Respiratory Futures spoke to Liz Fuller and Ann Ward from Newcastle Upon Tyne Hospitals NHS Foundation Trust about setting up Targeted Lung Health Checks (TLHC) and how they are managing the incidental findings the checks may identify.
Newcastle and Gateshead were one of the first areas to establish the expanded TLHC programme, with three programmes now set up in the region. A fourth programme is on the way, which will allow programmes to deliver services across eight Trusts in total. Ann was instrumental in setting up the service infrastructure for the first wave, while Liz is responsible for rolling out the programme across additional areas in the region in conjunction with the Northern Cancer Alliance.
Tell us about Targeted Lung Health Checks and what it means for Respiratory
TLHC are now offered to people between aged 55 and 75 who have ever smoked cigarettes. This initiative has the potential to make a huge impact as it enables clinicians to detect lung cancer at an early stage which will vastly improve survival rates. Because the tests do not focus on the lungs in isolation – they scan everything in the body from the chin down to the waist, the tests enable clinicians to spot other conditions – known as incidental findings. These cover a wide range of conditions, including respiratory illnesses like emphysema and diseases affecting other major organs like the kidneys.
Ann, tell us about the programme you set up in Newcastle and Gateshead
Although there was a national protocol for establishing a TLHC programme, we needed to use this to develop a local delivery protocol. We referenced the national protocol to create a localised Standard Operating Protocol for incidental findings with all the different specialties. This was a lot of work as local solutions differed, even between Newcastle and Gateshead.
We had to create communications for patients taking part in the programme, along with comms for GPs and professionals. It was a huge undertaking because, before we could automate any letters, they all had to be written first.
We used text from the NHS website where possible, as this was already approved and quality assured. It took many hours of work to tailor the letters to patients with conditions in line with local pathways to treatment.
What happened after you created the resources?
We needed an IT solution because the checks involved contacting thousands of patients. The local programme manager helped purchase and develop a bespoke software programme to automate communications and create patient appointments.
Although the front end of the system manages the day-to-day interactions with the GPs and patients really well, there are still some issues around reporting. We are working hard on a solution, as challenges with reporting the activity and outputs of the programme have an impact at local and national levels.
What challenges did you both face in setting up TLHC across the region?
Aside from the reporting, the main challenges have been to tailor the Standard Operating Procedures for the different programmes. For example, with emphysema, our local service programme only refers people with severe emphysema, while other programmes plan to refer any incidences of this disease. Trusts are advised to develop and agree on local SOPs for incidental findings before they begin their programme. This is important from a participant experience perspective for primary care and for secondary care. Many programmes will refer lung cancers to a cancer centre and a thoracic surgery centre for treatment. It is essential to work with these centres in advance to create the capacity to treat the cases in a timely fashion. If not, this risks delays both for participants from Targeted Lung Health Checks and for symptomatic patients arising in the same timeframe.
Tell us about the funding for TLHC
Initially, the funding was only for two years, which made it a hard sell to Trusts when we requested resources for what looked like a short-term programme. Fortunately, we are now seeing funding for the longer term, but we may need to ask Integrated Care Boards to pay for additional resources due to the increased workload associated with screening.
Another funding challenge is that we only receive NHS funding for patients’ services. The Trust pays a nurse whether they see a patient or not, and in Newcastle and Gateshead, the high levels of social deprivation mean frequent Did Not Attends (DNA) in terms of appointments.
The scale of the TLHC programme means there is a risk that some Trusts may outsource lung checks to external providers. External providers may recruit NHS staff to do the work, leading to the danger of an external drain on the system and higher long-term costs to the NHS.
What is the impact of TLHC on respiratory staff?
While this is a fantastic initiative, its sheer scale significantly impacts the respiratory workforce. Lung checks were previously carried out on a much smaller scale. This work is done in addition to all the other work clinicians do against a backdrop of staff shortages.
We also need to have a workstream to develop the reporting of incidental findings to GPs – primary care is also under huge pressure at the moment, and there is a risk that Targeted Lung Health Checks can add to that burden. An increase in THLC requires more radiologists and surgeons to treat people who have been diagnosed. The NHS needs time to recruit and train these staff, and this doesn’t happen overnight.
The need to tailor the programme to each Trust can also be time-consuming. That is why we want to share some of the letters and SOPs through Respiratory Futures, to save other Trusts from “reinventing the wheel”. We are currently working with the British Thoracic Society on how this might be achieved. Sites will be welcome to use our information or modify it as required for local use.
What would you like the future of TLHC to look like?
In the ideal world, TLHC would roll out in a controlled manner with appropriate planning in primary, secondary and tertiary care so that the experience from invitation to treatment of a diagnosed lung cancer participant would be smooth and efficient.
This would require cooperation between NHSE, ICB colleagues, Trusts, private providers and primary care colleagues. Importantly, there would be advance communication before lung cancer cases are referred in significant numbers, and incident lung cancer cases would not be disadvantaged by competing with screening cases for limited capacity in lung cancer services.
For more information about the resources available please email contact@respiratoryfutures.org.uk