Pioneering nurse project tackles poor lung health
Liverpool-based specialist respiratory nurses in GP centres are leading the way in identifying undiagnosed cases of lung cancer and COPD in a city tainted with poor lung health.
Liverpool-based specialist respiratory nurses in GP centres are leading the way in identifying undiagnosed cases of lung cancer and COPD in a city tainted with poor lung health
A nurse-led project in Liverpool is recording great success in picking up life-threatening lung cancer at an earlier and more treatable stage.
Clinics run by specialist respiratory nurses in GP centres are finding undiagnosed cases of lung cancer and chronic obstructive pulmonary disease (COPD).
Liverpool’s Healthy Lung Programme was developed by the Liverpool Clinical Commissioning Group, NHS England, Cancer Research UK and Macmillan Cancer Support to improve respiratory health in a city blighted with poor lung health.
Liverpool has one of the highest respiratory morbidity rates in England, with double the national lung cancer incidence, particularly in lower socioeconomic groups.
High levels of deprivation
The programme was launched in April 2016 in Everton, Picton, Speke and Norris Green – areas united by high levels of deprivation, chronic disease and smoking.
Five specialist respiratory nurses (three whole-time equivalent) run clinics in GP practices that carry out in-depth lung assessments on patients at high risk of developing lung cancer. They refer on where more tests are needed and provide healthy lung advice, such as encouraging smoking cessation.
In its first year, the Healthy Lung Programme invited a total of 7,150 people between the ages of 58 and 70 to attend a lung health clinic, and more than 3,200 have either attended the clinic already or booked an appointment to visit one soon.
‘This is a proactive approach, which aims to identify lung cancers at an earlier stage than usual making treatment options better’
It is one of 65 projects nationally involved in the first wave of the Accelerate, Coordinate, Evaluate (ACE) Programme, an NHS England early diagnosis initiative supported by Cancer Research UK and Macmillan Cancer support.
Following a successful first year, it is being rolled out to other areas of the city and extending the age range it covers.
Five-year survival rates
An independent study of almost 1,600 records of patients seen by the nurses between April 2016 and January 2017 found that 75% of the lung cancers were diagnosed at an early stage, bringing a substantial improvement in five-year survival rates. In the preliminary evaluation published earlier this year, the researchers from the University of Liverpool and Queen Mary University of London also found screening for lung disease was a cost-effective approach.
Lead healthy lung nurse Linda Johns says: ‘This is a proactive approach, which aims to identify lung cancers at an earlier stage than usual making treatment options better. This is important in Liverpool, where insight work has shown that fear and fatalism abounds.
‘Identifying lung cancer in patients who are asymptomatic and who would not have had any cause to go to see their GP for investigations is rewarding for staff and also for the patient whose treatment outcomes are likely to be far better.’
The first phase involved public engagement events throughout the city, starting in areas with the highest lung cancer incidence, promoting positive messages around lung health, and addressing attitudes of fear and fatalism around lung cancer.
‘Breathe freely’ events
These ‘breathe freely’ events included posters about the lung health clinics. More than 2,100 people attended and 800 completed spirometry tests, which diagnose and monitor lung conditions. Almost one in five of the tests was abnormal, which triggered a referral to primary care.
The second and ongoing phase involves inviting people in the chosen age bracket who have ever smoked and/or have COPD, from GP practices in the targeted areas to a nurse-led healthy lung check. If the patient does not attend, they get a second letter and are then followed up by phone.
‘The nurses bring many skills including health promotion, referring to smoking cessation and pulmonary rehabilitation’
Those attending receive a 45-minute appointment with a respiratory nurse in a community setting. A detailed risk assessment is carried out including BMI, spirometry-assessed lung function, risk factors for a number of lung diseases, family history, exposure to asbestos and smoking duration. Those who have more than a 5% risk of developing lung cancer over the next five years are invited for a CT scan. Anyone with a less than 5% risk is referred to a health trainer.
40% uptake of appointments
There was a 40% uptake of appointments among those targeted, the research found. A third of attendants reported asbestos exposure and a similar number had a family history of lung cancer. They had smoked for an average of 60 years. Of those who received spirometry tests, 41% (almost 400) had an abnormal reading. Research suggests that 63% of them would expect to be diagnosed with COPD, so around 250 people are likely to have the condition and receive help at an earlier date.
Of the 1,600 records examined in the study, 658 patients were recommended to have a CT scan, and nine in ten of them underwent the test. Of these, 10% required another scan at either three or at 12 months due to pulmonary nodules, and eight were diagnosed with lung cancer. Three quarters of these were at stage I, and five have so far received surgery. Generally, lung cancer is not diagnosed until stage III or IV. The earlier diagnosis boosts five-year survival rates from 10% or less to 30%.
