Professional Documents
Culture Documents
April 2010
Acknowledgements
Billie Moores
Consultant in Public Health
NHS Bolton
Kathy Sandler
Cancer and Palliative Care
Royal Bolton Hospital
David Holt
Head of Public Health Intelligence
NHS Bolton
2
aggressive and spreads beyond the lungs
Introduction very early on in the disease3.
1
Ferlay, J., Autier, P., Boniol, M., Heanue, M., Colombet,
M. and P. Boyle (2007) „Estimates of the cancer incidence
and mortality in Europe in 2006‟, Annals of Oncology,
18(3):581-92.
2 3
Since 1997. Cancer Research UK (2010) www.cancerresearchuk.org
Key inequalities
Mortality
Incidence/prevalence
Survival
Pathway
Smoking
Diagnosis
Treatment
Mortality
Incidence
Survival
Smoking
General
On the horizon
Treatment
Pathway
Diagnostic tests
Lung cancer screening
In September 2009 the Prime Minister
announced that GPs in England will have
“Screening programmes are used
speedier access to diagnostic tests for
to detect asymptomatic cancers
less clear cut cases of cancer. The
and pre-cancerous changes. For a
scheme will initially be targeted at lung,
cancer screening programme to be
colorectal, and ovarian cancers but is
successful it must be able to
expected to be expanded to all cancers
identify some cancers at a point in
within the next five years.
their natural history when cure is
still an option. This is a complex
problem requiring an
Radiotherapy
understanding of the natural
history of the disease, a diagnostic
5
Greater Manchester Public Health Practice Unit (2010)
The Greater Manchester and Cheshire Cancer Network
Prevention, Early Detection, and Inequalities Strategy, 6
Greater Manchester Public Health Practice Unit, Salford. Cancer Research UK (2010) www.cancerresearchuk.org
Demand on radiotherapy services is increases in data and
expected to increase over the next ten 7
publications ;
years. There is little local primary care
data concerning lung cancer at the
Smoking level of the primary care audits
given above.
Illegal tobacco
Problems to overcome
7
Adapted from North West Cancer Intelligence Service
(2010) www.nwph.net
Epidemiological profile
Mortality
Incidence and prevalence
Summary: Cancer Commissioning
Toolkit
Inequalities in cancer
Targets
Vital Signs
Bolton Vision Partnership (LSP)
Strategic Plan
Mortality monitoring rates
Waiting times
Smoking target
Prevention
Curative
Mortality in hospital
End of life care
National Lung Cancer Audit: Points
of focus for the future
Programme budgeting
Geodemographic segmentation
mortality rate in Bolton‟s male population
Epidemiological profile compared to the national average. This is
portrayed on the below charts where
Bolton is shown in a similar position for
men as for persons overall, but lies within
Mortality the deviation limits for female mortality.
For context, the Greater Manchester and Furthermore, Bolton is slightly above
Cheshire Cancer Network has a higher average for its statistical peer group for
mortality rate than England. Of the excess male mortality and below this average for
cancer deaths in the Network 69% are female mortality. Comapred to the peer
excess deaths from lung cancer8. group, Dudley PCT demonstrates a very
low cancer mortality rate.
Bolton in comparison
8
Greater Manchester Public Health Practice Unit (2010)
The Greater Manchester and Cheshire Cancer Network
Prevention, Early Detection, and Inequalities Strategy,
Greater Manchester Public Health Practice Unit, Salford.
Table a. Lung cancer SMR mortality, all ages
2006/08 Males Females
OBS SMR 95% Confidence OBS SMR 95% Confidence
Lower Upper Lower Upper
North West 7632 119 116.8 122.2 6330 130 126.9 133.3
Heywood, Middleton, & Rochdale 220 127 110.6 144.8 191 144 124.5 166.1
Tameside & Glossop 282 130 115.4 146.3 207 125 108.6 143.3
Oldham 242 133 116.8 150.9 212 150 130.7 171.8
Coventry 273 104 91.9 117.0 198 101 87.3 115.9
Walsall 291 118 105.1 132.7 185 101 86.7 116.2
Ashton, Leigh, & Wigan 330 120 107.6 133.9 271 132 116.5 148.4
Bury 195 121 104.4 138.9 174 140 120.2 162.8
Dudley 305 99 87.9 110.3 181 78 67.4 90.8
Kirklees 373 109 98.3 120.7 326 125 111.4 138.9
Bradford & Airedale 446 115 104.7 126.3 403 133 120.4 146.7
Salford 291 153 136.1 171.8 292 201 178.4 225.1
Halton & St. Helens 318 119 106.7 133.4 280 139 123.0 156.1
Wakefield 390 130 117.8 144.1 315 139 124.4 155.6
Rotherham 316 132 118.2 147.8 223 125 108.8 142.1
Sandwell 335 130 116.6 144.9 221 112 97.8 127.8
Table b. Lung cancer SMR mortality, premature (<75 years)
2006/08 Males Females
OBS SMR 95% Confidence OBS SMR 95% Confidence
Lower Upper Lower Upper
North West 4232 120 116.3 123.6 3317 133 128.6 137.7
Heywood, Middleton, & Rochdale 120 124 102.6 148.0 107 155 127.2 187.6
Tameside & Glossop 168 136 116.5 158.5 102 118 95.8 142.7
Oldham 139 133 111.7 156.9 117 157 130.2 188.7
Coventry 150 111 94.1 130.4 109 113 92.8 136.3
Walsall 155 115 97.7 134.7 100 106 86.3 128.9
Ashton, Leigh, & Wigan 175 104 89.6 121.1 151 132 111.8 154.8
Bury 110 121 99.2 145.5 89 136 108.8 166.8
Dudley 158 92 78.2 107.5 84 71 56.4 87.5
Kirklees 212 111 96.6 127.0 168 125 106.6 145.1
Bradford & Airedale 247 117 102.8 132.4 212 140 121.7 160.0
Salford 160 153 130.0 178.4 149 207 175.5 243.6
Halton & St. Helens 190 122 105.0 140.3 157 142 120.4 165.6
Wakefield 211 125 109.0 143.4 165 140 119.2 162.8
Rotherham 195 144 124.5 165.7 132 139 116.2 164.7
Sandwell 191 139 119.8 159.9 106 109 88.9 131.3
The difference in mortality between Bolton deaths under the age of 75 compared to
and England is more apparent when we England vastly influences the SMR and
consider premature (<75 years) deaths. should be seen as a major issue to tackle.
In table b. Bolton is shown to be
considerably greater than the national Another important factor in evaluating lung
average; 35% higher for male mortality, cancer mortality in Bolton is how this has
and 42% higher for female mortality. The changed respective to its statistical peers.
female figure in particular is of concern. As shown on the below chart, Bolton has
Following Salford (207) as an outlier, only achieved a very small decrease in the
Oldham (157), and Heywood, Middleton, lung cancer mortality rate since 1995/97
and Rochdale (155) it is the fourth highest compared to its peers. Excluding
female rate for the statistical peer group. Tameside and Glossop, for which no data
Again, Dudley PCT has very low lung is available prior to 2002, Bolton has
cancer mortality. achieved the lowest percentage decrease
over this period. This is not a result of
Nationally, 52.1% of all lung cancer deaths Bolton have a lower directly standardised
over the period 2006/08 were premature; rate compared to its peers, as Bolton is
this figure increases to 54.1% for the almost exactly average for the group.
North West. The average for the above Dudley had the lowest rate in 1995/97 and
statistical peer group is 54.7%. For retains this position in 2006/08, and yet
Bolton, this figure is 60.7% and, along with has still made the third greatest
Rotherham (60.7%), is the highest for the percentage reduction.
entire peer group. The proportion of
For percentage change within the peer the funnel plots previously, when
group there is a clear divide between male standardised to the national average
and female mortality. Every PCT shows Bolton is within the deviation limits for this
decreases in male mortality since 1995/97 indicator; however, the local increases
and again Bolton is second from bottom in seen in the female rate since 1995/97 are
the magnitude of the change. However, a important, and if this continues, and the
large proportion of the peer group show male rate continues to fall at a slower rate
increases in female mortality over this than statistically similar areas, then it may
period, Bolton showing the third highest prove vital in forcing Bolton PCT beyond
(the second if we exclude Tameside and the deviation limits for female mortality,
Glossop). and pose a greater influence on the local
lung cancer mortality rate overall.
The reducing male rate remains higher
than the female rate, and as depicted on
Trends all three areas is the decline evident in the
higher male trend and the lack of change
The first chart below shows the lung in the female trend. The male rate has
cancer mortality trend for Bolton, the North fallen for all three areas and this is widely
West, and England. The figures are acknowledged to be a result of the falling
directly standardised rates for the period smoking prevalence, which has been
1993-2008. particularly noticeable in men in the UK9.
The Bolton trend lines for both male and The same pattern is largely carried over
female are more erratic than those into premature mortality (<75 years).
representing England and the North West
because of the relatively fewer numbers
involved in the calculation. Taking this
into account, Bolton has largely been
between the lower national rate and higher
regional rate for both sexes for all age
lung cancer mortality. Most noticeable for 9
Cancer Research UK (2010) www.cancerresearchuk.org
Cancer Research UK highlights the female rates, the ratio is now 4:3” (Source:
significance of the reducing gap between Cancer Research UK, 2010, www.cancerresearchuk.org)
the falling male lung cancer mortality rate
and the static/increasing female rate: Age is another important factor for
assessing lung cancer trends. Lung
“In the 1950s the male/female ratio for cancer is rarely diagnosed in those less
lung cancer cases was 6:1 but with than 40 years old, with the majority of
decreasing male rates and increasing cases in the UK affecting people over the
age of 60. The plot below shows the
number of deaths in Bolton between 2002 The average age of death from lung
and 2008 from malignant neoplasm of cancer in Bolton varies by almost two
trachea, bronchus, and lung (ICD-10 code years depending on demography. Table
C33-C34) by age. c. shows the mean age of death from lung
cancer for all deaths recorded between
We know that more men die from these 2002 and 2008 by deprivation quintile.
conditions than women, but the below Over the total period the mean age of
chart demonstrates there to be little death from lung cancer is shown to
difference between the age at which the increase from 71 years in the most
greater proportion of deaths occur for deprived quintile to 73 years in the least
each sex. This is an important indicator deprived.
given the high proportion of premature
deaths in Bolton from lung cancer.
Survival
10
North West Cancer Intelligence Service (2010)
www.nwph.net
11
The Information Centre (2006) National Lung Cancer
Audit: Report for the audit period 2005, The IC, London.
Overall, the Greater Manchester and estimates reveal that if non-small cell lung
Cheshire Network has lower five year cancer is detected at an operable stage,
survival rates than England but one year then five year survival rates for stage IA
survival rates tend to be similar to other patients may increase to 54-80% and
parts of the country. This pattern indicates survival of stage IB patients may reach 38-
that a greater proportion of cancer patients 65%13.
present with the disease when it is at an
incurable stage, but that the treatment of In addition to those diagnosed early,
cancer is as effective in the Network as it inequalities in survival also subsist as a
is in the rest of the country12. result of socioeconomic deprivation. A
study undertaken by Coleman et al in
As with the majority of cancer types, those 2001 found that between 1986 and 1990
diagnosed at a younger age have higher an estimated 1,200 deaths from lung
survival rates than those diagnosed in cancer could have been avoided if all
older age groups. Age is often related to socioeconomic groups had the same
the stage of the disease when diagnosed. survival rate as the most affluent group14.
National data shows that those diagnosed
with the early stage of the disease have a NCIS have also demonstrated15 that at
higher survival rate than those suffering national level, age-standardised relative
the metastatic stage of the disease (the survival for the Asian ethnic group is
process in which cancer cells break away significantly higher than the White
from the primary tumour and spread to population at both one and three years.
other areas of the body and form Variation here is also influenced by gender
secondary tumours). This reinforces the and age. For all male age groups the
importance of early diagnosis and
13
treatment. The potential early diagnosis Scottish Intercollegiate Guidelines Network (2005)
offers for survival rates for lung cancer has Management of patients with lung cancer, SIGN,
Edinburgh.
been quantified by SIGN; SIGNs 14
Coleman, M. et al (2001) Trends in socioeconomic
inequalities in cancer survival in England and Wales,
12 Cancer, 91:208-16.
Greater Manchester Public Health Practice Unit (2010)
15
The Greater Manchester and Cheshire Cancer Network National Cancer Intelligence Network (2009) Cancer
Prevention, Early Detection, and Inequalities Strategy, Incidence and Survival By Major Ethnic Group, NCIS,
Greater Manchester Public Health Practice Unit, Salford. London.
Asian group has a higher relative survival
than the White population, while there is
no significant difference between the
White and Black population groups. The
Asian group has significantly higher
relative survival for those diagnosed aged
15-64 than the White and Black
populations at both one and three years.
However, for females diagnosed aged 65-
99 survival is higher at one year, but not at
three years.
16
National Awareness and Early Diagnosis Team (2010)
www.ncin.org.uk
the x-axis show that Bolton is higher than
Incidence and prevalence of lung the England rate. For lung cancer the
cancer Bolton incidence rate in 2004/06 was
17.4% higher than the equivalent rate for
England as a whole. Furthermore, of the
This section will forward an examination of major cancers lung cancer demonstrates
lung cancer incidence and prevalence in the greatest percentage difference from
Bolton with reference to national and local England.
data sources.
The percentage gap in lung cancer
Incidence incidence between Bolton and England
has only been consistently greater than
Unless treatment becomes more effective 10% since the mid-1990s, with the latest
an increase in incidence leads to an figure (17.3%) being one of the highest
increase in mortality. when compared to the trend. Prior to this
the two rates were very high but very
The chart below shows the percentage similar; the England rate has changed
difference in directly standardised quicker than the Bolton rate and this is
incidence rate between Bolton and why we have such a wide gap today.
England for major cancers. Bar‟s above
Incidence records new cases of lung rate is far higher than the female for all
cancer and so is more representative of areas; however, the male rate shows a
the disease in the population. As it downward trend, while the female
records the rate of new cases in the incidence rate, like the mortality rate seen
population, incidence should be used to earlier, is static.
measure the effectiveness of prevention
strategies.
17
Quinn, M., Cooper, N. and S. Rowan (2005) Cancer
Atlas of the United Kingdom and Ireland 1991-2000, Office
for National Statistics, London.
18
Pearce J. and P. Boyle (2005) „Is the urban excess in
lung cancer in Scotland explained by patterns of
smoking?‟, Social Science and Medicine, 60(12):2833-43.
The graph below shows lung cancer pattern. The incidence of lung cancer is
incidence in Bolton over the period 2002 almost exclusively represented by those
to 2006 by age group. Firstly, male aged over 50 years, and increases rapidly
incidence is consistently a lot higher than from there. The age groups illustrated are
female; secondly, male incidence those to target for symptom education and
continues to increase and peaks at the early diagnosis efforts, however, the
eldest age group (85+), while incidence for greatest impact upon future incidence
women declines after age group 75-79. rates is smoking prevention for younger
For both points Bolton follows the national age groups.
Lung cancer is one of the most 1985. Figures are directly standardised
preventable types of cancer. As smoking rates and are presented as three year
levels decrease so will lung cancer rolling averages. The trend has
incidence. For this reason, as mentioned, historically been resistant to significant
incidence is the measure of how decreases, but whilst there are no
successful prevention strategies are. In consecutive significant changes, and we
particular, incidence in those aged under should not expect any, there have been
75 years should be monitored; the small significant changes between
monitoring of incidence above this age is different points in time. However, the
more complex as everyone must die of latest official incidence figure is for
something and cancer incidence increases 2004/06 and this makes monitoring
significantly with old age19. The Greater difficult. Whilst accepting that prevention
Manchester and Cheshire Cancer methods at present cannot be expected to
Network‟s Prevention, Early Detection, result in observable changes until years
and Inequalities strategy states, with and decades into the future, we should
respect to all cancers: work towards processes enabling timelier
monitoring of local lung cancer incidence.
