Doncaster CCG saw an innovative opportunity for pharmacists to intervene in this prevalent disease through direct referral to hospital specialists, says Doncaster LPC secretary Nick Hunter
Around three or four years ago, I was in a meeting in Doncaster with the clinical commissioning group (CCG). During a discussion about the problem of late diagnosis of cancers, the GP board member said: ‘Why can’t pharmacists make direct referrals?’
The meeting pondered this for a while and no one could come up with an answer. This was the lightbulb moment that triggered much further work that eventually led to the Doncaster Lung Health Service, which involved community pharmacists making direct referrals for chest X-rays.
Lung cancer is one of the three most common cancer killers, with 241 cases in Doncaster in 2014/15. The area has more than 15,000 more smokers than similar-sized areas, and incidence of lung cancer in women is 68% higher than the national average.
We set out with the CCG and a range of partners on a 12-month pilot to evaluate whether direct access to chest X-ray by community pharmacists increases early detection of symptomatic lung cancer presented as a non-emergency in the Doncaster area.
What we did
We identified a service outline: to find patients who presented in pharmacies with red-flag signs and refer them to the hospital radiology team in the same way a GP would. Patients had to be smokers or ex-smokers aged over 40, and have one of the following symptoms not explained by obvious causes:
- Cough for three weeks or more
- Shortness of breath
- Chest pain
- Weight loss
- Appetite loss
- Coughing up blood (haemoptysis)
- Persistent or recurrent chest infections
Counter staff were trained in identifying the red flag symptoms and provided with a prompt card they could use to make initial referrals to the community pharmacist. The pharmacist would then explain the next part of the process to the patient, including checking if they were safe for X-ray. If referral for X-ray was appropriate, the pharmacist would complete a referral form and mark it ‘urgent’. The report was automatically sent to the patient’s GP practice and a copy also went to the pharmacist. Any suspicious chest X-ray results were to be picked up by the chest physicians. Pharmacists and their teams were trained in the referral process by the hospital radiology team and in evening workshops on lung cancer led by local clinicians and patients.
A challenge we encountered was the small size of the pilot, which meant pharmacies could only refer patients from certain practices. This contributed to the low number of referrals and made it difficult to keep the initiative alive.
Over 30 pharmacists from just nine pharmacies received the additional training and made 10 referrals and countless other healthy lifestyle interventions. Activity data was captured using PharmOutcomes and even with low referral numbers, we observed a good spread across all age ranges over 40. NHS staff said the pilot showed community pharmacy can take on a diagnostic role and Doncaster CCG said the pilot will help lung cancer be spotted earlier in patients who wouldn’t usually see their GP.
The stop-smoking service was by far the best way to engage patients in the lung cancer pilot. This was followed by New Medicines Service and medicines use reviews and presentations of cough. Additional interventions pharmacists made were lifestyle advice or smoking cessation support. A few poor inhaler techniques were identified, which were dealt with through the CCG inhaler technique service.
The pilot hasn’t been continued because of a lack of personnel at the CCG rather than any failing in the service. However, recommendations for the future would be to include all practices and pharmacies
to enable comprehensive marketing. In addition, the service should include other cancers such as skin.
Pharmacists who are interested in doing something similar should speak to their local commissioners – in England, the CCG and the public health team. They should also speak with their LPC to see if anything is already being discussed and be aware of the Sustainability and Transformation and Place Plan for the area as these will highlight priorities for the next five years.