Ms Johns says the healthy lung nurses come to the appointments with a wealth of experience. ‘The nurses bring many skills including health promotion, referring to smoking cessation and pulmonary rehabilitation,’ she says. ‘They are able to advise patients about their inhalers if required, often checking technique if time allows. A couple of our part-time nurses came from a background of COPD nursing and have been able to support and help to educate the other nurses with their knowledge.’
‘If we have an early pick up of lung cancer or COPD, we can implement changes that improve quality and longevity of life. It is a win-win situation’
Healthy lung specialist nurse Deborah Fleetwood says that the programme allows the team to provide accessible holistic care. ‘We try to make arrangements for people to come to clinics in their own surgery as much as possible so they can be seen locally rather than having to travel,’ she says. ‘We want to provide care as close to the patient as possible as some of them will be 75 and may not be in good health, so making ourselves available in a place they know helps get people through the doors.’
‘If we have an early pick up of lung cancer or COPD we can implement some good changes that improve quality and longevity of life. It is a win-win situation.’
She has received training in techniques to encourage people to adopt healthier lifestyles, such as giving up smoking. ‘If people are still smoking we ask if they want to look at this and seek some help,’ she says.
The nurses are employed by the Liverpool Heart and Chest Hospital NHS Foundation Trust, and while all their work is out in the community, they have good links with the consultants who are part of their team. They can also discuss and refer any concerns that arise about any other health issues with the patient’s GP.
Surveys carried out as part of the study reveal high patient satisfaction regarding the service. In one survey, 96% of 71 people who had a healthy lung check reported that they would recommend it to a friend. However, a separate survey of 60 people who had a CT scan revealed concerns among a significant minority about the time it took to get their results and the explanation they received about them.
So far, a total of 19 lung cancer cases have been found at an early stage and treated. But researchers pointed out that while picking up cases of cancer may have a higher profile, the effect of the programme in highlighting large numbers of undiagnosed cases of COPD may have a greater benefit. Their recommendation that people up to the age of 75 should be included has been introduced.
Healthy lung specialist nurse Paula McCann Finney says that many patients report having had symptoms of COPD for years.
‘A lot of patients open up a bit during the appointment and say they have had breathlessness and sputum production and symptoms of COPD that they associated with smoking rather than an actual illness,’ she says.
‘There’s no need to see a GP or another doctor for a second opinion – it’s all done right there for the patient on the day in a single clinic appointment’
The length of the appointment gives nurses time to have an in-depth conversation with patients and include health lifestyle interventions. ‘They have time with us, the appointments are not rushed and they are involved in decision making. The role is an interesting one because it bridges primary and secondary care. We are working in a practice setting and are directly referring patients found to be at high risk for a CT scan.
‘There’s no need to see a GP or another doctor for a second opinion – it’s all done right there for the patient on the day in a single clinic appointment.’
The healthy lung specialist nurses are now taking their proactive approach to other areas of the city to seek out the thousands with undiagnosed lung disease. ‘The statistics suggests that there are about 6,500 undiagnosed COPD patients in the city, so there is still a lot of work to do,’ adds Ms Fleetwood.
NHS England’s Accelerate, Coordinate, Evaluate programme
Liverpool’s Healthy Lung Programme is part of a major national drive to find approaches that support early diagnosis and prevent people dying prematurely. NHS England is running the Accelerate, Coordinate, Evaluate (ACE) programme, which is a three-year initiative supported by Cancer Research UK and Macmillan Cancer Support.
The 60 projects from the first wave (which completed their evaluation reports by mid-2017) support a shift to early diagnosis of cancer at stages I and II, a decrease in cancer diagnoses via emergency presentations and improvements in overall patient experience.
They are divided into eight areas of work:
- Finding people at high risk of cancer to improve early diagnosis (Liverpool Healthy Lung is part of this strand).
- Improving lung cancer pathway from referral to diagnosis.
- Boosting bowel screening uptake.
- Improvements to vague symptoms pathway.
- Direct referral by optometrists and pharmacists for people with suspected cancer.
- Improving diagnosis of colorectal cancer.
- Better screening among vulnerable groups, including those with learning difficulties and from minority ethnic groups.
- Using IT support tools to support earlier diagnosis.
The five projects in the second wave of the programme pilot a new diagnostic pathway for patients with non-specific but concerning symptoms. Five multidisciplinary diagnostic centres are being tested to see if they can speed up diagnosis times for patients who often bounce between primary and secondary care and are referred to different specialists. Their final evaluation reports are due by the end of 2018.