“The aim of the strategy should be
to preventing as much cancer as As with all age incidence of lung cancer
possible from occurring in all age the decrease in the premature rate is
groups but the measurement of mainly a result of decreases in the male
progress should be confined to incidence rate, the female rate showing far
people under the age of 75” (Greater greater stability (table e.).
Manchester Public Health Practice Unit, 2010,
pg.13)
South Lakeland 65
Eden 70
Congleton 79
Ribble Valley 79
Fylde 86
Vale Royal 86
Macclesfield 86
Crewe and Nantwich 88
Warrington 89
Chester 90
Hyndburn 94
Lancaster 96
Chorley 100
West Lancashire 101
South Ribble 103
Barrow in Furness 104
Allerdale 106
Wyre 106
Copeland 107
Stockport 107
St. Helens 108
Carlisle 113
Bolton 113
Rossendale 113
Ellesmere Port & Neston 115
Pendle 116
Blackburn with Darwen 117
Sefton 117
Tameside 118
Preston 120
Bury 122
Trafford 122
Wirral 122
Oldham 126
Blackpool 127
Wigan 128
Rochdale 140
Halton 146
Burnley 151
Manchester 171
Salford 174
Knowsley 176
Liverpool 192
Despite being around average for the Bolton with the Bolton and regional
North West, areas such as the Town averages.
Centre, Halliwell Road, Breightmet N &
Withins, Tonge Fold, Lower Deane & The Variation due to socioeconomic
Willows, and Sweetlove within Bolton all deprivation
have a hospitalised prevalence far greater
than Bolton and the North West; several The NWPHO has analysed the influence
being almost 100% higher than the deprivation has upon observed rates of
average for England. This is portrayed on
the above radar chart which compares
hospitalised prevalence for small areas in
various conditions20. Those conditions MSOA population and hospitalised
showing an extremely strong relationship prevalence of lung cancer.
with deprivation (greater than 3-fold to 10-
fold variation from the least to the most
deprived quintile) were found to be:
Self-harm;
Violence;
COPD;
Alcohol related conditions.
20
North West Public Health Observatory (2006) Where
Wealth Means Health, NWPHO, Liverpool.
21
Cancer Research UK (2010)
www.cancerresearchuk.org
Smoking is very strongly associated with (all ages and both sexes) are between
socioeconomic deprivation, as well as 20% and 60% less likely to get cancer
living in an urban environment, and this than the White ethnic group. Also, Black
contributes significantly to the variation in females are between 10% and 40% less
hospitalised prevalence across the likely to get cancer than White females.
borough. For this reason smoking However, there is no significant difference
cessation is vital in the areas of greatest in risk for Black males and White males.
socioeconomic deprivation. In general, BME groups have a
significantly lower risk of getting cancer
In addition to the above, it is important to (with the exception of liver cancer, mouth
note that nationally, the association cancer, and cervical cancer depending of
between lung cancer and deprivation is the age and sex of the individual). For the
stronger for women than it is for men22. four major cancers (lung, colorectal,
breast, and prostate), BME groups, and in
Variation due to ethnicity particular those of Asian origin, are found
to have a lower risk.
The largest ethnic minority communities in
Bolton are those of Indian (17,000) and Whilst nationally lung cancer incidence is
Pakistani (6,500) origin. However, Bolton lower in the South Asian population, it is
also has significant Bangladeshi, Polish, increasing23, and this group accounts for
Ukrainian, Irish, and many other 11% (28,710) of the population of Bolton.
communities.
The following is taken from the North West
Males and females in the Asian, Chinese, Public Health Observatory and depicts
and Mixed ethnic groups all have a how prevalence of lung cancer varies by
significantly lower risk of getting cancer main ethnic group in the North West.
(all cancers C00-D48) than the White
population. At national level these groups 23
Smith, L., Peake, M. and J. Botha (2003) „Recent
22
changes in lung cancer incidence for south Asians: a
Cancer Research UK (2010) population based register study‟, British Medical Journal,
www.cancerresearchuk.org 326(7380):81-2.
which should be investigated by a
Summary: Cancer Commissioning PCT. The Toolkit states that two
Toolkit areas of action are available to PCTs;
the first is to raise public awareness of
The following is taken from the Cancer the signs and symptoms of lung
Commissioning Toolkit and shows Bolton cancer as well as encourage people to
PCT in comparison to national figures for seek help earlier, and the second is to
a range of lung cancer indicators. The work with primary care professionals
blue arrow represents the national level to ensure that patients presenting with
and the orange arrow represents the level appropriate symptoms are investigated
of Bolton PCT. The traffic light system
thoroughly and referred to hospital
depicts how each area is performing
against national targets and benchmarks. without delay. Five year survival rates
are known to be very influenced by
The data included in incidence and socioeconomic status and uptake and
survival figures relates to the June 2008 compliance with suitable high quality
data submission to CIS. treatment. The Toolkit recommends
that as well as the points discussed
1. Incidence shows that Bolton PCT is
previously, PCTs should also be
closer to the red area of the traffic
aware and make others aware of the
light system than the national figure,
influence socioeconomic status has
but the difference is not too great
upon presentation and treatment
(incidence rate of 50 per 100,000 in
compliance and factor this into any
England compared to a local rate of
action. Furthermore, PCTs should
55 per 100,000);
ensure that treatment and supportive
2. In terms of survival for lung cancer, the
care are suitable, of high quality, and
local level matches the national for
are available in sufficient quantity to
both one year and five year survival
serve the needs of the population;
(one year: National 28.2%, Bolton
3. Bolton PCT is almost in the red area
28%; five year: National 7.7%, Bolton
when benchmarked to the rest of the
7.7%). Early diagnosis is vital to
country for mortality of lung cancer,
survival as in general the earlier one is
48.9 per 100,000 compared to 41.2
diagnosed with lung cancer the more
per 100,000 for England;
likely it is to be operable and curable.
4. Bolton PCT is in the red for
That the UK has such a low rate of
percentage of successful quitters at
early diagnosis is a major reason for
four weeks with 43.7% compared to
the higher mortality rate and lower
an England average figure of 50.2%.
survival rate from lung cancer
From April 2008, success rates
compared to the rest of Europe. The
outside the range of 35% to 70% must
Cancer Reform Strategy includes early
be checked by the service and the
diagnosis as a priority at national and
reasons for the variation explained.
local level. The most suitable indicator
This is not the case at present for
for this is the stage at which cancer is
Bolton. Success rates are influenced
diagnosed, but this is not universally
by the intensity of service delivery and
available data. Staging information in
the population served. Furthermore,
Bolton will be discussed later in this
low success rates may indicate
assessment. However, low one year
populations with high deprivation and
survival rates can serve as a proxy
high levels of mental health problems.
indicator for very late presentation,
Smoking quitters at local level are
analysed in more detail later on in this that many of the emergency
assessment; admissions are the result of the side
5. Over the previous eight years, while effects of treatment, especially
elective day case episodes (usually chemotherapy and radiotherapy.
for chemotherapy) have increased, PCTs should work to ensure that
inpatient admissions for cancer emergency bed usage is minimised
admissions have also risen by 25% by the provision on individualised
nationally. The majority of this patient care, including a specialist out
increase is a result of emergency of hours service and effective
cancer inpatient episodes and community support. At present,
emergency bed days rising by 2.5% Bolton PCT is performing better than
every year. An indicator for local the national average on this indicator
action in Vital Signs measures the with 452 cancer emergency bed days
number of emergency bed days for per 100,000 population compared to
cancer per head of unified weighted 473 per 100,000 in England as a
population. It is important to be aware whole;
Table g. Percent two-week referrals Percent cases diagnosed
diagnosed with lung cancer through non-urgent routes
Table h.
Percent two-week referrals Percent cases diagnosed
Bolton diagnosed with cancer through non-urgent routes
Bolton
Monitoring England
Year Bolton (nchod) monitoring Quintile 1 Percentage gap
period (nchod)
rate
Early diagnosis is especially important for The Cancer Research Campaign argue
lung cancer where treatment options are the perception of lung cancer as self-
entirely dependent upon the stage of the inflicted not only contributes to the low
disease and the fitness of the patient to public profile the disease receives in
undergo invasive surgery and other comparison with other cancers and major
procedures. This need to improve the killers, but also negatively influences the
stage at which people are diagnosed and perception of those suffering with the
referred to appropriate specialist care illness:
must be addressed if mortality and
survival rates are to be improved. That “If you think it's your own fault that
there are gaps in the pathway, especially you have got lung cancer, you're
at the population level and primary care is more likely to 'put up and shut up'
known: and that's exactly the attitude we
need to change" (Source: Prof. Gordon
McVie, Director General of The Cancer
“There is ample evidence of delays Research Campaign (2000))
between the onset of symptoms
and patients reaching specialist This „put up and shut up‟ attitude
care and these delays have a increases the difficulty of raising the public
patient component and a clinician profile of lung cancer. However, despite
component. Thus any efforts to the negativity surrounding lung cancer,
encourage earlier referral would especially for those who developed the
ideally include elements of disease from smoking, where the NHS is
increasing the awareness and concerned views are more positive. The
knowledge of both the general study found that 84% of those polled
public and non-specialist health believe that lung cancer sufferers were as
care professionals” (NHS Evidence, deserving of NHS treatment as other
www.library.nhs.uk, 2010) cancer patients.
Seen in this light it is necessary for this Lung cancer patients, perhaps already
assessment to establish the views of the more disempowered than other types of
general public, health professionals, and patient, have traditionally felt clinicians
lung cancer patients regarding the illness, and health professionals to view their
its cause, and its impact. condition negatively. Whether this is true
or not health professionals need to ensure
Perceptions of lung cancer: public that patients are empowered and are dealt
views with enthusiastically:
years, the disease remains seriously
“There has been a wall of silence stigmatised. The recommendation being
surrounding lung cancer for far too that to impact positively upon lung cancer
long. We need to break this down mortality, and especially early presentation
and show that we do care for and diagnosis, we need to overcome the
patients with the disease - stigma associated with the disease
regardless of whether or not they amongst both the general public and
developed it because of smoking" health professionals.
(Prof. Gordon McVie, Director General of The
Cancer Research Campaign (2000))
Perceptions of lung cancer and
Roy Castle Foundation: UK Lung Cancer treatment: patients
Attitude Assessment 2008
Stigma, shame, and blame experienced
by patients with lung cancer: qualitative
Although lung cancer mortality rates in the
study, BMJ 200425
UK are amongst the highest in the world,
the public and health professional
This study draws on narrative interviews
perceptions of the disease are largely
with lung cancer patients recruited through
negative. In 2008 the Roy Castle Lung
general practices, oncologists, chest
Cancer Foundation canvassed opinion on
physicians, and support groups. Patients
a range of issues relating to lung cancer
were asked to tell the story of their illness
from patients, clinical nurse specialists,
from the time they first suspected they had
and clinicians. Several important results
a problem. Amongst many topics,
were discovered:
researchers were particularly interested in
how patients perceived the cause of their
Consensus across all three groups illness and how other people reacted to
was found concerning the lack of their diagnosis of lung cancer. Major
awareness of symptoms of lung themes that emerged were stigma, guilt,
cancer. More nurses thought this and shame.
to be the case than clinicians (90%
compared to 77%), while 77% of The study found that the stigma
associated with lung cancer is primarily
patients admitted they were
due the association between smoking and
unaware of the symptoms of lung the disease, the perception of the disease
cancer before they were as self-inflicted, its high mortality rate, and
diagnosed; the type of death involved:
Stigma around lung cancer was a
central theme. In the clinician “Respondent: I think they [others]
are frightened... it's like when you
group only 66% believed there
get a death in the family, people
continues to be a stigma will cross the road so as not to
associated with a diagnosis of lung actually have to bring up the
cancer. This figure was much subject, and I think it's the same
higher for patients and nurses with cancer.
(94% and 98% respectively);
Most seriously, 87% of patients Interviewee: Do you think it's the
same with all cancers or more so with lung
and 84% of nurses believed that cancer?
this stigma impacts upon late
presentation with symptoms of Respondent: I think more so with
lung cancer. lung cancer because people think
The Cancer Plan for the North West of To speed up results following
England to 2012 (2008) cervical screening:
The Cancer Plan for the North West was Pledge 7: Having been the first
developed in parallel with the national SHA in the country to fully
Cancer Reform Strategy (CRS) and is in introduce Liquid Based Cytology
effect a local response identifying those (LBC) screening, we now want to
actions that need to take place in the go further with system redesign of
North West.
cytology services and to ensure
The Cancer Plan in the North West that all patients receive their
complements the Our Life programme in results within 14 days by 2010. By
the North West and the aims identified in March 2011, networks will have
the Darzi review Our NHS Our Future. implemented changes arising out
of the North West Review of
To ensure delivery the NHS in the cytology services;
North West:
To reduce variation in screening
Pledge 1: By 2012 the NHS in the rates:
North West will have implemented
the actions identified in this plan; Pledge 8: Unacceptable variations
in screening uptake will be
To help prevent cancer: investigated and appropriate action
will be taken to target the
Pledge 2: Implement the Regional population never screened. PCTs
Tobacco Control plan; leads will examine the coverage
Pledge 3: Use the „Our Life‟ and uptake rates for all screening
programme to push for a decrease programmes to improve and
in hazardous and harmful alcohol maintain uptake by their
consumption; populations;
Pledge 4: Networks will support
PCTs with the implementation of To improve and extend breast
the Human Papilloma Virus (HPV) screening services:
vaccination programme to
commence September 2008 and
will ensure that by September
Pledge 9: We will review and be treated within 62 days by
enhance capacity within our breast December 2009;
services to ensure that we meet
the new standards including the To improve access to radiotherapy:
introduction of digital
mammography. Those with a high Pledge 12: Networks will develop
familial risk of breast cancer will be radiotherapy satellite facilities to
kept under surveillance through the meet the expectations within the
breast screening service. We will CRS and NRAG which will
see greater integration with the guarantee that patients have a
symptomatic breast services. This maximum travel time of 45 minutes
will be fully implemented by (by car/ambulance) for the more
December 2012; common cancers and for those
requiring palliative treatment.
To improve and extend bowel Those patients with cancer or more
screening services: complex treatment needs may
need to travel beyond this time.
Pledge 10: As the bowel screening Networks will identify sites by end
programme is made available to of 2008 with a view to
more people we will increase implementing the first of these by
colonoscopy capacity and ensure 2010/11. PCTs will commission
that patients who require this any additional capacity that cannot
following their positive FOB (blood be met from better utilisation of
in stool) test will wait no longer existing equipment. Where
than 2 weeks. From 2010 people radiotherapy is a second or
aged between 70-75 years will be subsequent treatment, this will be
invited for bowel screening; ensured within 31 days by
December 2010;
To improve waiting times for
cancer treatments: To provide greater consistency
across a range of treatments:
Pledge 11: We will ensure that all
patients in the North West will Pledge 13: Review treatment
meet extended standards for protocols and clinical guidelines to
waiting times. For second or ensure these are consistent with
subsequent surgery and best practice and standardised
chemotherapy this will mean that across the North West. We will
patients will; wait no longer than 31 make treatment such as High Dose
days by December 2008. All Rate Brachytherapy accessible
women referred by their GP with across the North West. Patients
breast symptoms will be seen will be supported wherever
within two weeks by December possible to have their radiotherapy
2009. All patients with a treatment at a location convenient
suspected cancer detected through to them;
screening programmes or as
upgraded by their consultant will To ensure equity of access to
cancer drugs:
Pledge 14: Patients across the appropriate) will be required for
North West will continue to have each network by September 2008;
access to cancer drugs positively
appraised by NICE. For pre-NICE To ensure access to the latest
drugs and those unlikely to be surgical techniques:
considered in the short term by
NICE there will be a common Pledge 18: Network organisations
approach adopted by will ensure that all surgeons can
commissioners to ensure equity access training in the latest
across the North West. The surgical techniques. Agreed new
opportunity to standardise technologies such as laparoscopic
treatment protocols will be procedures (e.g. for prostate,
explored and a commitment is gynae, and renal cancers) will be
given that all patients will be introduced once these become
treated the same regardless of more the norm in practice and
geographical location by 2012; PCTs will then only commission
from those providers who can offer
To deliver local, consistent and these techniques;
safe chemotherapy:
To respond to new guidance for
Pledge 15: By 2012 chemotherapy rare cancers:
and other systemic therapies will
be delivered as close to home as Pledge 19: We will balance the
possible where this is safe to do needs of travel distances with the
so; need to concentrate some services
in fewer locations for the rare
To commission services only from cancers. Clinical guidelines will be
accredited providers: standardised across the North
West centres where there is more
Pledge 16: Commissioners will than one using best practice
only commission care from guidelines and tools;
hospitals specifically designated to
deliver care in accordance with To be responsive to patients living
NICE Improving Outcomes with and beyond cancer:
Guidance by 2012 at the latest;
Pledge 17: Commitment has been Pledge 20: By listening to what
given by all PCTs across the North patients tell us, we will constantly
West to accelerate the keep under review their views
implementation of the plans where through a series of surveys and
these have slipped behind national through Network Patient
implementation milestones. In Partnership and other Patient and
addition, network organisations Public Involvement arrangements.
should ensure that peer review We will ensure providers have
action plans are also auctioned. A robust systems in place to
state of readiness report and IOG measure patient satisfaction and
remedial action plan (if then act upon the findings.
