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Success for community nursing project identifying lung diseases at earlier stages

A community nurse-led project in Liverpool is recording great success in picking up life-threatening lung diseases at an earlier and more treatable stage.

A community nurse-led project in Liverpool is recording great success in picking up life-threatening lung diseases at an earlier and more treatable stage.


Deborah Fleetwood and Paula McCann-Finney. Picture: John Houlihan

The programme, which is run by specialist respiratory nurses in GP centres, are finding undiagnosed cases of lung cancer and chronic obstructive pulmonary disease (COPD).

The Liverpool Healthy Lung programme was developed by 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 deprivation areas launch

The programme was launched in April 2016 in Everton, Picton and Speke and Norris Green – areas which are united by high levels of deprivation, chronic disease and smoking.

Five specialist respiratory nurses (three whole-time equivalent) run clinics in GP practices carrying out in depth lung assessments on patients at high-risk of developing lung cancer. They refer to 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 to attend a Healthy Lung Clinic, and more than 3,200 have either already attended the lung clinic or booked an appointment to attend a clinic soon.

The Liverpool Healthy Lung programme

The first phase involved public engagement events throughout the city, starting in areas with the highest lung cancer incidence, promoting positive messages on lung health, and addressing attitudes of fear and fatalism around lung cancer. These ‘Breathe freely’ events included posters about the lung health clinics. More than 2,100 people attended, and 800 completed spirometry tests. Almost one in five of these tests were abnormal, which triggered a referral to primary care.

The second and ongoing phase involved inviting people aged between 58 and 70 who have ever smoked and/or have COPD, from GP practices in the targeted areas to a nurse-led healthy lung check. If patients do not attend, they get a second letter, and are then followed up by phone.

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 with a risk of more than 5% of developing lung cancer over the next five years are invited for a CT scan. Those with a less than 5% risk are referred to a health trainer.

 

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.

Age range extension

Following the success of its first year, it is extending the age range it covers and is being rolled out to other areas of the city.

An independent study of almost 1,600 patient records seen by the nurses between April 2016 and January 2017 found that 75% of the lung cancers were diagnosed at an early stage, which brings a substantial improvement in five-year survival rates. The researchers from the University of Liverpool and Queen Mary University of London also found screening for lung disease was a cost-effective approach in the preliminary evaluation published earlier this year.

'Significant importance'

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 particularly 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.’

Research results

The research found there was a 40% uptake of appointments from those targeted. One third of attendees reported asbestos exposure and a similar number a family history of lung cancer. They had smoked for an average of 60 years. Of those who received spirometry, 41%, or almost 400, had an abnormal reading. Research suggests that 63% of them would be expected to be diagnosed with COPD, so almost 250 people are likely to have the condition, and to receive help at an earlier date.

Of the 1,600 patients in the study, almost 660 patients were recommended to have a CT scan, and 90% of these underwent the test. Out of these, 10% required follow-up with another scan in three or 12 months time due to pulmonary nodules, and 8 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 that the healthy lung nurses bring a wealth of experience to the appointments. ‘The nurses bring many skills including health promotion, referring to smoking cessation and pulmonary rehabilitation. They are able to advise patients about their inhalers if required, often checking technique if time allows.

'We try to arrange people to come to clinics in their own surgery as much as possible so they can be seen locally rather than having to travel'

Deborah Fleetwood

'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.’

Deborah Fleetwood, a healthy lung specialist nurse, says that the programme allows the team to provide accessible holistic care to the people they see. ‘We try to arrange people to come to clinics in their own surgery as much as possible so they can be seen locally rather than having to travel.

‘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 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.

Consultant and team work

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.

Ms Johns says: ‘GPs are available in case there are any issues that need resolving, with regards to their patients. This has been a good way to bridge the primary and secondary care interface promoting mutual respect for each other’s roles.’

The service has high levels of patient satisfaction from surveys, and 96% of participants reported that if a friend asked them if they should attend, they would encourage or strongly encourage the friend to do so. Although there were also reports of anxiety, particularly about being referred for a scan, and waiting for the results.

So far, a total of 19 lung cancers 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 picking up 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.


Deborah Fleetwood, Paula McCann-Finney and manager Linda Johns with a programme pamphlet
Picture: John Houlihan

Paula McCann Finney, a healthy lung specialist nurse, says that many patients say they have 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 lots of symptoms of COPD that they associated with smoking rather than an actual illness,’ she says.

Work to do

The length of the appointment gives nurses time to have an indepth conversation with patients and include health lifestyle interventions. ‘They have time with us, the appointments are not rushed and they and are involved a lot in the decision making. The role is a really interesting one because it bridges primary and secondary care.

'We are working in a practice setting and then 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 others areas of the city to seek out the thousands with undiagnosed lung disease. ‘The statistics suggests that there are approximately 6,500 undiagnosed COPD patients in the city, so there is still work to do,’ Ms Fleetwood says.

NHS England’s Accelerate, Coordinate, Evaluate programme

The Liverpool Healthy Lung programme is part of a major drive to find approaches that support early diagnosis and prevent people dying prematurely.

NHS England’s Accelerate, Coordinate, Evaluate programme is a three-year initiative, supported by Cancer Research UK and Macmillan Cancer Support.

The 60 projects from the first wave are aiming to 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 including driving up bowel screening uptake, improvements to vague symptoms pathway, and improving diagnosis of colorectal cancer. Improving screening among vulnerable groups, including those with learning difficulties and from minority ethnic groups, and direct referral by optometrists and pharmacists for people with suspected cancer.

The Liverpool Healthy Lung programme is part of the strand looking at improving early diagnosis among people at high risk of lung cancer.

The second wave projects 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, being referred to different specialists.

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