Expression of interest form

Asthma diagnosis and monitoring guideline:

Primary Care Implementation Feasibility Project

Responses to be received no later than 27 February 2016

CONTACT DETAILS
Name of practice/organisation
Address
Website
Project lead
Email address
Telephone number
Lead clinician
Email address
Telephone number
Primary contact
Email address
Telephone number
Do you have senior partner/director agreement to participate? Please name.
DEMOGRAPHICS
Practice/site population; (number of registered patients, geographical factors and age distribution)
Number of patients with an asthma diagnosis
Number of GPs (FTE)
Number of practice nurses (FTE)
Other in-house clinics and services offered.
ASTHMA PROVISION - Please describe your current model of service delivery for diagnosing and monitoring asthma (e.g. staff involved, staff training, clinic system, length and number of appointments, tests undertaken, location (in house or referral)
DIAGNOSTIC TESTS FOR ASTHMA CURRENTLY UNDERTAKEN IN-HOUSE
Do you currently use spirometry to aid asthma diagnosis?
Who does this?
What training has been undertaken? (state if ARTP/BTS accredited and level)
How often is this renewed?
Do you currently use spirometry to monitor asthma?
Who does this?
What training has been undertaken? (state if ARTP/BTS accredited and level)
How often is this renewed?
Do you currently use spirometry to aid COPD diagnosis?
Who does this?
What training has been undertaken? (state if ARTP/BTS accredited and level)
How often is this renewed?
Do you currently use FeNO to aid asthma diagnosis?
Who does this?
What training has been undertaken?
How often is this renewed?
How are the device and consumables funded?
Do you currently use FeNO to monitor asthma?
Who does this?
What training has been undertaken?
How often is this renewed?
How are the device and consumables funded?
DATA COLLECTION
Are you able to provide data on the burden of asthma diagnosis to your practice/site as outlined in section 5 for the 6 month equivalent period in 2015?
  • number of undiagnosed patients presenting to GP with asthma symptoms
  • time spent on diagnosis appointments
  • number of patients receiving an asthma diagnosis

Can you commit to collecting the information above and included in section 5 of the information pack during the 6 month implementation feasibility project?
STATEMENT OF INTEREST (please describe why you want to be involved in this project)
DECLARATION OF INTEREST
Please complete the declaration of interest form included on the next page for all practice/site staff who would be involved in the project.
The determination as to whether or not a declared interest is in conflict with the work of NICE will sometimes require careful judgement based on the facts and the nature of the business being conducted (in this case, the diagnosis and monitoring of asthma). In the event of doubt, it is best determined by considering how the interest will be perceived by an ordinary member of the public.

Declarations of interests form for the asthma diagnosis and monitoring guideline: Implementation Feasibility Project

All interests that might unduly influence an individual’s judgement and objectivity in the conduct of NICE business should be declared. If in doubt, please declare all interests.

Particular consideration should be given to interests involving payment or financial inducement or any reputational interest related to the delivery of asthma services, including drugs, devices and technologies which may affect the delivery of the project.

I declare that I have read and understood the NICE Conflicts of Interest Policy and that I wish the following interests to be recorded, in accordance with the relevant provisions of the policy. I am aware that failure to declare relevant interests may result in being required to stand down from the project.

The time period for relevant interests is 12 months before the start of the project and for the duration of the project.

Name(s): / Practice:
Interests to be declared:
Signature / Date

Data Protection Act 1998 – The information submitted will be held by the National Institute for Health and Care Excellence for personnel or other reasons specified on this form and to comply with the Institute’s policies. This information may be held in both manual and computer form in accordance with the Data Protection Act 1998. Information may be disclosed to third parties in accordance with the Freedom of Information Act 2000.

On completion, please return to:

Adoption and Impact Programme (Asthma Project)

National Institute for Health and Care Excellence

Level 1A, City Tower

Piccadilly Plaza

Manchester M1 4BT

Or by email to:

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