Providers will also ensure that
professionals access the Pledge 26: The inequalities in
appropriate education and training, cancer mortality rates will be
e.g. communication skills; rigorously monitored by the SHA;
Pledge 21: To ensure that all
patients receive care as close to To commission and deliver world
their home as is possible and that class cancer services:
their stay as an inpatient is kept to
a minimum. Where this cannot be Pledge 27: PCTs in the North West
avoided, we will enhance the commit to the Department of
quality of the patient experience, Health World Class
particularly for those with Commissioning programme and
advanced disease. Continuity of the use of the cancer
care will be ensured through the commissioning toolkit, through
transformation and development of which standardised care across
nursing roles such as through the North West can be monitored;
implementation of the Integrated Pledge 28: PCTs will ensure the
Cancer Care Programme (ICCP). ambitions and pledges in this plan
This will also ensure that Clinical are reflected in their strategic plans
Nurse Specialists are used more by September 2008.
effectively and appropriately;
Pledge 22: Patients and Carers will
The Greater Manchester and Cheshire
have access to an appropriate
Cancer Network Prevention, Early
level of psychological support Detection, and Inequalities Strategy
throughout and beyond their (2010)
cancer journey. Using the
Improving Access to Psychological
Therapies initiative patients will be Based on the major challenges faced by
referred to an appropriate service the Network of reducing the burden of
cancer across the whole of the Network,
once they are diagnosed;
and dramatically improving the situation in
Pledge 23: Support patients in areas that have the worst outcomes, the
making choices around their end of Strategy proposes actions to reduce
life including increasing the inequality.
numbers of people supported to
die at home and to achieve their The Strategic Goal of the Strategy:
priorities for care;
“A long-term reduction in the
Pledge 24: To support the agreed incidence of preventable cancers
key recommendations of the End and an improvement in the stage
of Life Care clinical pathway group; distribution of new cancer cases in
all population groups across the
To reduce cancer inequalities: Greater Manchester and Cheshire
Cancer Network”
Pledge 25: By the end of 2008 all
networks will have developed This Goal is reinforced with the following
rigorous plans to reduce the health ten Strategic Aims:
inequalities experienced by their
1. Reduce the prevalence of
population;
smoking;
2. Improve the diet of the This Strategy will be achieved based on
population; five clearly defined areas:
3. Reduce the prevalence of
obesity and overweight; Co-ordinated care: a smoother,
4. Increase the amount of faster, and more joined up care
physical activity; experience will be determined
5. Reduce the excessive through better planning and
consumption of alcohol; sharing of information concerning
6. Reduce exposure to specific the needs of patients between
causes of cancer; different sections of the health
7. Reduce the spread of service and partner organisations;
infections that can cause Better training and education: to be
cancer; implemented in all settings where
8. Improve communication about care is delivered for people at the
cancer signs and symptoms; end of life;
9. Make diagnostic pathways 24 hour access: to a broad range
follow best practice and be of community services enabling
available to all; patients and their carers to receive
10. Improve attendance at cancer support at the end of life, including
screening, especially in bereavement;
disadvantaged groups. Dignity at the end of life: to strive to
ensure that whatever the cause of
illness, and wherever care is
provided, a dignified and, as far as
End of Life Care Strategy: Promoting possible, pain free death can be
high quality care for all adults at the
achieved;
end of life (2008)
Choice: as far as possible in where
the patient would like to be cared
The Strategy sets out key areas for for in the last days of life.
improvement when providing people
approaching the end of life with more
choice about where they would like to live Bolton’s Joint Strategic Needs
and die. The Strategy covers all adults Assessment (2008)
with advanced, progressive illness and
care provided in all settings. Contains the
requirement for local end of life care The JSNA identified the following areas
strategies based on its findings and relevant to lung cancer as priorities on
recommendations (see below). which partner agencies should focus in
order to impact on reducing the poor
health and inequalities:
Bolton End of Life Care: A strategy for
improving care for people living with Smoking reduction;
and dying from long-term conditions Early symptom recognition of
2006 – 2011 cancer.
Sets out a five-year strategy to jointly High Quality Care for All – Darzi Review
develop end of life services throughout (2008)
Bolton for people with long-term conditions
in their last six to twelve months of life.
Driving:
The final method of diagnosis is chance The relationship between smoking and
finding. This is usually the result of an lung cancer is evident in the below graph
emergency presentation or referral from produced by Cancer Research UK. The
another specialism in secondary care. graph depicts how the incidence of lung
The latter is often a result of a chest X- cancer has historically reduced along with
Ray or other chest examination for other the prevalence of cigarette smoking in
purposes. Great Britain.
30 31
Cancer Research UK (2010) About Cancer, Cancer Peto, R. (2006) Mortality from smoking in developed
Research UK, London. countries 1950-2000, Oxford University Press, Oxford.
There is a QOF prevalence register for 2007, one month before the smoke free
smoking, but it lacks historical data. The legislation was introduced, making it illegal
indicator comprises the percentage of to smoke in virtually all enclosed public
patients with presence of any or any places and workplaces. We expect the
combination of the following conditions: number of smokers to have fallen further
coronary heart disease, stroke or TIA, since the new legislation.
hypertension, diabetes, COPD, CKD,
asthma, schizophrenia, bipolar affective Men in Bolton are more likely to smoke
disorder or other psychoses whose notes than women (25.2% of men and 20.9% of
record smoking status in the previous 15 women). The proportion of women
months. smoking has fallen at a slightly faster rate
than in men (27.3% women smoked in
There are 66,519 people on the smoking 2001, 31.8% of men smoked in 2001).
register in Bolton for 2008/09.
The percentage of heavy smokers (20 or
The most reliable source for smoking more cigarettes a day) in Bolton has also
prevalence in Bolton is from the Bolton fallen since 2001. This has reduced from
Health and Lifestyle Survey 2007. The 8.6% in 2001 to 6.0% in 2007. Men in
local trend from the survey supports a Bolton are more likely to be heavy
projected decline in future smoking smokers than women (7.1% men, 4.9%
prevalence. There has been a significant women).
reduction in the percentage of people who
smoke in the borough since the last Comparing smoking in Bolton to national
survey in 2001. In 2001, the prevalence of rates is not straightforward as the most
smoking in adults was almost 30%. In recent national figures are from 2006 and
2007, this had dropped to 23%. This the questions used may differ slightly from
reduction reflects the amount of work that those used in the Bolton Health Survey
NHS Bolton and our partners have put in 2007. However, the Health Survey for
place to reduce smoking in the borough. England for 2006 found that 24% of males
Importantly, it should be noted, that the and 21% females were currently smoking.
health survey took place during June The General Household Survey found
smoking prevalence rates in England of from 29.5% to 23%; 20+ smoker from
23% for men and 21% for women. 8.6% to 6%).
However, it must be noted that both
surveys include people aged from 16 The chart below shows the percentage of
years of age. These figures suggest that adults who smoke in each Local Authority
Bolton has a higher prevalence of smoking of the North West for the period 2003-
in men when compared nationally. 2005.
Table k.
34
Ethnicity: Smoking prevalence
34
NHS Bolton (2007) Bolton Health & Lifestyle Survey
2007, NHS Bolton, Bolton.
In addition to demographic factors, living calling for uniform branding and more
in a house in which cigarette smoking severe display limitations.
occurs can increase the risk of lung
cancer - by almost a quarter. It is also On a related point, research suggests that
widely acknowledged that children from stopping smoking before middle age
smoking families are more likely to smoke eliminates most of the risk of lung cancer
when adults. However, there does seem from tobacco37. For this reason the group
to be a crucial age range at which children prior to middle age is key in targeted
begin smoking; less than 1% of 11-12 year initiatives.
olds smoke, but by 15 years of age this
figure has increased to 20%, typically with Finally, we must appreciate that being
a larger proportion of girls smoking exposed to second hand smoke can
compared to boys35. The most important increase the risk of a non-smoker getting
issue for this age group is that although lung cancer by 24%38.
smoking prevalence in the general
population continues to decline, this is not The World Health Organisation asserts
the case for adolescent smoking. In that tobacco smoke is a carcinogen (a
seeking to address this stasis, strategies substance that causes cancer in human
must be conscious of the complex beings) and this places it alongside other
relationship between adolescents and poisonous substances such as asbestos,
authority, as well as the confused radon, and arsenic. In sum, the toxic
messages about cigarettes36. In addition, substances of second hand smoke contain
an issue that is expected to become over sixty-nine cancer causing chemicals.
prominent in the future is the branding of It is important to note that there are two
cigarettes with many pressure groups types of tobacco smoke:
35 37
Cancer Research UK (2009) CancerStats: Lung cancer Cancer Research UK (2009) CancerStats: Lung cancer
and smoking November 2009, Cancer Research UK, and smoking November 2009, Cancer Research UK,
London. London.
36 38
Stevens, A. et al (2004) Health Care Needs Smokefree England (2010)
Assessments, Radcliffe Publishing Ltd., Oxford. wwww.smokefreeengland.co.uk
1. Mainstream smoke: inhaled the Royal Bolton Hospital to work with the
through the mouth of the smoker at hospital, train staff in giving advice and
the end of the cigarette and later support to patients who smoke, and to
design new practices and procedures to
exhaled;
make it easier to encourage patients and
2. Sidestream smoke: that arising visitors to quit.
from the burning tip of the
cigarette. The North West annual returns for
smoking cessation services across the
Second hand smoke consists country are released by the Information
predominantly of sidestream smoke, and Centre and show the rate of successful
although this is inhaled in a diluted form quitters for specific PCTs. The following
compared to direct inhalation, sidestream graph shows how Bolton compares for
smoke is almost four times more toxic successful quitters against its target for
than mainstream smoke39. 2008/09, and how this compares against
the PCTs of the North West. For this
Today, the impact of second hand smoke period Bolton PCT saw 1718 successful
can be expected to be severely reduced quitters. However, this means Bolton has
by the introduction of the Smokefree a successful quitters rate of 827.6 (per
legislation in July 2007: 100,000 16+ population) compared to an
Annual Plan target of 1006.9 (per 100,000
“Across the world and in a very 16+ population). The chart below shows
short space of time, smokefree the difference in actual numbers to
laws have proved to be highly illustrate the PCTs who achieved their
effective in protecting people from target.
the harm of second hand smoke” As evident below from the variance
(Source: Smokefree England, 2010)
between number of successful quitters
Despite this gain, the effect upon mortality achieved and planned number of quitters,
should be considered limited given that Bolton has a higher variance than the
95% of deaths associated with second North West as a whole and needed to pick
hand smoke are from exposure in the up an extra 412 successful quitters to
reach its target.
home40, and as the public places and
workplaces legislation is fully implemented
focus should now be on creating smoke Many of Bolton‟s benchmarked peer PCTs
free homes in Bolton. such as Ashton, Leigh, & Wigan, Halton &
St. Helens, Heywood, Middleton, &
Stop Smoking Service Rochdale, Oldham, Tameside & Glossop,
and Salford all have a lower variance than
Bolton, and these are matched for
Since the Bolton NHS Stop Smoking demographic and deprivation related
service was established in 1999 it has characteristics. (Bury is the only
helped over 4,500 people quit smoking. exception with a higher variance than
Within this, 7-week intensive quit groups Bolton).
have helped over 3,000 people quit
smoking in Bolton over the last three
years.
Community quit groups and one-to-one
therapy sessions are also available, as are
services based at the maternity unit,
pharmacies, and GP practices. Also, a
Stop Smoking Specialist is employed at
39
Cancer Research UK (2010) www.canceresearchuk.org
40
Smokefree England (2010)
wwww.smokefreeengland.co.uk
Table l.
Successful Quitters who attended NHS Stop Smoking Services: 2008/09 (cumulative)
Table m. breaks down the success rate of highest successful quit rate relative to
quitters and attempters of people using smoking population (20%). The success
the service by area within Bolton. A rate is lower for the most deprived (17%)
quitter is a person who has quit, verified and quintile 2 (16%).
by testing for carbon monoxide levels
and/or self-report. An attempter is a At geographical level the areas with a
person who has set a quit date. smoking prevalence greater than 30%
(highlighted) all have a relatively low quit
For the 2008/09 financial year, 23% of all rate. With an average quit rate of 17.9
successful quitters who came through (per 1000 smoking population) for all
smoking cessation services in Bolton were areas, the MSOAs of greatest smoking
from the most deprived quintile. Quintiles prevalence, with the exception of Tonge
2, 3, and 4 are roughly equal to this, while Moor & Hall i‟th‟ Wood, all fall below this.
10% of all successful quitters were from Horwich Town has by far the highest rate
the least deprived quintile. However, of successful quitters (46.6).
quintiles 3 and 4 are shown to have the
Table m.
Bolton MSOA: Smoking cessation quitters and attempters 1st April 2008 - 31st March 2009
Number Percentage
Set quit date Population Smoking Rate/1000 Rate/1000
Quitters of successful
(attempters) (age 18+) prevalence quitters attempters
smokers attempters
The first map below shows the rate per smoking prevalence feature in the highest
smoking population of all referrals made to rate of referrals per smoking population.
the smoking cessation service by MSOA
regardless of success. To an extent this translates onto the
second map of successful quitters per
There is a high rate of referral per smoking 1000 smoking population. The urban
population in the areas of Lower Deane & areas around the Town Centre, where the
The Willows and Middlebrook & Brazley. highest prevalence of smoking exists, are
A slightly lower rate, but still reasonably shown to have a relatively low rate of
high, is seen in the areas of Deane & successful quitters compared to smoking
Middle Hulton, Leverhulme & Darcy Lever, population.
Central Kearsley, Tonge Moor & Hall I‟th‟
Wood, and Turton. Horwich Town has the There are differences in the method of
highest rate of all referrals. However, with referral to smoking cessation services
the exception again of Tonge Moor & Hall over this period by deprivation quintile.
i‟th‟ Wood, none of the areas of greatest
The greatest single referral method across
all quintiles is listed as „self‟; self-referral Beaumont Hospital Breathlessness Clinic
accounted for over 900 referrals to the
service over this period. For referrals from Research has long identified deprivation-
the most deprived quintile, 31% were self- related inequities in effective procedures
referred compared to 43% for the least for a variety of disease areas. This
deprived and quintile 4. The second most section will compare the prevalence of
significant method of referral for the most breathlessness with referrals made to the
deprived quintile is via PAMU (Princess Beaumont Hospital Breathlessness Clinic.
