Author: Jenny Casey, Respiratory Nurse Specialist and EQUIP Trainer. Letter to Chief Executives of Mid & South Essex, North East Essex, Hertfordshire & West Essex ICBs.
The publication of the 2024 NICE/BTS/SIGN asthma guidelines represents a significant step forward in promoting early, accurate diagnosis and optimised management of asthma across the UK. Central to these recommendations is the use of Fractional Exhaled Nitric Oxide (FeNO) testing as a first-line investigation for many adults and children with suspected asthma, when supported by an appropriate clinical history.
FeNO testing is a quick, simple and non-invasive investigation that can support diagnostic certainty and enable earlier initiation of appropriate treatment. In theory, this should enhance patient outcomes, reduce diagnostic uncertainty, and improve overall efficiency within primary care respiratory pathways.
However, in my role as a Respiratory Nurse Specialist and respiratory trainer working across multiple NHS training hubs and primary care organisations in Suffolk, North East Essex, South and Mid Essex, Herts and West Essex, I am increasingly concerned by the growing disconnect between national guidance and what many practices are realistically able to deliver.
Despite FeNO testing being positioned as a key component of the diagnostic pathway, many GP practices do not have access to FeNO equipment. While some Integrated Care Boards (ICBs) have supported local provision, this remains inconsistent. As a result, patients are frequently referred to centralised hubs for FeNO testing, despite the test itself taking only seconds to perform.
These referrals often introduce delays of weeks or even months. From a clinical perspective, this has significant implications. Delayed diagnosis can result in prolonged periods of uncontrolled symptoms, delayed initiation of appropriate therapy, and an increased risk of preventable exacerbations. From a system perspective, this creates inefficiency, unnecessary administrative burden, and increased pressure on already stretched secondary and community services.
As a trainer, I regularly encounter respiratory clinicians who are motivated, highly skilled, and committed to delivering care in line with national best practice. However, they are being asked to follow a diagnostic pathway without access to the essential tools required to do so. This places clinicians in an untenable position, undermines professional morale, and risks widening variation in care based on local funding decisions rather than clinical need.
Having worked in the NHS for over 30 years, I have witnessed many iterations of national guidance and service redesign. A consistent theme is that successful implementation depends not only on evidence-based recommendations, but on appropriate resourcing and equitable access to enabling technologies.
Without universal access to FeNO testing in primary care, the aspirations of the 2024 asthma guidelines cannot be fully realised. Furthermore, inequity in access risks creating a postcode lottery in asthma diagnosis and management, which is at odds with the principles of equitable, high-quality NHS care.
There is a strong case for national investment and a coordinated implementation strategy to ensure that all GP practices have access to FeNO equipment. Universal provision would support:
- Rapid and accurate asthma diagnosis
- Timely initiation of appropriate treatment
- Reduction in unnecessary referrals and delays
- Improved patient outcomes and reduced exacerbation risk
- Greater alignment between national guidance and frontline delivery
- Improved system efficiency across primary and community care
In conclusion, FeNO testing represents a relatively small technological investment with the potential for significant clinical and system-wide benefit. Ensuring equitable access across primary care is essential if the 2024 NICE/BTS/SIGN asthma guidelines are to translate into meaningful improvements for patients and clinicians alike.