Better care for all: improving access to surgery

We want everyone living with lung disease to have access to surgery, if this is the right treatment for them.

At the moment, many people with a lung disease who would benefit from different types of surgery are not given the option. Sometimes it is because lengthy delays in diagnosis and treatment mean patients are no longer well enough for surgery. It can also be because it is not always clear to clinicians what choices of surgery are available and which steps to take.

A lung transplant can give more years of good quality life. But despite advances in surgical procedures and an increase in the number of donor organs, the number of lung transplants every year is still low, in contrast to other types of transplant. 1 in 4 patients waiting for a transplant will either die on the waiting list, or be removed, because they have become too frail.

We want to see all those health care professionals involved in lung transplants share and understand the best practice for assessing and referring patients to ensure that no patients miss out. There should also be regular monitoring of all those who would benefit from a lung transplant.

The same steps should be taken to increase the number of people who benefit from lung volume reduction surgery. This is an operation which blocks off the worst affected areas of the lungs so that the healthier parts can work better.

Some 16,300 people in England could be eligible but only around 100 procedures are performed a year. Referral is not routinely considered for all patients and frequently those who would benefit must fight to be considered for lung volume reduction procedures. We need a national network of specialists to champion lung volume reduction surgery. They’ll be able to identify patients who will benefit.

The NHS has a proven treatment programme called ERAS (Enhanced Recovery after Surgery), which uses exercise and diet to reduce the risk of complications following lung surgery, and reduce the number of days spent in hospital. At the moment, ERAS is used for some operations, but not yet routinely for lung surgery. We want to see ERAS being adopted by all surgery units who operate on patients with lung disease.

Practice example: A treatment option for patients requiring lung cancer surgery

In 2010, the thoracic surgical unit at Bristol Royal Infirmary was one of the first units in Europe to adopt an Enhanced Recovery after Surgery (ERAS) pathway for patients requiring lung cancer surgery. At the time, ERAS guidelines revolved principally around colorectal surgery. The goal was to develop similar care to achieve early recovery for patients undergoing major thoracic surgery.

ERAS requires the entire patient pathway, from referral to discharge, to be broken down into component steps and each step improved using best available evidence. In Bristol, investment in a sophisticated preoperative assessment unit became the cornerstone for the development of the thoracic ERAS pathway.

Around 1,400 patients with lung cancer coming through the Bristol unit have been on an ERAS pathway. Improvements have included “getting fit for surgery”, patient education and smoking cessation support before surgery.  Minimally-invasive surgical techniques are used along with very short-acting anaesthetic agents. Pain relief and nausea control is focussed on reducing side effects and getting people moving again. After surgery, patients have diaries with daily activity milestones and a predicted date of discharge. The results have been impressive with a reduction in complications after surgery and a halving in the length of hospital stay.

Measures of success

An increase in the number of people living with a lung disease receiving an annual review at a transplant centre, as monitored by NHS Trusts.

Data need: NHS Trusts to publish transplant review data on an annual basis.

All people with advanced COPD who may benefit to undergo tests to assess lung volume and all those with significant lung hyperinflation to be referred to a multi-disciplinary team for consideration for lung volume reduction procedures.

All lung surgery units to implement ERAS as part of a perioperative care pathway, to be reported by NHS trusts.