Anne Maternity Unit). PAMU is The data concerns referrals made by GPs
responsible for 19% of all referrals in the to the Clinic and so considers inequities a
most deprived quintile, but accounts for level beyond that of visiting a GP.
just 6% of all referrals in the least deprived
quintile. Referrals from Royal Bolton Many patients present at their GP surgery
Hospital are consistent at between 9% with breathlessness and would benefit
and 10% of all referrals across quintiles, from rapid investigation and diagnosis. As
while referrals from GPs do fluctuate by such conditions can rapidly deteriorate,
deprivation quintile, but not greatly, GPs often refer directly to hospital for an
accounting for between 8% and 13% of all emergency admission. Wherever possible
referrals depending on the quintile. alternatives are to be sought to prevent
Interestingly, around 12% of all referrals in avoidable admission to hospital by
quintiles 1,2, and 5 come via a pharmacy; designing services which can provide both
this figure drops between 5% and 6% for the GP and the patient with the confidence
quintiles 3 and 4. Youth services referred that the appropriate treatment is being
2% of the all referrals in the most deprived provided. The Breathlessness Clinic was
quintile, but accounts for none in the least commissioned in 2007 to meet this need.
deprived. Finally, over the year period
discussed, advertising, notice boards, face
to face events, leaflets, and the Quit It
campaign accounted for a very minor
proportion of all referrals.
The service is specifically aimed at demographic makeup. For this reason we
patients presenting with mild to moderate would expect more referrals in this cluster.
breathlessness where there has not However, activity overall does not reflect
previously been a diagnosis and where the need of the whole population. The
admission to hospital would be considered following tables compare breathlessness
to remove diagnostic uncertainty; the from the Bolton Health and Lifestyle
service is not designed to meet the needs Survey 2007 to activity from the
of patients who are acutely breathless or Breathlessness Clinic.
breathless at rest or are in need of
immediate hospital admission. A question The Indigo cluster is shown to have the
from the Bolton Health and Lifestyle lowest percent of breathlessness of all the
Survey 2007 aims to identify respondents clusters and yet has the highest rate of
who are breathless when hurrying on level those in need referred to the Clinic. In
ground or walking up a slight hill. This contrast, the Red cluster has the highest
question has been used to compare need percent of breathlessness and the lowest
in Bolton with referrals at the Clinic. The rate of those in need referred to the Clinic.
following shows GP referrals to the
breathless clinic by GP cluster.
Table n. Need Need met
In total, for the period April 2008 to March Percent Number Crude rate Number
breathless breathless (per referred
2009, there were 241 referrals by GPs in 100,000)
Bolton to the Breathlessness Clinic. A
large proportion of referrals were made by Indigo 22 18746 570.8 107
GPs in the Indigo GP peer cluster. The Blue 25 13775 341.2 47
Indigo GP peer cluster is comprised of Green 31 16652 222.2 37
practices with predominantly an Yellow 32 12409 217.6 27
old/normal white population with low Orange 35 11208 160.6 18
deprivation. Red 39 7367 67.9 5
Not supplied 85
Ethnicity is less reliable as eighty five are repeated which is not ideal for
referrals over the period did not supply the patient”.
their ethnicity. From the survey the Asian
ethnic groups have the highest reported It is possible referrals may also be
breathlessness, while the mixed/Asian affected by the location of the Clinic,
other/other and the black groups have the situated as it is away from the Town
lowest. The mixed/Asian other/other Centre and the areas of greatest
group has the highest rate of those in deprivation and surrounded by practices
need referred to the Clinic. In contrast, from the Indigo cluster. This is shown
the Asian ethnic groups have the lowest below.
rate of referral. This is shown in table o.
above. From the survey conducted, the reasons
are unclear, but what is certain is that
Bearing in mind that the survey had a very clear differences persist linked to
low response rate, the following are deprivation for referrals to the
examples of negative feedback from GPs Breathlessness Clinic.
in Bolton concerning the Clinic:
Illegal tobacco
Breightmet 6
Crompton 6
Farnworth 0 As tax increases make smoking ever more
Great Lever 30 difficult for those in the more deprived
Halliwell X
Hall ith Wood X
areas of the borough, illegal tobacco is
Hulton Lane X becoming an increasingly important
Johnson Fold X problem.
Rumworth 16
Tonge w t Haulgh 5
Washacre X Price is known to be one of the most
Not NRS or no postcode 69 successful methods of reducing smoking
Total 144 prevalence. The UK tax on cigarettes,
cigars, hand rolled tobacco, and other 5. Working with businesses to assist
tobacco products is the highest in the and educate routine and manual
European Union. Against this, illegal and employers;
counterfeit cigarettes are cheaper and so
6. Education of the tobacco retail
encourage the continuation of smoking in
spite of tax penalties. This is an especially sector and pub and club watchers
important issue for deprived communities, about illicit tobacco and impact
as well as children and young people. upon their businesses.
There are three specific types of illegal In addition to the above, Tobacco and
tobacco41: Borders: Life Made Cheaper,
recommendations include better
Smuggling: Involves the illegal information systems to provide high quality
transportation, distribution, and data on illegal tobacco.
sale of tobacco. This happens
Bolton‟s Community Strategy monitoring
when legitimately produced of interventions throughout the borough
tobacco products are diverted to now includes an indicator for illegal
evade tax (usually in the wholesale tobacco. The intervention concerns
distribution chain). This makes the research to understand prevalence of illicit
products cheaper to the consumer; sales of tobacco in NRS areas. Work
began in the first quarter of 2009/10 to
Bootlegging: Products are
organise the collection of cigarette packets
purchased in a country with low in Farnworth and having them analysed to
taxation and illegally brought into ascertain the level of the illicit tobacco
countries with high taxation; problem in Bolton. At last report, 150
Counterfeiting: The illegal packets had been collected and progress
manufacture and distribution of towards implementation is continuing.
tobacco products to avoid tax.
Healthy Schools
Both counterfeiting and smuggling
are typically part of large scale Healthy Schools is a long-term initiative
organised crime. aimed at promoting the link between good
health, behaviour, and achievement. The
Due to the high smoking prevalence and programme is constructed around four
low income, the North West of England is themes: Healthy Eating, Physical Activity,
an area of great demand for illegal Emotional Health and Wellbeing, and
tobacco. The North of England Tackling Personal, Social, and Health Education
Tobacco for Better Health Plan suggests (PHSE) (including Sex and Relationship
six aspects that must be vital to regional Education and Drug Education). Smoking
and local work: cessation is included in PHSE and comes
under Drug Education, which includes
1. Development of the role of health tobacco, alcohol, and volatile substance
workers through education; abuse. From the Bolton Schools Survey
2. Intelligence sharing between 2005 (Secondary School Information),
relevant organisations; 42% of Year 8 and 10 pupils reported
3. Mapping informal markets where trying smoking in the past, while 13% say
they smoke regularly or occasionally.
products are traded; Furthermore, 75% of this group said that
4. Marketing and communication to they would like to quit.
target key groups and
development of partnerships;
41
SmokeFree North West (2010)
www.smokefreenorthwest.org/
Table q.
Total number of
School type Number involved Percentage involved
schools
4
Nursery (Local authority) 4 100%
102;
Primary 39 schools FSME 92 90%
(20%)
16;
Secondary 16 7 schools FSME (20%) 100%
Special 5 5 100%
PRU (Long-term) 3 3 100%
The Healthy Schools programme in Bolton provide universal and targeted health
has developed from 6 schools interested interventions. The enhanced model builds
in January 2002 to 123 schools on the 41 criteria governing Healthy
participating in January 2010. In the past Schools Status and begins with an annual
ten years there has been a great deal of review to check Healthy Schools continue
legislation supporting and recognising the to meet the standard criteria. This is to be
importance of Healthy Schools (Every followed by a detailed eight-stage process
Child Matters, etc.). to further improve the health of schools.
The national expectation is that 10% of all
The Department for Education and Skills‟ schools will have reached Stage 4. Part 2.
Five Year Strategy for Children and (needs analysis, identification of priorities,
Learners (2004) stated that every school meaningful outcomes developed, early
should be a healthy school. Furthermore, success indicators developed, and signed
Choosing Health: Making Healthy Choices off by the QUAG (Quality Assurance
Easier (2004) included the targets that Group), by March 2010, and that all
50% of all schools should be Healthy schools will be Enhanced Health Schools
Schools by 2006 and the remainder by 2020.
working towards this by 2009. In Bolton,
55% of all schools had achieved Healthy Radon
Schools Status by 2007, 65% by 2008,
and 75% by 2009. At present 83% of Radon is categorized as a Class 1
Bolton schools have achieved National carcinogen and is the second largest
Healthy School Status, with over 98% of cause of lung cancer in the UK,
Bolton schools participating in the responsible for up to 2,000 fatal cancers
programme. each year42. Radon is a naturally
occurring gas, exposure to which
In Bolton, primary schools are the only increases the risk of an individual
type of school covered by the programme developing lung cancer. Radon-222 is the
that are yet to show full subscription (table most important isotope in the context of
q.). this needs assessment and comes from
naturally occurring uranium in rocks and
The Enhanced Healthy Schools model is a soils. When inhaled, alpha particles and
recent development and aims to translate other decay products can irradiate
the Government‟s vision of the 21st sensitive lung cells, increasing the risk of
century school (outlined in the Children‟s lung cancer. This risk is increased further,
Plan ) into practice. This enhanced model to almost twenty-five times, for smokers.
43 45
Stevens, A. et al (2004) Health Care Needs Stevens, A. et al (2004) Health Care Needs
Assessments, Radcliffe Publishing Ltd., Oxford. Assessments, Radcliffe Publishing Ltd., Oxford.
44 46
AGMA (2009) AGMA Place Survey: Bolton, AGMA, Cancer Research UK (2009) CancerStats: Lung cancer
Manchester. and smoking November, Cancer Research UK, London.
cancer following treatment for non- studies demonstrating this association it
Hodgkin‟s lymphoma, as well as testicular comes with the caveat that further
cancer, which is linked to radiation to the research is needed in order to clarify the
chest from previous treatments47 48 49. relationship between physical activity and
risk of lung cancer55.
In addition, a family history of lung cancer
in a first-degree relative is associated with Common sense and wider epidemiology
a 2-fold increased risk, independent of imply that this lower risk may be due to the
smoking50. The association between fact that smokers are less likely to
family history and lung cancer risk may be undertake physical activity. This need not
stronger in Black ethnic groups compared be a negative association as encouraging
to White51. people to undertake more physical activity
may also impact upon smoking
Lifestyle factors other than smoking prevalence.
Beyond smoking, there are other Bolton is below the North West average
modifiable lifestyle risk factors that may for physically active adults. This is shown
protect against lung cancer. on the below chart. (Data is for the period
2005/06).
Physical activity
From the Bolton Health and Lifestyle
A meta-analysis52 conducted in 2005 Survey 2007 we know that the central and
found that people undertaking higher more deprived parts of Bolton show the
levels of physical activity compared to the highest proportions of physical
general population have a decreased risk inactivity/sedentary lifestyle. However,
of developing lung cancer. Other studies only Burnden and Lever Edge are
have demonstrated that women who are significantly higher than the average for
current or ex-smokers and take part in a the borough as a whole. These are areas
high level of physical activity have a with higher than average levels of BME
reduced risk of lung cancer53 54. Whilst population. Areas with the highest
Cancer Research UK highlights other proportions of recommended levels of
physical activity include Turton, Johnson
47 Fold & Doffcocker and Central Kearsley.
Lorigan, P. et al (2005) „Lung cancer after treatment for
Hodgkin's lymphoma: a systematic review‟, The Lancet
Oncology, 6(10):773-9. For the 2007 survey, we changed the
48
Mudie, N. et al (2006) „Risk of second malignancy after question on levels of physical activity from
non-Hodgkin's lymphoma: a British Cohort Study‟, Journal
of Clinical Oncology, 24(10):1568-74.
that used in 2001, so comparison to the
49
Travis, L. et al (2005) „Second cancers among 40,576 previous survey is not possible.
testicular cancer patients: focus on long-term survivors‟,
Journal of the National Cancer Institute, 97(18):1354-65.
50
Nitadori, J. et al (2006) „Association between lung
cancer incidence and family history of lung cancer: data
from a large-scale population-based cohort study, the
JPHC study‟, Chest, 130(4):968-75.
51
Cote, M. et al (2005) „Risk of lung cancer among white
and black relatives of individuals with early-onset lung
cancer‟, Journal of the American Medical Association,
293(24):3036-42.
52
Tardon, A. et al (2005) „Leisure-time physical activity
and lung cancer: a meta-analysis‟, Cancer Causes and
Control, 16(4):389-97.
53
Sinner, P. et al (2006) „The association of physical
activity with lung cancer incidence in a cohort of older
women: the Iowa Women's Health Study‟, Cancer
Epidemiology Biomarkers and Prevention, 15(12):2359-
63.
54
Alfano, C. et al (2004) „Physical activity in relation to all-
site and lung cancer incidence and mortality in current and 55
former smokers‟, Cancer Epidemiology Biomarkers and Cancer Research UK (2010)
Prevention, 13(12):2233-41. www.cancerresearchuk.org
Diet The below chart shows Bolton to be below
the average for the North West for healthy
Evidence is mixed concerning the eating adults, with peaks often being in the
potential association between dietary Cumbrian region of the North West. (Data
habits and lung cancer risk56. However, is for the period 2003/05).
some studies do show that a diet rich in
vegetables is associated with a reduced The Bolton Health and Lifestyle Survey
risk of lung cancer57 58 59, but others show 2007 asked people how many portions of
this may only apply to smokers60 61. fruit and/or vegetables they eat a day.
Since 2001, the proportion of people
eating five or more portions has risen
significantly from 11.6% to 18.9% of the
56 adult population of Bolton. This still leaves
Liu, Y. et al (2004) „Vegetables, fruit consumption and
risk of lung cancer among middle-aged Japanese men Bolton some way behind the national
and women: JPHC study‟, Cancer Causes and Control, figure62 of 30%.
15(4):349-57.
57
Galeone, C. et al (2007) „Dietary intake of fruit and
vegetable and lung cancer risk: a case-control study in
The areas in Bolton with the greatest
Harbin, northeast China‟, Annals of Oncology, 18(2):388- prevalence of those eating no fruit and
92.
58
vegetables are the areas of high
Rylander, R. and G. Axelsson (2006) „Lung cancer risks deprivation, particularly the Town Centre,
in relation to vegetable and fruit consumption and
smoking‟, International Journal of Cancer, 118(3):739-43. Tonge Moor & Hall i‟th‟ Wood, and
59
Balder, H., Goldbohm, R. and P. van den Brandt (2005) Breightmet and Withins. In contrast, less
„Dietary patterns associated with male lung cancer risk in deprived areas such as Egerton &
the Netherlands cohort study‟, Cancer Epidemiology
Biomarkers and Prevention, 14(2):483-90. Dunscar, Townleys, and Blackrod have
60
Holick, C. et al (2002) „Dietary carotenoids, serum beta- extremely low levels of no fruit and
carotene, and retinol and risk of lung cancer in the alpha- vegetable consumption.
tocopherol, beta-carotene cohort study‟, American Journal
of Epidemiology, 156(6):536-47.
61
Linseisen, J. et al (2007) „Fruit and vegetable
consumption and lung cancer risk: Updated information
from the European Prospective Investigation into Cancer 62
and Nutrition (EPIC)‟, International Journal of Cancer, Department of Health (2006) Health Survey for
121:1103-1114. England, DoH, London.
No strong relation has been found
between alcohol intake and risk of lung
cancer. The strong association between
alcohol intake and smoking is too
significant a confounding factor for any link
to be established63 64
.
63
Freudenheim, J. et al (2005) „Alcohol consumption and
risk of lung cancer: a pooled analysis of cohort studies‟,
American Journal of Clinical Nutrition, 82(3):657-67.
64
Rohrmann, S. et al (2006) „Ethanol intake and risk of
lung cancer in the European Prospective Investigation into
Cancer and Nutrition (EPIC)‟, American Journal of
Epidemiology, 164(11):1103-14.
cancer. It should be borne in mind that
Curative this does not represent the number of
patients in Bolton as all trusts receive
patients from other PCTs due to the
In general there are four modalities of specialist nature of cancer treatments.
treatment for lung cancer: However, it does provide an idea of the
type of treatments to which referrals are
Surgery; made in Bolton and surrounding areas
Radiotherapy; compared to England and Wales.
