Identifying lung disease: getting people to the right person at the right time
Everyone needs to know what steps to take when there might be a chance someone has lung disease.
We think there should be time-limited targets for diagnosing all aggressive lung diseases in line with the ones already in place for cancer. GPs, community pharmacists, nurses and other health care professionals need a clear set of steps to take when a patient who might have lung disease sees them.
Practice example: Pharmacies helping to identify people at risk of COPD
A pilot project involving 21 community pharmacies in the Wirral area found that there are significant benefits to patients, as well as cost savings, through case-finding by screening people at risk of developing COPD. The pharmacies provided a case-finding service for six months, using a symptom questionnaire and spirometry test of lung function.
A total of 238 people identified as either smokers or regular purchasers of cough medicines were screened. More than half (56.7%) were identified at risk of COPD. People were given general lifestyle advice, including advice about smoking cessation services. According to an evaluation, if the Wirral findings were replicated nationally, case-finding would identify more than 205,000 people at risk of COPD and achieve savings of around £215 million.
Personal perspective: improved communications between health care professionals needed
Steve Holmes is a GP in Shepton Mallet, Somerset, who has a strong commitment to lung health. He is respiratory clinical lead for Somerset CCG and chairs the Somerset Respiratory Network.
He says that one of the main obstacles to good care of patients with lung disease is the delay caused by poor communication between GPs and hospitals. This is rooted in the NHS’s continued dependence on outdated paper-based systems and the failure to use the latest technology. This means that Steve’s patients must often wait several weeks for vital information about their health after seeing a consultant in hospital. Steve cannot access records in hospital on behalf of his patients, nor can a hospital consultant see patient records held at the GP surgery. This has a material impact on decisions that must be taken affecting care, particularly when a patient’s condition is deteriorating.
Steve says: “Quite rightly, patients find it hard to understand that the clinicians responsible for the care don’t all have the same information at their disposal at the same time. It doesn’t happen in other walks of life.
“We’ve been talking about a paperless NHS since the mid-1990s and we are still a long way from that. We are using technology from two decades ago and it is affecting care.”
GP practices should have access to high quality tests that help with diagnosis and be able to refer patients with suspected lung disease to a special breathlessness team or to a specialist for diagnosis when they need to be.
Practice example: specialist diagnostic clinics
University Hospitals Leicester NHS Trust has taken part in a pilot programme to improve the speed and accuracy of diagnosis in patients with symptoms of breathlessness in Leicestershire and Rutland. The approach involved a specialist-led diagnostic clinic for both cardiac and respiratory causes of breathlessness, providing a one-stop diagnostic shop in a secondary care setting for patients referred from primary care. The clinic achieved a marked improvement in earlier diagnosis compared to historical data, and access to physiotherapy was speeded up by having a physiotherapist on site.
The trust surveyed 10 patients who attended the breathlessness clinic and reported that all 10 respondents rated the care as excellent and indicated that they were treated with respect and dignity. Patients had more confidence in their diagnosis and treatment because they could see they were being treated by a team working together. They were better able to understand and accept their diagnosis because they receive consistent messages from different professionals on the same day. They received care from clinicians with a keen interest in tackling breathlessness as a symptom.
What is spirometry testing?
Spirometry is used to tell if breathing is obstructed by narrowed or inflamed airways. The results are useful in diagnosing lung conditions such as chronic obstructive pulmonary disease (COPD) and asthma. It can also be used to grade the severity of conditions.
Spirometry measures the total amount of air you can breathe out from your lungs and how fast you can blow it out. It can help to assess if inhaled medication can open up your airways by reversibility testing. This is when your health care professional asks you to use your inhaler or other medication, wait some minutes, and then repeat the test. A spirometry test usually takes less than 10 minutes but will last about 30 minutes if it includes reversibility testing.
There should be guidelines to help diagnose lung diseases early. This should help health care professionals know the different options available to make sure the right diagnoses are offered to patients as quickly as possible. By using the guidelines, patients with suspected lung disease will get the treatment and support they need.
Here’s what we think that the guidelines could look like:
Other conditions, like cancer, have clear guidelines on how long you should wait for diagnosis and treatment. We need that for lung disease.
To make sure people are in the right place at the right time, we need to help community pharmacists refer patients to their GP practice. People who buy a lot of over-the-counter products like cough medicines or nasal sprays might have an undiagnosed lung disease. If pharmacists could look out for these warning signs and refer them to GP practices, we can help more people get diagnosed.
Pharmacists also have opportunities to give people advice on wider lung health. They can do this when people come to them for help to quit smoking or buy nicotine replacement products over the counter, or have a flu vaccination. Pharmacists are also in a good position to see if patients are taking the right medication and know how to use it.
Personal perspective: a delay in diagnosis
Almost a decade after first reporting the symptoms to her GP, Liz Ames, from London, was diagnosed with bronchiectasis, a disease in which there is permanent enlargement of parts of the airways of the lung.
She challenged his diagnosis and eventually was referred to a specialist at her local hospital, who agreed with her GP without carrying out a CT scan, and did not offer additional treatment, such as physiotherapy or chest clearance techniques to alleviate her coughing.
It was not until Liz insisted on being referred to the Royal Brompton Hospital that she was diagnosed with bronchiectasis and chronic pseudomonas infection.
Liz, now 41, says: “If I had received help earlier, especially from respiratory physios, I am sure some of the damage and perhaps also the pseudomonas infections could have been avoided.”
Measure of success:
93% of patients to be referred to a specialist if appropriate within two weeks and 96% to start treatment within 31 days of a diagnosis and with a package of care agreed, in line with NHS England cancer targets.
85% of patients to begin their first treatment within 62 days of an urgent GP referral, in line with NHS England cancer targets.
Data need: NHS England to establish baseline data for speed of respiratory diagnosis and referral within one year.
A formal system for community pharmacists to refer people with suspected lung disease to general practice to be developed and implemented across England.