Publish date: 31 July 2023
Targeting lung cancer: How TLHCs are rolling out across Cheshire and Merseyside
by Max Thomasson, Health Inequalities and PMO Lead, Targeted Lung Health Checks
Targeted Lung Health Checks (TLHCs) is a flagship programme by the NHS designed to help detect and diagnose more lung cancers at earlier stages.
At the Cheshire and Merseyside Cancer Alliance we are proud to have been overseeing this scheme for more than two years and are excited by the recent announcement that TLHCs will become the UK’s next national screening programme, joining the breast, bowel, and cervical programmes.
Lung cancer is one of the most common and severe forms of cancer but at stages one and two, where the disease is much more treatable, there are often no or only vague symptoms. This means many people with lung cancer start to have symptoms that prompt them to speak to health professionals only after the cancer is already at a later stage. This often means that the cancer has spread to multiple areas in the lungs and/or around to other areas of the body.
73% of all lung cancers were diagnosed at the later stages of 3 and 4 in England in 2020. In line with NHS England’s Long Term Plan to diagnose three-quarters of cancers at stages 1 or 2, the intervention of the TLHC programme is flipping the lung cancer diagnosis trend, with 77% of the 1,300 lung cancers already detected by TLHC nationally being diagnosed at stages one and two.
What is the programme?
Commissioned by NHS England, and following recommendation by Nation Screening Committee, the TLHC programme recently received the ministerial decision to begin transitioning into a full, national screening programme.
With the national ambition to fully roll out across England before the end of the decade, the scheme is a ground-breaking example of early detection and prevention aiming to improve the long-term lung cancer outcomes in England.
Everyone aged between 55 and 74 who are either current or former smokers will be invited through their GP surgery to a ‘Lung Health Check’ appointment with a nurse.
Over the phone, these TLHC nurses generate a participant’s lung-risk-score which is calculated by asking questions on health, lifestyle, and family medical history.
Following this check-up and depending on the assessment of our TLHC nurses, some participants are booked on to have a low dose CT scan, held in a mobile scanning van that will be parked in accessible parts of the local community.
The scanning appointment takes around half an hour, with the CT scan itself taking only a few minutes and is un-invasive and pain free. A Low-Dose CT scan machine is often nicknamed a polo-scanner as only a small portion of your body passes through the loop of the machine. The scan takes a detailed picture of your torso which can be analysed by radiologists.
An integral part of the programme’s commitment to reducing smoking means that all TLHC participants who are current smokers are offered advice and referral to local services on how to help quit. 33% of people invited to a TLHC who are offered referral to smoking cessation services have taken up the offer as of June 2023.
Additionally, spirometry, a simple test to help diagnose other chest conditions, is also fully integrated into the TLHC service and often performed on the van alongside the scan.
For the majority of TLHC participants, taking part in the programme will not lead to suspected lung cancer being found or a diagnosis of any other condition.
However, for those who do have a suspected cancer identified through the scan, they will be quickly referred into the local suspected cancer pathway, ensuring an investigation and results can be fed back within just a few weeks.
In Cheshire and Merseyside, we have seen first-hand that many people who have had a new lung cancer diagnosis through the TLHC programme had no symptoms or suspicions beforehand.
TLHCs act as a proactive intervention to diagnose cancers people do not know they have. Taking part in this programme and having a lung cancer diagnosis through a TLHC means curative treatment or more effective quality of life improving treatment is possible when it might have otherwise not be.
What has happened in Cheshire and Merseyside?
The Cheshire and Merseyside Cancer Alliance TLHC programme integrates support from a wide range of regional services. Following on from its predecessor the ‘Liverpool Health Lung Programme’, TLHCs began roll out to Liverpool, Halton and Knowsley from July 2021. Our most recent phase, which includes south Sefton and St Helens, joined in December 2022.
It is CMCA’s ambition to roll out the programme to 100% of Cheshire and Merseyside ahead of recent national announcement’s aim to offer TLHC to all eligible people by mid-2030. Planning is ongoing for the next round of expansion and onboarding of north Sefton, Warrington and Wirral.
Liverpool Heart and Chest Hospital (LHCH) is the service provider of Cheshire and Merseyside’s TLHC programme. With an expert team devoted to caring for and facilitating our local participants throughout the programme, LHCH provides a service which is looked to by other national TLHC programmes and has a fantastic reputation locally.
LHCH is also always looking to further improve the programme and suggests new ways to supplement and work alongside TLHCs to improve health outcomes in the region. There are even current discussions over a sister project which would use some data from the TLHC programme and work adjacently on separate investigations and care.