Chemotherapy;
The main acute trusts/hospitals for Bolton
Palliative care. lung cancer patients are Royal Bolton
Hospitals (RMC), The Christie (RBV),
In recent years more than one modality Manchester Royal Infirmary which comes
has often been used to treat an individual under Central Manchester University
patient. For example, surgery followed by Hospitals (RW3), and Wythenshawe
chemotherapy, chemotherapy followed by Hospital which comes under South
radiotherapy, or simultaneous Manchester University Hospitals (RM2).
radiotherapy and palliative care. In addition, Bolton is part of the Greater
Treatment options should be discussed Manchester and Cheshire Cancer Network
with the patient where possible to allow an (N02). In table s. South Manchester has
informed decision to be made65. only recorded 23% of its expected cases
in the audit and so this data is not
Treatments are specific to whether the representative. The Christie does not
cancer is non-small cell or small-cell. For participate fully in the audit as it is a
this reason accurate histological diagnosis tertiary trust.
is critical.
RBV 0 0 0 0 0
Main trust sites for
Bolton patients
RM2* 75 81 45.3 21.3 100
65
The Information Centre (2009) National Lung Cancer
Audit: Report for the audit period 2007, The IC, London.
The Cancer Commissioning Toolkit groups especially given that the North West is an
types of cancers into groups for area historically showing wide variation
presentation purposes. Thoracic cancer from the national picture as well as wide
includes lung, tracheal, oesophageal, variation within its own borders.
mesothelioma, thymomas, chest wall
tumours, and other mediastinal tumours; The second chart shows PCTs‟
the most common of these are lung, benchmarked activity by cancer type;
oesophageal, and mesothelioma. here, thorax. The activity is in FCEs per
100,000 population. The line represents
The below chart is based on Health the activity of all PCTs in England with
Episodes Statistics (HES) data and shows Bolton and its statistical peers highlighted.
the activity for patients of Bolton PCT Compared to its peers Bolton has the
admitted through all methods (all classes fourth lowest activity for thoracic cancer. If
of patient) recorded as cancer type thorax. a PCT has a particularly high incidence of
National episodes for the thorax cancer a cancer type per head of population
type show a steady and consistent compared to England, it would be
increase since 1997/98. Trends in this expected to have a higher activity, and
indicator reflect the influence of changing vice versa. If a PCT has a low incidence
cancer incidence, early detection, and per 100,000 population of a particular
changes to the provision or uptake of cancer type but has a high activity, then
services. There will also be an upward this suggests that patient selection and
trend where new and additional forms of management should be reviewed. Table t.
treatment become available. The Bolton allows us to compare incidence previously
trend is more erratic because of the lower given in this assessment (2004/06 is the
numbers involved, but since 2003/04 has latest available incidence figure) with
roughly followed the pattern of the national activity for England, Bolton, and its
trend. As standardisation of cancer statistical peers. Table t. is ranked by
treatment, care, and outcome is a frequent incidence, with all PCTs except Dudley
message of the lung cancer audit, the showing a higher incidence than England;
closer Bolton mirrors the national trend the for this reason England is not an
better we can expect services to be, appropriate comparator. Compared to the
group as a whole, Walsall is perhaps an and around average within the group for
example of a PCT with a relatively low both; thus, this indicator does not reveal
incidence and high activity. Bolton is any serious problems with patient
higher than England for both indicators, selection and management in Bolton.
Non Elective
Elective Cancer Total Cancer % Share of Cancer % Share of all Bed
Cancer type Cancer Bed
Bed Days Bed Days Bed Days Days
Days
Breast 12394 8182 20576 6.13 0.73
Endocrine System 1692 485 2177 0.65 0.08
Gynaecology 8764 7107 15871 4.73 0.56
Haematology 20670 28946 49616 14.78 1.75
Head & Neck 7552 3923 11475 3.42 0.4
Lower GI 22638 20892 43530 12.96 1.54
Metastases 7662 15279 22941 6.83 0.81
Multiple ICD10 Codes 1785 5816 7601 2.26 0.27
Musculoskeletal 3285 2064 5349 1.59 0.19
Neurology 7035 8513 15548 4.63 0.55
Other Cancer 3109 13775 16884 5.03 0.6
Skin 2280 1354 3634 1.08 0.13
Thorax 9585 31041 40626 12.1 1.43
Upper GI 11688 25430 37118 11.05 1.31
Urology 19042 23672 42714 12.72 1.51
Tablevu.
Bolton Hospitals Trust: 2007/08
Non Elective
Elective Cancer Total Cancer % Share of Cancer % Share of all Bed
Cancer type Cancer Bed
Bed Days Bed Days Bed Days Days
Days
Breast 1066 618 1684 9.77 0.77
Endocrine System 211 100 311 1.8 0.14
Gynaecology 113 411 524 3.04 0.24
Haematology 259 1472 1731 10.05 0.79
Head & Neck 38 278 316 1.83 0.14
Lower GI 1216 1625 2841 16.49 1.3
Metastases 76 883 959 5.57 0.44
Multiple ICD10 Codes 167 523 690 4 0.32
Musculoskeletal 26 38 64 0.37 0.03
Neurology 14 368 382 2.22 0.18
Other Cancer 228 1152 1380 8.01 0.63
Skin 32 61 93 0.54 0.04
Thorax 197 2131 2328 13.51 1.07
Upper GI 425 1476 1901 11.03 0.87
Urology 814 1207 2021 11.73 0.93
In the Greater Manchester and Cheshire Bolton suffering with cancers in the
Cancer Network as a whole thoracic thoracic group are less likely than the
cancers account for 1.43% of all bed days; Network as a whole to be referred by
12.1% of all cancer bed days. For Bolton appropriate pathways and so must present
Hospitals Trust the share of all bed days as a non-elective admission, or that
falls to 1.07%, whilst share of all cancer comparatively, people stay in Bolton
bed days increases to 13.51%. Thus, Hospitals Trust for longer with thoracic
within the cancer types themselves, cancers than do those in the Network as a
thoracic cancer has the fourth highest whole.
share of all beds days and all cancer bed
days in the Network as a whole, but the Through analysis of excess bed days,
second highest share in Bolton Hospitals table w. shows the potential savings that a
Trust (behind lower GI) for all bed days PCT could make if its providers of services
and all cancer bed days. were treating all patients within the
maximum expected bed days set by the
An important factor evident from these HRG trim point. Calculations show that in
tables is the proportion of all thoracic bed 2007/08 Bolton PCT had 56 excess
days that are non-elective. In the Greater elective bed days and 132 excess non-
Manchester and Cheshire Cancer Network elective bed days for thoracic cancers,
76.4% of the total bed days for thoracic totalling 188 excess bed days. In Bolton
cancer are non-elective. In contrast, for PCT this accounts for a 5.74% share of
Bolton Hospitals Trust this figure is 91.5%. excess costs.
Reasons for this may be that people in
Table w.
Bolton PCT: 2007/08
Cancer type Actual Bed Elective Excess Non Elective Total Excess Total Excess % Share of
Days Bed Days Excess Bed Days Bed Days Costs Excess Costs
Breast 1677 11 171 182 36003 4.84
Endocrine System 351 172 18 190 49718 6.69
Gynaecology 1176 55 37 92 23521 3.16
Haematology 3251 300 309 609 183735 24.71
Head & Neck 860 50 89 139 35202 4.73
Lower GI 2676 57 159 216 48952 6.58
Metastases 1252 73 59 132 26333 3.54
Multiple ICD10 Codes 523 6 57 63 13205 1.78
Musculoskeletal 444 15 55 70 25476 3.43
Neurology 802 62 50 112 28232 3.8
Other Cancer 1392 23 578 601 135954 18.29
Skin 179 22 0 22 5808 0.78
Thorax 3026 56 132 188 42705 5.74
Upper GI 2538 69 128 197 47091 6.33
Urology 2139 73 106 179 41536 5.59
Lung cancer care pathway Establishing a tissue diagnosis is difficult,
often demanding an invasive procedure
The care pathway for people with (more detail below). The result of this is
suspected lung cancer can begin from any that there will always remain a proportion
number of referral routes; this is because of patients for whom diagnosis must be
the symptoms of lung cancer and established by clinical or radiographical
mesothelioma are relatively non-specific means. In addition, there are a proportion
(more detail below). Nationally, of those of patients whose illness and/or
diagnosed with lung cancer no more than comorbidities are too severe to be referred
half are directly referred from primary care to secondary care. The specialist nature
to the lung cancer specialist team. of the procedures required to diagnose
Furthermore, there are frequent delays in and treat lung cancer, mainly surgery,
diagnosis. Patients may not recognise radiotherapy, and chemotherapy, mean
their symptoms as predictive of lung that patients are frequently managed by a
cancer, especially as a persistent cough is number of trusts. In Bolton the chief of
not normally associated with a serious these are the Royal Bolton Hospital
illness. A delay furthered as the majority (predominantly palliative care), Central
of symptoms are often normal for a Manchester University Hospitals NHS
smoker. For such reasons GPs may not Trust (predominantly surgery), South
immediately suspect lung cancer and so Manchester University Hospitals NHS
referral may be delayed for further Trust (predominantly chemotherapy), and
investigation. Christies Hospital NHS Trust
(predominantly radiotherapy with some
Rapid referral guidelines are available: Bolton patients sent for chemotherapy
NICE Referral Guidelines for Suspected also).
Cancer 2004.
The diagram below details the lung cancer
Management of lung cancer patients is care pathway for Bolton patients. The
almost exclusively carried out by specialist blue section is the standard pathway and
multi-disciplinary teams (MDTs). Both maximum times set in days for the Greater
lung cancer and mesothelioma are Manchester and Cheshire Cancer Network
managed by the same specialist clinical of which Bolton is a part. (Pathway data
groups. given below is for the 2007 audit period
which was reported in 2009).
Nationally, almost half (47%) of lung care in general than is seen nationally, as
cancer cases are referred to a lung cancer socioeconomic deprivation and lack of
specialist from a primary care physician. presentation are associated to a certain
The remainder are predominantly referred extent.
following an emergency presentation or
from other secondary care specialists. For Nationally, the median wait date between
Royal Bolton Hospitals Trust this is 39%, referral and date seen (first specialist
only slightly less than the Greater appointment) is 6 days (interquartile range
Manchester and Cheshire Cancer Network 0-11 days). For Royal Bolton Hospitals
as a whole (40%). This may be seen as a Trust this is 2 days (interquartile range 0-
gap at primary care that may be improved 7) and is lower than that for the Greater
upon. We know Bolton has a higher Manchester and Cheshire Cancer Network
incidence and mortality rate than England as a whole (5 days). The interquartile
and Wales from lung cancer (see relevant ranges of these figures cross and so it is
previous sections), therefore we would difficult to make any significant
expect more people to present at primary comparative conclusions.
care with suspected lung cancer.
However, a higher proportion of people in The same is true for wait times between
Bolton compared to England and Wales date first seen and initial treatment.
have to wait until they suffer an Nationally, the median wait between date
emergency admission or enter secondary first seen and initial treatment is 29 days.
care for another illness. It is not clear This is longer for GP referrals (median 35
whether this is a problem with referral days) than for non-GP referrals (median
strategies at primary care in Bolton or 23 days)66. For Royal Bolton Hospitals
knowledge of symptoms and lack of
presentation in the Bolton population. As
66
a relatively more deprived population The pathway times given in the National Lung Cancer
however, we can expect a lower Audit differ from The Department of Health‟s „Cancer
Waiting Times‟ targets discussed previously in this
proportion of people to present at primary assessment.
Trust this is 31 days (28 days for GP Diagnosis
referral), which is lower than the Greater
Manchester and Cheshire Cancer Network As mentioned. diagnosis by a GP is
as a whole at 34 days (33 days for GP difficult as many symptoms of lung cancer
referral). The lower figure for Bolton for all are also symptoms of less severe
referrals compared to GP referrals differs respiratory diseases and ailments. From
from the national trend. The GP referral case studies, Beckles et al (2003)
route has a longer pathway, but the identifies the following symptoms of lung
unexpected figure may be influenced to an cancer and their frequency:
extent by the lower proportion of all
suspected lung cancer referrals made by
Table x. Range of frequency
GPs in Bolton compared to England and Symptoms (%)
Wales.
1 Symptomatic, but ambulatory (able to carry out light 90 Normal activity, minor symptoms
work)
2 In bed <50% of day (unable to work but able to live 70 Unable to work, cares for self
at home with some assistance)
10 Moribund
0 Dead
Treatment options are contingent upon the
performance status of the patient and
stage at diagnosis. The treatment matrix
pictured above is taken from NICE Lung
Cancer. The diagram is meant only as a
summary of the recommendations made
in the guidance and should be read in
conjunction with the more detailed findings
in the full document. However, for the
present purpose it serves to illustrates
how possible treatments vary according to
stage of lung cancer and performance
status of the patient.
67
The Information Centre (2009) National Lung Cancer
Audit: Report for the audit period 2007, The IC, London.
Table z.
National Lung Cancer Audit 2009
RMC
7 0
RBV
x x
Main trust sites for Bolton patients
RM2*
x x
RW3
8 37.5
N02
202 26.2
T1a or T1b, N0, M0 T2a, N0, M0 T1a, N1, M0 T2b, N1, M0 T1a, N2, M0 Any T, N3, M0 Any T, any N, with
M1a or M1b
T1b, N1, M1 T3, N0, M0 T1b, N2, M0 T4, N2, M0
T2a, N1, M0 T2a, N2, M0 T4, N3, M0
T2b, N0, M0 T2b, N2, M0
T3, N1, M0
T4, N0, M0
T4, N1, M0
In certain cases, for non-small cell lung the UK than it is for other Western
cancer, Stage I, II, and some IIIA are developed countries. Improving the
operable. resection rate is seen as the key goal in
improving survival rates72. As noted, the
Surgery is the main curative treatment for likelihood of surgery is affected by stage at
non-small cell lung cancer in the early presentation and comorbidity as well as
stages. However, early assessment is general health and fitness in the elderly;
vital in order to determine whether the despite this some cancer units in the UK
tumour is operable. Whether or not each reported resection rates of 15-20% in
individual case is operable is influenced by 2007. For the 2007 audit period Bolton
the health of the patient, the size of the Hospitals Trust reports a surgery
tumour, the location of the tumour, percentage of 10.6%. This met the Local
whether there is nodal or distant spread, Action Plan (LAP) target. (Bolton
and if mediastinal disease is present70. Hospitals Trust also attained its LAP target
in 2007 for percentage receiving any
However, radical surgery is appropriate for active treatment and percentage with
only a small proportion (around 20-30%) small cell lung cancer receiving
of all those with non-small cell lung cancer chemotherapy). The resection rate itself
in England. Importantly, this surgery does increased to 13.9% in 2009. In both
positively influence five year survival rates periods Bolton Hospitals Trust
– over 60% for early stage treatments, and demonstrates a higher percentage than
as high as 80% for very early squamous the Greater Manchester and Cheshire
cell carcinomas71. Cancer Network as a whole.
73 74
Souhami R, and J. Tobias (2005) Cancer and its The Information Centre (2009) National Lung Cancer
management (5th edition), Blackwell, Oxford. Audit: Report for the audit period 2007, The IC, London.
Table ab.
National Lung Cancer Audit 2009
RBV 0 0 0
Main trust sites for
Bolton patients
RM2* 75 88 6.7
The hazard ratio compares the death rates In the Greater Manchester and Cheshire
between two groups. In the National Lung Cancer Network Bolton Hospitals NHS
Cancer Audit this is a particular Trust has the second lowest ratio for 2007
trust/network compared to a baseline and the fourth highest, just above 1 at
trust/network. A hazard ratio of 1 1.03, for 2009. This however, represents
indicates no difference in death rates a significant improvement for Bolton
between the two groups. A ratio greater Hospitals Trust. The trusts immediately
than 1 indicates the trust/network has a prior and following are trusts that Bolton
better survival rate than the baseline trust. refers lung cancer patients to for specialist
treatments; South Manchester as the
lowest has failed to improve, while Central
Manchester has improved since 2007
(though the confidence intervals cross and
so this improvement cannot be said to be
significant).
