exacerbations and admissions to hospital.  FeNO devices measure fractional exhaled nitric oxide in the breath of patients. This provides an indication of the level of inflammation in the lungs, a marker which helps make the diagnosis of asthma and also helps to define the best initial treatment.

The West of England AHSN has been working collaboratively with all three Integrated Care Systems (ICSs) in the region to support the implementation of FeNO testing in primary care.  Two projects were awarded Pathway Transformation Funding.  The South West Respiratory Clinical Network, supported the programme with additional funding for devices and mouthpieces.

There has been high uptake of FeNO testing; 143 GP practices across the region now offer this service to their patients.  More than 2,500 patients have accessed FeNO testing since October 2021, resulting in improved care and outcomes.

“It is very useful.  I’ve never had this test before and had not been taking my treatment.  I do have symptoms and the test made me realise that I need to be better with taking inhalers and other treatment”  Anonymous

The challenge

Respiratory disease is identified as a clinical priority in the NHS Long Term Plan, with a commitment to do more to detect and diagnose respiratory problems earlier.

Over 5.4 million people in the UK suffer from asthma with the NHS spending £1.1 billion on asthma annually1.  90% of this cost goes directly on asthma medication including the excessive prescription of steroid inhalers2.

Statistics released from Asthma UK3 show that over 120,000 asthma sufferers in the UK are at risk from wrongly prescribed medication and NICE findings on studies of adults diagnosed with asthma suggest that up to 30% do not have clear evidence of asthma with other studies suggesting that asthma may be underdiagnosed . As a consequence, people could potentially be on medications that they do not need or not receiving medication they require to control their symptoms.

NICE recommends objective testing with FeNO (and spirometry) for most people with suspected asthma, but the infrastructure and training needed in primary care, along with the cost of devices, has been a barrier to implementing this.

Our approach

FeNO testing was included in the national Rapid Uptake Products Programme in 2021.

The benefits of FeNO testing include:

  • Improved accuracy of diagnosis for patients with suspected asthma
  • Improved effectiveness of patient care through better understanding of an individual’s condition
  • Improved patient outcomes, reducing the risk of exacerbations and admissions to hospital
  • Reduction in inappropriate prescribing
  • Reduction in the number of inappropriate referrals to secondary care clinics.

The West of England AHSN worked collaboratively to spread FeNO testing to GP practices in Bath, Swindon and Wiltshire (BSW) ICS and Gloucestershire ICS, who were successful in bidding for Pathway Transformation Funding.  The West of England AHSN also developed an implementation checklist, delivered education webinars, coordinated device training and managed staff and patient experience surveys.

ICS teams met with the West of England AHSN monthly to share progress, challenges and lessons learned.

Different models of implementation were used in different localities. Gloucestershire ICS used a hospital-based referral clinic as a blueprint for primary care based FeNO testing with devices allocated at practice level. BSW ICS tested a mobile model within primary care with shared devices moving between multiple practices.

Patients with suspected asthma were invited for a FeNO test at their local GP practice to try and confirm a diagnosis, as per NICE guidelines. FeNO testing was also offered to patients with poorly controlled asthma for monitoring and treatment adherence purposes.

“It’s a valuable tool for aiding the diagnosis of asthma as well as monitoring existing patients who are uncontrolled and needing potential treatment change or can be informed that their current treatment is working.  It is easy to use and can be done in a 10-minute appointment if you are only performing FeNO.  Patients find holding and breathing into the device quick and easy and it proves to patients that there is inflammation that needs dealing with”.
Nicci Mawer, Practice Nurse, Combe Down Surgery

Impacts to date

Between January and June 2022, the West of England AHSN delivered FeNO testing education webinars to 95 attendees.  There are currently 135 GP practices across the region offering FeNO testing to patients.

Patient stories have been developed, illustrating the benefits of FeNO testing.

Evaluation data from the two funded projects demonstrates the following impact on patients:

  • 2,374 patients were reviewed
  • 535 patients were diagnosed with asthma following a FeNO test
  • 62% of survey respondents4 feel more able to manage their symptoms following a FeNO test
  • Shorter waiting times than secondary care referrals – 70% of survey respondents waited less than 2 weeks for a FeNO test
  • Easier access to local testing – 64% of survey respondents travelled less than 3 miles for a FeNO test
  • Improved experience – 98% of survey respondents were satisfied or very satisfied with the service

“FeNO testing is improving the speed and accuracy of asthma diagnosis across the West of England region.  Patients are now able to access this service more easily at their local GP practice with shorter waiting times.  Networks for respiratory teams in primary care have been established to ensure ongoing support and sustainability of FeNO testing.”
Charlotte Hallett, Senior Project Manager, West of England AHSN

Feedback from staff experience surveys indicates:

  • Access to FeNO testing has supported diagnosis of asthma (90% out of 53 respondents)
  • Access to FeNO testing has influenced prescribing (57% out of 53 respondents)
  • Access to FeNO testing has improved confidence levels when diagnosing asthma (83% out of 47 respondents)

BSW ICS successfully submitted an abstract to the Primary Care Respiratory Society and the poster for their project was presented at the Annual Conference in September 2022.

“Having previously offered FeNO testing following referral and seen the improvements in accurate diagnosis, patient education and confidence in self-management, we are now able to offer the test without the delays associated with referral, close to the patient in their GP practice with competent healthcare professionals in a way that is sustainable in the longer term.  We achieved the aims of our project and have also been able to roll out the model across the whole ICB.”
Carol Stonham, Senior Nurse Practitioner – Respiratory, Gloucestershire ICB

Next steps

The Pathway Transformation Funding projects in both areas are now complete and have been evaluated.  Teams at the Integrated Care Boards (ICBs) are working to secure ongoing support to continue the important work that has been started and one ICS now has a Local Enhanced Service for respiratory which includes FeNO testing.

The West of England AHSN are continuing to support the national programme until March 2023 and are working with individual PCNs and practices in Bristol, North Somerset and South Gloucestershire ICS that are interested in implementing FeNO testing.

“It’s really exciting to see the impact of this project. Many more patients can now benefit from a rapid and accurate diagnostic pathway. Watching everyone collaborate and develop solutions together to deliver the changes needed has also been a highlight of this work.”
Mark Juniper, Medical Director, West of England AHSN

Find out more about FeNO or email: weahsn.transformation@nhs.net

  1. Mukherjee M, Stoddart A, Gupta RP et al. The epidemiology, healthcare and societal burden and costs of asthma in the UK and its member nations: analyses of standalone and linked national databases. BMC Med. 2016 The epidemiology, healthcare and societal burden and costs of asthma in the UK and its member nations: analyses of standalone and linked national databases | BMC Medicine | Full Text (biomedcentral.com)
  2. NHS Long Term Plan
  3. Asthma UK. Patient Safety Failures in Asthma Care: the scale of unsafe prescribing in the UK. 2014. Patient Safety Failures in Asthma Care
  4. 73 patient survey respondents.

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