Partners and colleagues in primary care are the foundation of the TLHC programme. They facilitate the local population’s access to TLHCs and provide invaluable support and guidance.
Teams in NHS localities give support to tailor the programme’s rollout to each area. This helps the programme to be as efficient as possible and provides learning that can be shared both in Cheshire and Merseyside and nationally. The Alliance’s Primary Care Engagement Leads also provide invaluable support to the mobilisation and roll out of TLHC locally.
The Cancer Alliance’s Health Inequalities and Patient Experience team has been finding ways to promote, integrate and improve the TLHC service to make it as effective and accessible as possible. Engagement through public events and through the Alliance’s Community Engagement project also hold exciting opportunities to continue spreading the word about the TLHC project.
What are the challenges?
It is understood that current smokers are more likely to decline a TLHC invitation when compared to ex-smokers. In most cases, being a current smoker will make a participant’s lung cancer risk score exceed that of participants who are former smokers. Trying to improve confidence and trust in the TLHC programme is at the forefront of activity both locally and nationally.
Excellent support from the Roy Castle Lung Cancer Foundation, LHCH, Cancer Alliance and local NHS place teams is key to finding new and improved ways to increase promotion and boost uptake of the TLHC programme.
To support engagement in the programme and help improve awareness and understanding the Roy Castle Lung Cancer Foundation run regular ‘engagement days’. Notable for the use of a large pair of inflatable lungs, these sessions grab the attention of people in the area and use their excellent local knowledge to listen to people and find ways to support their questions.
These sessions have a good reputation in allowing the public to chat to representatives and try to work through any worries associated with accessing the programme.
Additionally, behavioural science research is providing valuable insights that could in the future be integrated into the programmes outreach in hopes of better targeting harder to reach populations.
Paired with our pursuit of the programme’s rollout to 100% of Cheshire and Merseyside, we want to explore strategies for long-term re-engagement and proactive measures aimed at re-assuring and facilitating those who have previously turned down a TLHC invitation.
We recognise that balancing the commitments of expanding to new area of the sub-region whilst providing a continuing service to onboarded areas will need to stay at the forefront of focus to make TLHCs a programme that Cheshire and Merseyside really values.
What is happening now?
On average, more than 50 people a day in the sub-region attend their CT scan appointments in the TLHC mobile scanning vans. Across Merseyside right now there are members of the public receiving guidance from stop smoking services, having spirometry assessments, lung health checks and CT scans.
As part of the TLHC service, follow-up surveillance scans are being offered to all participants who went for a CT scan two years ago. The first of these surveillance scans have just begun as one of the mobile scanning vans returns to Liverpool, and then to Halton and Knowsley.
Overall, the Cheshire and Merseyside TLHC programme has identified over 200 lung cancers as of June 2023. Of those, nearly 80% of patients have been identified at stages 1 or 2, and more than 65% of patients have gone on to receive curative treatment.
Satisfaction in the TLHC programme in Cheshire and Merseyside with people who have participated in it is high. A recent survey has shown excellent results, with 93% of 2,700 people surveyed between February and May 2023 being satisfied with their experience (see diagram below).
Ambitions for the future
At a national level, the TLHC programme demonstrates an impressive commitment to pioneering earlier lung cancer diagnosis and at the local level is the ambition of the Cancer Alliance to develop our ownership of the programme to make it as innovative, effective and accessible a service as possible.
We want to keep on improving the way that TLHCs discover lung cancers at early and more treatable stages, and better integrate them with other projects that the Cancer Alliance is running.
Exploration into new partners, staffing models, rollout strategies and targeted campaigns will also help push the programme to be well tailored to our region and population.
We are planning for the speedy onboarding of the rest of Cheshire and Merseyside into the programme and are excited to fully transition into England’s next national screening service.
If you would like more information on the programme, please visit Liverpool Heart and Chest Hospital’s website: Lung Health Check | Liverpool Heart and Chest Hospital (lhch.nhs.uk)
For any queries regarding the Cheshire and Merseyside Cancer Alliance’s involvement with Targeted Lung Health Checks, please email ccf-tr.admin.cmca@nhs.net, with subject ‘TLHC’.
For general information on lung cancer, see:
Cancer incidence by stage – NDRS (digital.nhs.uk)
Lung cancer statistics | Cancer Research UK
To watch a video of press coverage of the TLHC programme in St Helens, click here.