75
Taken from presentation by Peake, M., National Lung
Cancer Clinical Lead, NHS Improvement and National
Cancer Intelligence Network, available on NHS Evidence
(www.library.nhs.uk)
76
The Expert Advisory Group on Cancer to the Chief
Medical Officers of England and Wales (2005) A Policy
Framework For Commissioning Cancer Services,
Department of Health, London.
Table ac.
Thoracic oncology
77
Transbronchial Needle Aspiration (TBNA); Endobronchial Ultrasound (EBUS); Endoscopic ultrasonography (EUS);
Ultrasound neck (US neck).
78
Immunohistochemistry (IHC).
79
Continuous Hyperfractionated Accelerated Ratio Therapy (CHART).
Two-week referrals to Royal Bolton The mean age at referral for the entire
Hospital period above is 69.6 years. This age has
varied slightly for each year: 68.8 years in
The following makes use of two-week 2005, 69.2 years in 2006, 70.6 years in
referral data at the Royal Bolton Hospital 2007, 68.0 years in 2008, and 71.3 years
for the calendar years 2005 to 2009, in 2009. This includes patients referred
supplemented by published National Lung from outside Bolton. For lung cancer the
Cancer Audit information where younger at which a person is diagnosed
appropriate. the more likely they are to be viable for
curative treatment, both in terms of their
As discussed previously in this fitness to undergo invasive procedures
assessment, Bolton Hospitals Trust met its and the stage of their lung cancer.
„two-week target‟ wait from urgent GP
referral to first outpatient appointment with Following diagnosis, the stage of the lung
suspected cancer for all cases between cancer must be ascertained to inform
Quarter 1 2004/05 and Quarter 2 2009/10. appropriate treatment and management.
Table ad. details the total number of two- For all diagnoses with a stage recorded
week referrals made to the Royal Bolton between 2005 and 2009 at Royal Bolton
between 2005 and 2009, totalling 1,316 in the greatest proportion are made in the
all (this includes patients referred to the later stages of lung cancer – 41.9% at
Trust from outside Bolton). The difficulty Stage III, and 37.9% at Stage IV.
of diagnosis is evident when we consider Nationally, patients most often present
that of these 1,316 referrals for suspected with Stage IV lung cancer (metastatic
lung cancer only 372 (28%) were actually disease)80.
diagnosed as lung cancer.
Table af.
Royal Bolton Hospital: Staging at
Table ad. Year Number of 2 week referrals diagnosis 2005-2009
2005 253
2006 277 Stage I 15.0%
2005 21%
2006 34%
2007 28%
2008 27%
2009 30%
2005-2009 28%
80
The Information Centre (2009) National Lung Cancer
Audit: Report for the audit period 2007, The IC, London.
Stage III and Stage IV diagnoses Inequalities in lung cancer begin with
dominate, accounting for over 70% of all lifestyle, chiefly smoking, but persist into
diagnoses in each age group. Though not diagnosis:
portrayed on the above chart, all Stages
(with the exception of Stage II, for which “Deprived groups have an
there are very few diagnoses at all) reflect increased risk of getting cancer
the mean age of diagnosis at Royal Bolton and a lower likelihood of gaining an
of 69.6 years. This reflects the national early diagnosis” (Greater Manchester
picture where the majority of cases are Public Health Practice Unit, 2010, pg.15)
diagnosed between 60 and 85 years of
age81. At Bolton Hospitals Trust, age This is partially reflected in two-week
groups 65-74 and 75-84 feature the referrals for whom a diagnosis of lung
largest number of diagnoses, the majority cancer is made at the Royal Bolton. Here
of which, as shown above, are diagnosed it is demonstrated that 44% of all patients
at Stages III and IV. from the most deprived quintile in Bolton
are diagnosed in the later stages of lung
That the majority of lung cancer at cancer (stages III and IV) compared to
diagnosis in Bolton is found to be in the 37% of Bolton patients overall. (This data
later stages III and IV means that the is only for those patients referred for
treatment options available are severely diagnosis at the Trust who have a Bolton
limited. This has a considerable negative postcode and so does not include a great
impact upon the outcome for a diagnosis proportion of patients who are diagnosed
of lung cancer for Bolton people, and is a here from outside Bolton).
major contributory factor to the high
mortality rate and low survival rate The following concerns only those
following diagnosis. referrals to Royal Bolton with a diagnosis
of lung cancer who are also Bolton
residents. The two periods below do not
match exactly, but they are wide enough
for a simple comparison to be made.
81
The Information Centre (2009) National Lung Cancer Despite the large time scale, the two-week
Audit: Report for the audit period 2007, The IC, London.
referral data features a much lower mortality, the ideal would be for these two
number of counts and this is reflected in charts to roughly demonstrate the same
the confidence intervals for each quintile. declining significant pattern across
quintiles.
The first chart shows the standardised rate
of two-week referrals to the Royal Bolton Given that the mortality rate in the most
diagnosed with lung cancer over the deprived quintile in Bolton is so high
period 2005-2009. The confidence compared to the least deprived, it is
intervals show there to be no significant reasonable to expect that a significantly
difference between the quintiles. In greater proportion of two-week referrals
contrast, the next chart shows that are diagnosed with lung cancer
standardised mortality from lung cancer in should come from the most deprived
Bolton over the period 2002-2008 to be quintile. This is not the case. While there
strongly associated with deprivation is clearly a greater proportion of morbidity
quintile. The difference between the most in the most deprived quintile, that results
deprived and the least deprived in in the higher mortality rate above, this
particular demonstrates a considerable does not appear to translate significantly
significant difference. Accepting that into two-week referrals to the Royal
deprivation influences lung cancer Bolton.
Very few two-week referrals diagnosed as clusters are however generally less
lung cancer are for patients registered with deprived than the Red, Orange, and
practices within the Red, Orange, and Yellow. There is very little published
Yellow GP clusters. These clusters all literature concerning lung cancer at
have a high level of deprivation (Red – primary care. We do know that despite
high; Orange – High; Yellow – the high mortality from lung cancer, it is
High/Medium). However, these clusters rare at the level of GP practice. GPs can
all have a comparatively young and expect to encounter a new lung cancer
ethnically BME and mixed populations. every eight months; this means that GPs
This demographic make-up can be typically build up very little personal
expected to skew the referrals we would experience of its diagnosis.
expect from people referred from these
practices. Whilst these are the most The mean age of two-week referrals
deprived practice populations in Bolton, diagnosed as lung cancer at the Royal
lung cancer is a disease that primarily Bolton who also have a Bolton postcode is
affects older people and smokers (as 68 years. This is almost two years
noted previously, while smoking younger than for all two-week referrals
prevalence in South Asian men is similar diagnosed as lung cancer at the Royal
to the White population in Bolton, smoking Bolton (69.9 years as discussed above).
in South Asian women is extremely low). Differences are evident by gender for
In contrast, 28.9% of all two-week referrals diagnosed Bolton residents with the
to Royal Bolton are from practices within average age for women being 67.4 years
the Blue cluster, 27.7% from the Green compared to 68.7 years for men.
cluster, and 24.1% from the Indigo cluster. Differences are also apparent by NRS
These clusters have the largest area where the mean age at referral is
populations (Indigo – 81,445; Blue – 67.8 for those not living in an NRS area
56,855; Green – 58,342) compared to compared to 68.5 for those within an NRS
those above (Red – 20,484; Orange – area, almost one year difference.
34,710; Yellow – 36,847), have However, greater differences are
predominantly white populations, and illustrated when we put these two
principally normal/old age ranges. These together. The first thing to notice (table
ag.) is that female referrals show a 50% Bolton resident diagnosed with lung
split by NRS and non-NRS area. NRS cancer at the Royal Bolton over a five year
areas account for just 32% of the total period and so is representative of the
population of Bolton, but as the most types of people there referred. There is a
deprived areas we would expect higher switch by gender across the areas. In
smoking prevalence (Bolton‟s NRS areas Bolton overall, two-week referrals
taken together have a smoking prevalence diagnosed as lung cancer are made for
10% higher than Bolton as a whole, and women at a mean age of 67.4 years and
this has remained static between the 2001 men at 68.7 years, as mentioned above.
and 2007 health surveys), morbidity, lung This difference becomes unbalanced at
cancer incidence, and co-morbidities. The NRS area level where men are more likely
pattern is very different for Bolton men to be referred younger than women. This
where 70% of all male referrals are from reflects the morbidity in the population
non-NRS areas. Again, obviously there where women live longer and men are
are more men in non-NRS areas than more likely to get lung cancer younger as
NRS areas, and the percentage split they have a higher smoking prevalence.
almost exactly fits the 32% proportion. Smoking levels decrease steadily in
However, we know there is higher Bolton as you move from the most
mortality from lung cancer in NRS areas; deprived quintile through to least deprived
therefore we would reasonably expect the quintile. People in the most deprived
percentage split to be skewed beyond quintile are more than twice as likely to
32% because of the greater morbidity in smoke as those in the least deprived
the NRS population compared to the non- quintile, and across all groups men are
NRS areas. However, two factors are at more likely to smoke than women.
play here that are well known but difficult Therefore, table ah. shows the result of
to overcome. The first is, following the this behaviour in NRS areas.
quote above from the Greater Manchester
Public Health Practice Unit that the most Table ah.
Two-week referrals at Royal Bolton: Bolton residents (age
deprived (and so those in NRS areas) are in years)
less likely to seek help; the second is an
exacerbation of this as men in general are Female Men
less likely to visit primary care compared NRS 71.6 63.9
to women, a gap that may be widened in
deprived areas in Bolton. At least, this
seems to be the case for two-week lung Non-NRS 63.3 70.7
referrals diagnosed as lung cancer.
Bolton 67.4 68.7
Table ag.
Two-week referrals at Royal Bolton: Bolton residents
Non-NRS NRS
The reversal for non-NRS areas is difficult
Female 51.3% 48.7% to explain. Considerations are that the
difference between men and women in
Male 70.5% 29.5%
terms of smoking prevalence is not as
great in lesser deprived quintiles
compared to the most deprived. Plus,
Persons 61.4% 38.6% lower smoking prevalence overall in the
non-NRS group is likely to produce less of
an effect. We should also consider the
Further dividing referrals diagnosed with possibility that men in the NRS group are
lung cancer by NRS area produces an more likely to be exposed to harmful
unusual result. Table ah. gives the mean working conditions that may affect
age at diagnosis for men and women split incidence. However, smoking is still
by NRS and non-NRS area. The numbers higher in men in the non-NRS group than
are relatively small, but this includes every it is women, and women still live longer in
this group than men. As mentioned, The overall aim of the research was to
women are more likely to access primary gain insights into the events surrounding
care and so we would expect women to be the diagnostic processes for the two
diagnosed and referred earlier; for named cancer groups drawn from a
instance, rather than waiting for a chance secondary analysis of significant event
finding or an emergency admittance. audit (SEA) documents. The research
Therefore, to a degree the non-NRS age was carried out in trusts within the North of
split also makes sense. England Cancer Network. While not
carried out in the Greater Manchester and
The major issue from all this is the Cheshire Cancer Network, the North of
worryingly late age women in NRS areas England Cancer Network is perhaps the
are referred, and the similar picture seen most comparable, and as this is a study
for men in Non-NRS areas. undertaken by NAEDI in response to the
Cancer Reform Strategy the findings
Finally, despite covering a five year period should be considered of high importance
for all Bolton residents referred to the to this assessment and has value to the
Royal Bolton the numbers at GP practice goal of improving cancer diagnosis and
level, and to a lesser extent GP cluster referral from primary care.
level, are relatively small. For this reason,
and with reference to the likelihood of a Insights into the referral process for lung
particular GP having experienced many cancer
lung cancer referrals, it is unwise to focus
on individual practices. The confidence The first point of note the research found
intervals are extremely wide and this is was the complexity involved in the process
why referrals to the Royal Bolton have not of diagnosis of lung cancer at primary
been analysed at practice level in this care:
assessment. Rather, the data justifies
treating primary care as a whole for this “Chest symptoms are common in
particular issue, with perhaps greater general practice, and extremely
emphasis on practices with older, or a common among smokers, who
high smoking population. This is a have a much higher risk of lung
straightforward reflection of the causes cancer than other population
and aetiology of the disease, but as the groups. It is within this context that
numbers are small at practice level, little GPs have to decide who to treat,
can be expected to be gained from who to investigate, and who to
singling out individual practices. refer” (Mitchell, E. et al, 2009, pg.15)
Exemplar a.
L-06: Patient presented with a history of URTI with increasing cough. Examination revealed
tenderness over the anterior chest wall and right chest signs. The patient was prescribed analgesia
and antibiotics, and given a review appointment with the same GP to check resolution after treatment.
Patient was reviewed two weeks later and reported pain was much better but cough persisted.
Examination showed that there were still signs in the chest. CXR was organised and carried out two
days later. The following day the report was faxed to the surgery. The GP contacted the patient that
day and arranged for them to come into the surgery the same day with a family member, after which a
2WW referral was sent.
This case demonstrates the importance of good safety-netting, as well as good communication
between primary and secondary care, and between the GP and the patient and their family.
Exemplar b.
L-09: Patient presented with a hoarse voice and was treated by the GP. Review was arranged for
eight days later at which time the patient was no better. The patient was referred under the 2WW to
ENT for persistent hoarse voice. CXR was done as part of the work up and showed a suspicious
lesion. The patient was then referred under the 2WW to the chest clinic.
This case demonstrates the importance of good safety-netting, as well as good follow-up by the GP
as part of the referral process.
Exemplar c.
L-14: Patient (50 year old ex-miner) with a known diagnosis of asthma presented with a one month
history of dry cough. There were chest signs on examination and the patient was given a course of
steroids, but because of the duration of cough, a CXR was arranged at that initial consultation. This
showed signs of infection in the right lung. Follow-up was not recommended by the radiologist. The
patient attended again around three weeks later saying that they still had a dry cough and did not feel
quite right. Chest signs were heard corresponding to previous CXR changes; the patient was given
antibiotics but a repeat CXR was ordered to ensure resolution of infection. However, the CXR showed
progressive changes and the patient was immediately referred under the 2WW to the chest clinic.
This case demonstrates the importance of vigilance, good safety-netting, and GP follow-up.
Exemplar d.
L-28: Patient was under the care of the rheumatologists. GP noted that the inflammatory markers had
been rising and the haemoglobin falling, and so wrote to the rheumatology consultant. The patient did
not have any symptoms, but the rheumatology appointment was brought forward and a CXR carried
out at the clinic; this showed a lung mass.
This case demonstrates the importance vigilance by the GP, particularly as these blood tests were
secondary care results being copied to general practice. The communication between primary and
secondary care worked well.
Exemplar e.
L-43: Patient (72 year old) presented to the GP registrar with a three-week history of a productive
cough. In view of smoking history and clinical findings, a CXR was ordered. The same day the
radiologist phoned to say that there were significant changes in the left upper lobe and advised that
the patient should be given antibiotics followed by an interval CXR four weeks later. A week later the
patient returned no better and was offered immediate referral but declined this, instead opting for
another antibiotic. The patient was seen another week later, much improved. They then had the
repeat CXR as planned four weeks after the original one, which was slightly improved but urgent CT
scan was advised and arranged.
This case demonstrates prompt appropriate action by the GP registrar in line with guidance; it also
shows good communication between primary and secondary care.
Exemplar f.
L-68: The patient was noted by the nurse to be thin at COPD review. They were seen the following
month by the nurse, weight loss documented but declined to see the GP. The patient was persuaded
to see the GP around 2 weeks later and a CXR carried out that day was reported as normal.
