Reforming respiratory outpatient services: a before-and-after observational study assessing the impact of a quality improvement project applying British Thoracic Society criteria to the discharge of patients to primary care

  • Primary Care Respiratory Journal (2013) 22, 7278
  • doi:10.4104/pcrj.2013.00013
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Secondary care physicians caring for people with long-term conditions (LTCs) are under increasing pressure to discharge long-term follow-up patients to primary care. In respiratory medicine, the 2008 British Thoracic Society (BTS) statement on criteria for specialist referral, admission, discharge, and follow-up for adults with respiratory disease remains the only available basis for this dialogue. There is widespread concern about reforming outpatient clinics to meet these demands and the impact of discharging people with respiratory LTCs to primary care.


To examine the impact of implementing BTS guidance on secondary care follow-up of patients with respiratory disease.


We undertook a clinic reform project, which included one-stop medical reviews, providing more open access appointments, and implementing the BTS criteria. The impact on patients was assessed by patient survey, and the impact on GPs was assessed by an analysis of referral patterns pre- and post-reform.


There was a significant improvement in commissioner-mandated performance through reduction in follow-up (p=0.006) and the unscheduled hospital admission rate decreased significantly (p=0.021). However, many patients were dissatisfied with the process and re-referral rates rose.


Our findings suggest that the delivery of a responsive service capable of sustainable management of respiratory LTCs can be achieved using the BTS criteria. It seems to be efficacious within secondary care, increasing the quality and value of the clinic activity, although hidden impacts on primary care will require further prospective studies.

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  1. 1.

    Department of Health. Equality and excellence: liberating the NHS. London: Department of Health, 2011.

  2. 2.

    British Thoracic Society Standards of Care Committee. BTS statement on criteria for specialist referral, admission, discharge and follow-up for adults with respiratory disease. Thorax 2008;63(Suppl 1):i1–i16.

  3. 3.

    Hospital Outpatient Treatments (HOT) clinics. NHS Innovations South West, 2009.

  4. 4.

    , , , , , Systems for the management of respiratory disease in primary care — an international series: United Kingdom. Prim Care Respir J 2011;20(1):23–32.

  5. 5.

    Department of Health. Supporting people with long term conditions: an NHS and social care model to support local innovation and integration. London: Department of Health, 2005.

  6. 6.

    , , Moving beyond single and dual diagnosis in general practice: many patients have multiple morbidities, and their needs have to be addressed. BMJ 2003;326(7388):512–4.

  7. 7.

    , , , eds. Primary care in the driving seat? Organisational reform in European primary care. World Health Organisation, 2006.

  8. 8.

    British Thoracic Society. The burden of lung disease. London: British Thoracic Society, 2006.

  9. 9.

    , , Delivery of asthma and allergy care in Europe. J Asthma 2009;46(8):767–72.

  10. 10.

    Implementing chronic care for COPD: planned visits, care coordination, and patient empowerment for improved outcomes. Int J Chron Obstruct Pulmon Dis 2011;6:605–14.

  11. 11.

    , , , et al. From support to boundary: a qualitative study of the border between self-care and professional care. Patient Educ Couns 2010;79(1):55–61.

  12. 12.

    Department of Health. Supporting people with long term conditions: liberating the talents of nurses who care for people with long term conditions. London: Department of Health, 2005.

  13. 13.

    Clinical review: the genetics of type 2 diabetes: a realistic appraisal in 2008. J Clin Endocrinol Metab 2008;93(12):4633–42.

  14. 14.

    , , , Self-management and symptom monitoring among older adults with chronic obstructive pulmonary disease. J Adv Nurs 2010;66(4):784–93.

  15. 15.

    , , , et al. Changes in NHS organization of care and management of hospital admissions with COPD exacerbations between the national COPD audits of 2003 and 2008. QJM 2011;104(10):859–66.

  16. 16.

    Engaging patients in their healthcare: how is the UK doing relative to other countries? Oxford: Picker Institute Europe, 2006.

  17. 17.

    British Lung Foundation. Available from: .

  18. 18.

    , , , et al. Disease management program for chronic obstructive pulmonary disease: a randomized controlled trial. Am J Respir Crit Care Med 2010;182(7):890–6.

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Handling editor Niels Chavannes

Statistical review Gopal Netuveli

We would like to extend thanks to all the patients who contributed opinions to our patient satisfaction survey.

Funding This study received no specific funding. AMT has current funding from the Wellcome Trust, NIHR HTA, Alpha 1 Foundation, UHB charities and Linde REALfund; none of her funders had any input to this study.

Author information


  1. University of Birmingham, QEHB Research Laboratories, QEHB, Birmingham, UK

    • Alice M Turner
  2. Department of Respiratory Medicine, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, UK

    • Alice M Turner
    • , Satinder Kaur Dalay
    • , Ambika Talwar
    • , Catherine Snelson
    •  & Rahul Mukherjee


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AMT conducted all data analyses, some data collection, some of the patient satisfaction survey and drafted the manuscript. SD and CS collected data. AT contributed to the patient satisfaction survey. RM conceived the study and supervised the work.

Competing interests

The authors declare that they have no conflicts of interest in relation to this article.

Corresponding author

Correspondence to Alice M Turner.


Appendix 1. Clinic reform manuscript SQUIRE checklist