However, in view of the weight loss the patient was referred urgently to the chest clinic.
This case demonstrates that although the process in primary care did take some time, due mainly to
the patient‟s wishes, it was started by the observation of the nurse, who followed that observation up.
(Source: Mitchell, E. et al, 2009, pg.27-28)
Learning points related to lung cancer The study states that some points have
diagnosis been mentioned by only one or two GPs,
but the researchers have drawn out as
SEAs involve discussion of the event many as possible to document the key
within a team meeting. This allowed the issues raised by practices arising from the
discussion and reflection of GPs following completion of SEAs.
diagnosis of lung cancer to be evaluated
in the research. The learning points were Learning points concerning presentation
analysed under five broad themes: and diagnosis of lung cancer focused on
the complexity of atypical symptoms, the
1. Presentation and diagnosis of lung need for vigilance even when symptoms
cancer; appear straightforward, and the
2. System issues and the primary usefulness and limitations of CXR as a
diagnostic tool. The chief detailed
care/secondary care interface;
learning points identified by practitioners
3. Patient related factors; were:
4. Practitioner issues;
5. The role of guidelines. Lung cancer does not always
present typically and there are no
immediate warning signs or „red difficulties sometimes involved in
flags‟ on presentation; diagnosing malignancy;
Be aware of atypical symptoms CXR reports can sometimes give
and be prepared to investigate; false reassurance;
Do not always presume the most Lung cancer cannot be excluded
common cause for a problem; even if a CXR is normal;
Primary care input into A normal CXR can become
management can only be achieved abnormal over a relatively short
if patients present symptomatically; time period;
Initial presentation may be with Awareness to refer people with
secondary signs of malignancy, continuing symptoms, even if CXR
and this may obscure the issue is negative.
and potentially delay diagnosis;
Co-existing disease can mask Learning points concerning system issues
and the primary care/secondary care
symptoms of malignancy; interface focused on communication and
The possibility of a serious record keeping:
diagnosis should be considered in
patients with a known diagnosis, Effective communication and team
either those with an existing working is key;
respiratory condition (asthma, Be aware of those patients who
COPD) or other concurrent are under the care of several
disease; specialties, as key questions can
Have a heightened suspicion of be missed even when there is
lung cancer in patients with ongoing and regular
worsening COPD or new or communication;
persistent COPD symptoms; It would be useful to document
Malignancy should be considered when a patient was referred
as a possibility, even when urgently if a possible diagnosis of
symptoms sound innocuous; cancer was discussed;
Musculoskeletal sounding pain Difficulties related to the
(neck or shoulder) can be a importance of trying to ensure
presenting symptom for lung continuity within the practice so
cancer, and should have a low that patients with ongoing
threshold for CXR request; symptoms can be reviewed by the
There is a need to always remain same GP;
suspicious of symptoms in patients The importance of record keeping
who are smokers; to ensure that other colleagues are
Lung cancer can occur in patients aware of patients‟ previous
who are non-smokers; complaints;
Have a high index of suspicion and The importance of reviewing recent
a low threshold for investigation medical history (including hospital
and CXR in patients with persistent and GP appointments) when
cough (both smokers and non- seeing a patient;
smokers); The importance of ensuring that
Reminder of the general signs and test results are passed to the
symptoms of malignancy and the practitioner who requested the test,
for review;
The importance of review methods attends for reason or is discussing
for follow-up of abnormal tests (i.e. another issue;
would a telephone call be more There is a need for patient
appropriate than a letter); education in relation to
Consider reviewing patients longstanding new or vague
undergoing hospital investigations symptoms so that delay can be
and follow-up as this may prevent reduced;
delays in the hospital system if GP Patient autonomy during
can re-refer; diagnostic, treatment, and
Never be wary of re-referring to palliative phases need to be
secondary care, even if the patient respected.
has been discharged;
Learning points concerning practitioner
Awareness of the „two-week wait‟
issues focused on the need for safety-
and that it is very beneficial in netting (the inclusion of back-up
ensuring rapid access to processes to make predictions for and
secondary acre; deal with alternative outcomes following a
Be prepared to question working diagnosis and the creation of a
discharges from secondary acre; provisional management plan83. The
report quotes Neighbour‟s original safety-
The importance of immediate
netting concept as being comprised of
access to CT scan for sinister asking three specific questions: a) “If I‟m
symptoms; right, what do I expect to happen?” b)
The importance of direct access to “How will I know if I‟m wrong?” c) “What
CXR films electronically; would I do then?”84 Detailed learning
The benefit of rapid reporting of points identified were:
CXR results (fax was especially
Safety-netting is an important part
useful).
of the consultation;
Learning points in relation to patient There is a need to give robust
specific factors centre upon co-morbidities safety-netting advice;
and lifestyle factors: Too much detail around safety-
netting may prevent patients from
It is important to have a record of re-presenting;
a patient‟s smoking status and
It is important to „link‟
smoking history;
consultations, especially when
Although it is often difficult to continuity is an issue;
influence patient behaviour in
Recurrent or non-resolving
relation to smoking, practitioners
complaints should be investigated
should keep trying;
further;
Consider serious diagnosis in
Follow-up is important with upper
patients who present only
respiratory tract infections;
infrequently or who are not typical
Do not assume that results will
candidates for lung cancer (usual
automatically be reported or that
good health, younger age, non-
they will automatically be reported
smokers);
to the requesting practitioner;
Be vigilant of warning symptoms
even if these are brought up 83
Neighbour, R. (1987) The Inner Consultation, MTO
coincidentally when the patient Press, Lancaster.
84
Neighbour, R. (1987) The Inner Consultation, MTO
Press, Lancaster.
It is important to follow up patients „Gut instinct‟ and experience are
after negative results; also important;
It is important to prioritise clinical There is a need to remain patient
signs/symptoms rather than centred, and at times to negotiate
negative test results; a referral pathway that is
It is important to be aware of acceptable to the patient.
warning symptoms when
mentioned, even if that is not the Secondary care
focus of the consultation; The data discussed in this section is from
It is important to ask specific the Secondary Uses Service dataset and
questions when patients report concerns all patients with a diagnosis of
improvement on review; lung cancer with a Bolton postcode
Examination is a key part of early regardless of the trust at which they
diagnosis; received treatment.
Serially documenting patient Table ai. shows the total secondary care
weight is valuable; acute trust activity for residents of Bolton
Writing to patients who fail to between 2006/07 and 2008/09 with a
attend appointments is effective; diagnosis of lung cancer. In the
It is important to have up-to-date „Summary: Cancer Commissioning Toolkit‟
section of this assessment the problem of
contact details for patients in case
increasing emergency admissions for
urgent contact is required. cancers was discussed and the desire to
reduce this nationally made apparent.
Learning points concerning the role of Figures for the three yearly periods below
guidelines and existing referral pathways for lung cancer are however relatively
related to cases where guidelines had consistent, showing no increase or
been followed, to cases where the decrease in Bolton.
guideline was not appropriate due to other
associated factors such as symptoms not Table ai. Day Non-
Elective
meeting referral criteria, patient presenting cases elective
elsewhere (Accident and Emergency), and
the patient already being under specialist 2006/07 Count 179 151 139
care. Detailed points were: Bed days 0 630 1627
Average LOS 0.0 4.2 11.7
Raised awareness of the criteria
for urgent „two-week wait‟ referrals 2007/08 Count 112 138 148
Bed days 0 754 1468
for suspected cancer;
Average LOS 0.0 5.5 9.9
Reminder that the NICE guidelines
for COPD suggest CXR as part of 2008/09 Count 109 128 135
initial assessment; Bed days 0 497 1548
NICE guidelines do not always Average LOS 0.0 3.9 11.5
reflect local suspected cancer
referral protocols; The stability of the non-elective cases is
It is not necessary to have a CXR positive given Royal Bolton‟s overall high
emergency admissions; Royal Bolton‟s
result to refer under the „two-week
Accident and Emergency receives
wait‟; 100,000 attendances a year and
Guidelines are useful, but there is significantly more Greater Manchester
still a need for practitioners to be Ambulance Service ambulance arrivals
vigilant and to be suspicious of than any other acute trust in Greater
potentially serious symptoms; Manchester. Compared to Greater
Manchester the Royal Bolton is lesion of the lung‟. The figures used
consistently amongst the three busiest above are only for interventions E46-E63
trusts in terms of non-elective admissions with a diagnosis of lung cancer. However,
(38,000 per year) and has the highest taking all interventions undertaken on all
number of emergency admissions. persons with a diagnosis of lung cancer
Placing the Royal Bolton within this over the three year period allows
context, it is perhaps sensible to expect diagnostic and exploratory scans to be
high non-elective and emergency identified. Computed tomography (CT)
admissions for lung cancer from the scans of the head, chest, and spine are
Bolton population, but as demonstrated more common than Magnetic Resonance
earlier, Bolton PCT has comparatively Imaging (MRI) scans in the Bolton dataset.
low/average referrals for suspected lung
cancer from routes beyond primary care. Because of the aggressive nature of lung
However, this is an important indicator to cancer the disease rapidly spreads to
monitor for Bolton given the high Accident other parts of the body and many
and Emergency use in general. interventions are also undertaken to
combat this.
The most frequent interventions
undertaken for those with an ICD-10 code Taking primary cases of all those with a
of C33-C34 are diagnostic, as we would diagnosis of lung cancer a clear variation
expect. Most common is „Diagnostic across deprivation quintiles is evident.
fibreoptic endoscopic examination of lower This is shown below where the most
respiratory tract and biopsy of lesion of deprived quintile has a significantly higher
lower respiratory tract‟. This intervention directly standardised episode rate (per
is followed distantly by „Diagnostic 100,000) compared to the least deprived
fibreoptic endoscopic examination of lower quintile of Bolton‟s population. This is to
respiratory tract and broncho-alveolar be expected given that this quintile has a
lavage (cell differential)‟. These are higher lung cancer mortality rate and
followed distantly by „Biopsy of lesion of smoking prevalence.
the lung NEC‟ and „Needle biopsy of
The following considers episodes by GP smoking prevalence‟s are found in
practice. The SUS dataset cannot tell us practices from the Orange and Green
whether each episode was referred to clusters. Secondary care access is more
secondary care by primary care, or evenly spread across clusters and so does
whether the episodes result from not follow the pattern of smoking
unscheduled care or other means. prevalence as closely as other disease
However, in an equitable service we would areas with a strong association with
expect a higher proportion of people to be smoking. This is representative of the
treated in secondary care from the more entire lung cancer care pathway, where
deprived sectors of Bolton because of the standardisation is urgently needed. The
strong association between National Lung Cancer Audit continually
socioeconomic deprivation and lung emphasises the differences in access,
cancer incidence. One person can have, correct referral, and treatment between
and is indeed likely to have, more than Cancer Networks. What we see here at
one episode of treatment. This has been primary care level, while by no means
taken into account as far as possible by conclusive, is perhaps an indication of
only taking the first episode of care in the these wider discrepancies. However, we
below calculation. Those practices with must remember that not every smoker
the highest rate of patients who are gets lung cancer, and that those in
treated in secondary care for lung cancer deprived areas have a lower life
are mostly fairly evenly spread between expectancy than their lesser deprived
the Red, Orange, Yellow, and Green counterparts and that lung cancer is often
clusters. This is what we would expect to diagnosed in old age may influence the
an extent. It does reveal inequalities to a data. However, it is reasonable to assume
certain degree as lung cancer is a disease that if fully equitable secondary care
suffered in old age, but practices in these access should match and be as uniform
clusters have a relatively young population as smoking prevalence. At the very least,
(Red – young; Orange – young/normal; the wide variation in access between
Yellow – young/normal; Green – practice populations is a gap where gains
young/normal/old). However, much of this may potentially be made.
difference will have been accounted for in
the age standardisation involved in the
calculation. The Blue and Indigo clusters
have predominantly normal/old
populations and so with no knowledge of
the aetiology of lung cancer we would
expect higher incidence here, but
practices in these clusters are less
deprived and have a far lower smoking
prevalence.
85
Macmillan (2010) www.macmillan.org.uk
The chart above shows the number of
fractions per million population delivered The chart below shows that for 2007/08
by all local radiotherapy centres for the Christie had 7,547 average fractions
2007/08. The NRAG report recommends per linear accelerator per year. This is
that by 2010/11 an interim goal of 40,000 almost exactly average for all
fractions per million population should be Radiotherapy Centres in England. For
met by radiotherapy services. This goal 2006/07 the Christie was slightly below
recognizes that the workforce and linear average, but had a similar figure for this
accelerator capacity of radiotherapy indicator of 7,260.
services needs to be expanded to meet
the increased demand expected in the The Cancer Reform Strategy identifies key
future. priorities for improving the treatment of
cancer patients, of which the development
For the 2007/08 audit period the Christie of world class radiotherapy services is a
Hospital carried out 23,527 fractions per part. The indicator 3E compliance
million. This is an improvement on measures the performance of radiotherapy
2006/07 where 20,542 fractions per million services against measures identified in the
were carried out. This means that as Manual for Cancer Services. These
illustrated on the the below chart the measures focus on measuring high quality
Christie is the Radiotherapy Centre through clearly defined leadership and
carrying out the seventh lowest fractions organisational arrangements, adequate
per million; in 2006/07 the Centre was the provision of professional staffing and
third lowest. equipment, minimising delays for
treatment and breaks in treatment, the use
Also of interest are the average fractions of standardised processes for prescribing
per linear accelerator per year. This and checking radiotherapy treatments, the
performance indicator is based on the use of standard principles for the delivery
NRAG report which recommends 8,300 of radiotherapy, and the existence of clear
fractions per annum averaged across all documentation and quality assurance
linear accelerators in a department by processes.
2010/11.
The second chart below shows the localities is 81% (median 84%), and so the
Christie to have 75% compliance with 3E Christie falls just below this.
measures. The mean average for all
Chemotherapy above average for the Greater Manchester
and Cheshire Cancer Network (12.2%)
Chemotherapy is the use of anti-cancer (South Manchester has been removed as
(cytotoxic) drugs to destroy cancer cells by a tertiary trust).
disrupting their growth. Most
chemotherapy drugs are injected into the From NICE guidance discussed
vein or through a drip, but some are pills previously, chemotherapy should be the
the patient must swallow. Typically, a first recommended choice for patients
patient will receive a combination of two or presenting with Stage IIIb or IV non-small
three different drugs and have cell lung cancer. Of the non-small cell
chemotherapy every three or four weeks. lung cancer patients received by Bolton
A patient will usually receive four to six Hospitals Trust 56.2% were diagnosed at
treatments, and so a typical course can Stage IIIb or IV and this figure is the
take three to four months. highest in the whole Network. At Bolton
Hospitals Trust, of the 56.2% presenting
A patient with non-small cell lung cancer with Stage IIIb or IV non-small cell lung
may receive chemotherapy before or after cancer, only 12.6% received
surgery or radiotherapy. In advanced chemotherapy.
disease a patient may receive a combined
treatment of radiotherapy and The 2009 audit identifies the national
chemotherapy. Finally, chemotherapy mean for chemotherapy rates for
may be used to control the symptoms of performance status 0-1 stage IIIb or IV
non-small cell lung cancer. non-small cell lung cancer as 48%. The
figure for Bolton Hospitals Trust is 27.8%,
In the 2009 audit 14.2% of all non-small which is similar to that for the Network as
cell lung cancer cases (of which there a whole (26.2%).The audit recommends
were 169) at Bolton Hospitals Trust all Trust‟s below the national mean should
received chemotherapy. This is just be reviewed.
Improving the resection rate for non-small below the national mean (62%) and the
cell lung cancers is considered the audit recommends that chemotherapy
greatest way of reducing the mortality rate rates for small cell lung cancer falling
and increasing the survival rates in these below this should be reviewed.
patients86. Surgery is inappropriate for
small cell lung cancer as this is the most The Cancer Reform Strategy identified key
aggressive form of the disease and priorities for improving treatment to
spreads to the rest of the body very patients. The metric „Compliance with 3C-
quickly. However, small cell lung cancer 1 measures‟ provides an indication of the
is extremely chemosensitive, and for this performance of chemotherapy services, in
reason it is the main treatment for small particular the Clinical Chemotherapy
cell lung cancer. Furthermore, as Services, against measures contained
chemotherapy treats the whole body (as it within the Manual for Cancer Services.
travels through the blood stream) it can The metric considers governance
treat the cells that have broken away from arrangements for the chemotherapy
the main lung tumour87. From the 2009 service, the local chemotherapy group,
audit Bolton Hospitals Trust treated 44.4% guidelines and protocols, patient centred
of its small cell lung cancer patients, a care, safe delivery of chemotherapy, safe
figure similar to the Network as a whole workload arrangements, 24 hour
(43.6%). After Central Manchester (21 telephone advice, staff training, and
cases) Bolton Hospitals Trust recorded the service improvement.
greatest number of small cell cases in the
Network (18 cases). This is similar to the Percentage compliance with 3C-1
2007 audit where Bolton Hospitals Trust measures concerns clinical chemotherapy,
recorded 15 small cell cases, however, 3C-2 the oncology pharmacy service, and
80% of these received chemotherapy. 3C-3 IT chemotherapy.
However, the 2009 figure of 44.4% falls
86
The Information Centre (2009) National Lung Cancer
Audit: Report for the audit period 2007, The IC, London
87
Cancer Research UK (2010)
www.cancerresearchuk.org
As a locality, Bolton has 58% compliance Trust. The National Lung Cancer Audit
with 3C-1 measures. For comparison, records cases by the Trust at which they
average compliance for all localities is were first seen. (South Manchester has
73%, and compliance for the whole been excluded as a tertiary trust).
Greater Manchester and Cheshire Cancer
Network is 67%. From the 2009 audit, 12.9% of all lung
cancer cases within the Greater
As a locality, Bolton has 82% compliance Manchester and Cheshire Cancer Network
with 3C-2 measures. For comparison, receive surgery. There is great variation
average compliance for all localities is within the Network; Bolton Hospitals Trust
81% (median 91%), and compliance for is around this average with 13.9%
the whole Greater Manchester and receiving surgery, Central Manchester is
Cheshire Cancer Network is 78%. the lowest with only 11.5% receiving
surgery, whilst East Cheshire NHS Trust
For 3C-3 measures Bolton has a achieved resection rates over 45%.
compliance of 0% as it has zero counts for However, East Cheshire receives a
usage concerning this metric (IT relatively small amount of cases (53
chemotherapy). compared to 194 for Bolton Hospitals
Trust and 113 for Central Manchester,
All charts and data discussed previously in whilst Wrightington, Wigan, and Leigh,
this section are from the Cancer and Pennine Acute Hospitals Trust‟s both
Commissioning Toolkit88. recorded over 300 cases in 2009). The
surgical resection rate in England and
Surgery Wales is 11%. The audit recommends
that all trusts below the national mean
The majority of lung cancer cases should be reviewed. The main Trust‟s of
requiring surgery in Bolton are referred to greatest importance to the population of
the Manchester Royal Infirmary at Central Bolton and the Network as a whole all
Manchester University Hospitals NHS achieve the national mean.
88
Cancer Commissioning Toolkit (2010)
www.cancertoolkit.co.uk
Surgery is mostly appropriate for non- composition of population in terms of age,
small cell lung cancer. In the Greater sex, socioeconomic status, and stage. An
Manchester and Cheshire Cancer Network odds ratio less than one suggests that the
only 10.9% of all non-small cell lung outcome for patients in the Trust/Network
cancer cases receive surgery. For Bolton is less likely than the population average
Hospitals Trust this figure is 8.9%. Again, and the converse for odd ratios above
this is about average for most Trust‟s one. This is not a statistically significant
within the Network, with East Cheshire observation if the confidence intervals
achieving 40%. (Again, in comparison span one (identified on the below chart by
East Cheshire receives relatively few the red line). East Cheshire has been
cases of non-small cell lung cancer). excluded from the chart as it has an
extreme odds ratio (13.4) comparative to
Odds ratios represent a more considered the group.
and comparable measure of resection
rates across Trust‟s. The odds ratio As evident, all Trust‟s around one also
shows those having surgery in a specific have confidence intervals that span one
Trust/Network relative to the whole and so no firm conclusions can be drawn.
Lucada population, adjusted for
Mesothelioma audit: Greater where many of the tests used to diagnose
Manchester and Cheshire Cancer lung disease prove negative89.
Network
Bolton participated in the Greater
Mesothelioma is a relatively rare cancer Manchester and Cheshire Cancer Network
and it is difficult for GPs to effectively Mesothelioma audit.
diagnose suspected cancer as symptoms
may often be similar to much more minor Outcomes
conditions. NICE guidelines state that
GPs should refer patients for an urgent Majority (86%) of GP referrals
chest X-Ray if they have been exposed to seen in two weeks, but
asbestos in the past and have chest pain, subsequent delays in diagnosis
difficulty breathing, or unexplained
were evident;
symptoms lasting more than three weeks
such as shoulder pain, cough, or weight Very low diagnostic value of
loss. Where a chest X-Ray shows pleural fluid cytology;
anything abnormal the patient will be Delays for patients having open
referred to a specialist (according to the surgical biopsies after non-
two-week rule this is expected to be within diagnostic Abrams/percutaneous
two weeks of the original GP visit).
biopsy;
In addition to a chest X-Ray, diagnosis Performance of Greater
tests for mesothelioma may also include a Manchester and Cheshire Cancer
CT scan, a thorcoscopy, a laparocoscopy Network cohort higher than
with a biopsy, or involve fluid drainage national Lucada data;
from around the lungs. This is because of MDT discussion for 58% of
the difficulty in diagnosing mesothelioma
patients;
89
Cancer Research UK (2010)
www.cancerresearchuk.org
Low referrals to palliative care
consultants; The National Cancer Action Team and the
Audit found that 66% of patients Royal College of General Practitioners
undertook a primary care cancer audit in
were recorded as being seen by a
the Greater Midlands Cancer Network in
Specialist Nurse. March 2010. This also involved analysis
of SEAs and a current local version may
Recommendations made following the again prove useful.
audit
Finally, Doncaster PCT have successfully
Patients over 50 years of age with undertaken a social marketing project to
pleural effusion and history of improve early presentation and diagnosis
asbestos exposure should be of lung cancer in primary care and
treated as „two-week wait‟ patients increase uptake of X-Rays for patients
with expedited CT and diagnostic presenting with a persistent cough. This
project also targeted the families of the
tests;
key risk group identified (men over the age
Need improved access to of 50 in the most deprived areas of
diagnostic biopsy services Doncaster). Furthermore, Doncaster PCT
(especially thoracoscopy); conducted an X-Ray audit of the local
All patients PS-2 or less, who may acute trust and used this as one measure
be suitable for treatment, should of the success of the programme. This
work is provided here as Appendix d. as it
be discussed by SMDT;
is a relatively brief document and contains
Need for improved/earlier referral other useful information relevant to this
to Specialist Nurses and palliative assessment.
care consultants;
Patient survey required. These examples of good practice point the
way towards future work that has the
potential to improving early diagnosis of
Future work lung cancer at primary care in Bolton. In
the absence of local work, the findings
From the above, earlier presentation of from other areas discussed and
symptoms and earlier diagnoses are key referenced here serve as a proxy as what
to improving outcomes for lung cancer in works and the problems encountered in
Bolton. primary care.
Spell: One or more episodes linked into a Analysed by provider (table am.), the
period of continuous care at a single provider relative risk is very low for Others and The
from date of admission to date of discharge. Christie, but is high for the Royal Bolton.
However, comparatively, this is likely due
Superspell: First spell from a group of spells to the number and purpose of these
linked together by transfer. providers when treating lung cancer. The
Royal Bolton is a major provider of
Expected deaths: The expected number of palliative and end of life care for lung
deaths when casemix adjusted. cancer patients and so we would expect a
high level of mortality here compared to
Relative risk: The observed number of deaths
as a percentage of the expected number of tertiary trusts like the Christie. However,
deaths. this is accounted for in the below table
where expected deaths are included in the
The following details mortality (in hospital) relative risk calculation. Therefore, taken
for the diagnosis group “Cancer of in isolation from the other providers, the
bronchus, lung” during the period from conclusion must be that the relative risk of
April 2005 to January 2010 for patients dying from “Cancer of bronchus, lung” is
within Bolton PCT (except where stated). higher than it should be for Royal Bolton
Hospital over this period. There are
Over this period there were 1,868 spells 27.9% more deaths than should be
and 1,829 superspells for “Cancer of expected over the entire period.
bronchus, lung”. This activity resulted in
208 deaths from an expected 210.2 Table an. shows a drill down of all Royal
deaths. As such the relative risk is 98.9 Bolton Hospital activity from the above by
(86.0 and 113.3 being the respective calendar year from April 1996 to January
confidence intervals). 2010 (thus, 1996 and 2010 are not
representative). The years 2003, 2005,
“Cancer of the bronchus, lung” is the and 2006 are those years having the
“Neoplasm‟s” diagnosis group that greatest negative impact upon the
accounts for the greatest number of mortality overall at the Royal Bolton, with
hospital deaths. Table ak. shows the relative risks of 160.0, 161.7, and 146.8
breakdown of all 889 neoplasm deaths respectively. However, for the last three
over the period (excluding cancers with years of data (2007, 2008, and 2009) the
deaths less than five). Despite the high numbers of deaths and the associated
number of lung cancer deaths and spells, relative risks at the Trust have declined,
diagnosis groups “Leukaemia‟s” and especially in the past two years.
“Multiple Myeloma” are the only two with a
significantly high relative risk, though the Table ao. shows there to be no significant
respective confidence intervals are wide. difference in admissions and outcome by
Ward within Bolton. This picture carries
Over time there have been few significant over into mortality by deprivation quintile
variations in the number of deaths (in hospital).
resulting from the lung cancer activity, and
In addition, there are no GP practices in
90 Bolton where there have been significantly
Data is taken from The Real Time Monitoring Tool from
Dr. Foster (see bibliographic references)
more lung cancer hospital deaths than longer than one month. This picture can
expected for casemix. be demonstrative of the condition at which
patients arrive at hospital. A high number
The majority of spells and superspells for staying longer than one month may
lung cancer (85.3%) occur under the care indicate that these patients are admitted to
of one consultant team. The below chart die. For this reason this is an important
analyses relative risk for diagnosis group indicator and value can be gained from its
“Cancer of bronchus, lung” by how many future monitoring.
teams cared for patients during each spell.
Though not shown clearly on the chart, Table aq. shows mortality by length of
there is statistical significance for mortality stay. There is little statistical difference,
in those spells where the patients were but this analysis does show that the
under the care of two different consultant greatest number of deaths occurs in the
teams. The number of deaths in those medium to long length of stays, again
being cared for by three different suggesting patients were admitted
consultant teams is relatively small, and primarily to die.
so the main conclusion to draw here is the
increased risk of mortality (in hospital) for
lung cancer patients in Bolton when under
the care of two different consultant teams,
though this may be representative of a
greater need in those under the care of
two consultants.
Percent
Percent Percent
Diagnosis group Spells Superspells of all Deaths Expected RR Low High
(%) (%)
(%)
ALL 22751 22576 100.0% 889 3.9% 871.7 3.9% 102.0 95.4 108.9
Cancer of bronchus, lung 1868 1829 8.1% 208 11.4% 210.2 11.5% 98.9 86.0 113.3
Secondary malignancies 1089 1073 4.8% 86 8.0% 85.8 8.0% 100.2 80.2 123.8
Malignant neoplasm without
248 242 1.1% 76 31.4% 61.8 25.5% 123.0 96.9 153.9
specification of site
Cancer of colon 730 730 3.2% 56 7.7% 61.7 8.5% 90.7 68.5 117.8
Cancer of oesophagus 822 815 3.6% 48 5.9% 47.0 5.8% 102.1 75.3 135.4
Cancer of pancreas 278 272 1.2% 44 16.2% 41.4 15.2% 106.3 77.2 142.7
Leukaemia‟s 1937 1925 8.5% 37 1.9% 25.8 1.3% 143.1 100.8 197.3
Non-Hodgkin's lymphoma 1191 1181 5.2% 34 2.9% 35.3 3.0% 96.3 66.7 134.6
Cancer of stomach 556 552 2.4% 34 6.2% 36.9 6.7% 92.1 63.8 128.8
Cancer of rectum and anus 555 553 2.4% 27 4.9% 25.5 4.6% 105.7 69.6 153.8
Cancer of prostate 326 325 1.4% 24 7.4% 19.6 6.0% 122.4 78.4 182.2
Cancer of breast 1483 1483 6.6% 22 1.5% 26.6 1.8% 82.6 51.7 125.0
Neoplasms of unspecified
nature or uncertain 925 919 4.1% 20 2.2% 12.4 1.4% 160.9 98.3 248.6
behaviour
Cancer of brain and nervous
474 451 2.0% 19 4.2% 20.7 4.6% 91.7 55.2 143.3
system
Cancer of ovary 381 373 1.7% 19 5.1% 20.7 5.5% 92.0 55.3 143.6
Cancer of liver and
112 111 0.5% 19 17.1% 17.4 15.6% 109.5 65.9 171.0
intrahepatic bile duct
Multiple myeloma 497 495 2.2% 17 3.4% 9.6 1.9% 177.4 103.3 284.1
Cancer of head and neck 488 483 2.1% 16 3.3% 15.5 3.2% 103.5 59.1 168.1
Cancer of bladder 1043 1043 4.6% 14 1.3% 20.7 2.0% 67.5 36.9 113.2
Cancer of other GI organs, 126 122 0.5% 12 9.8% 9.5 7.8% 126.6 65.3 221.2
peritoneum
Cancer of kidney and renal
213 210 0.9% 11 5.2% 14.2 6.7% 77.7 38.7 139.0
pelvis
Cancer, other and
173 169 0.7% 9 5.3% 7.3 4.3% 122.9 56.1 233.3
unspecified primary
Cancer, other respiratory
186 186 0.8% 8 4.3% 10.4 5.6% 76.6 33.0 150.9
and intrathoracic
Cancer of uterus 211 211 0.9% 6 2.8% 7.3 3.4% 82.6 30.2 179.8
Table al.
Bolton PCT: All mortality (in hospital) Cancer of bronchus, lung (April 2005 to January 2010)
ALL 1868 1834 100.0% 211 11.5% 211.8 11.5% 99.6 86.7 114.0
Table am.
Bolton PCT: All mortality (in hospital) Cancer of bronchus, lung (April 2005 to January 2010)
Percent
Percent Percent
Provider Spells Superspells of all Deaths Expected RR Low High
(%) (%)
(%)
ALL 1868 1834 100.0% 211 11.5% 211.8 11.5% 99.6 86.7 114.0
Others 739 723 39.4% 18 2.5% 38.8 5.4% 46.4 27.5 73.4
Royal Bolton Hospital 715 705 38.4% 175 24.8% 136.9 19.4% 127.9 109.6 148.3
NHS Foundation Trust
The Christie NHS 292 285 15.5% 10 3.5% 26.2 9.2% 38.2 18.3 70.3
Foundation Trust
Central Manchester
101 100 X% <5 X% <5 X% X X X
University Hospitals
NHS Foundation Trust
Percent
Percent Percent
Trend (Year) Spells Superspells of all Deaths Expected RR Low High
(%) (%)
(%)
ALL 2205 2196 100.0% 557 25.4% 462.5 21.1% 120.4 110.6 130.9
Percent
Percent Percent
Ward (Census) Spells Superspells of all Deaths Expected RR Low High
(%) (%)
(%)
ALL 1868 1834 100.0% 211 11.5% 211.8 11.5% 99.6 86.7 114.0
Astley Bridge (00BLFA) 141 135 7.4% 14 10.4% 14.7 10.9% 95.0 51.9 159.5
Kearsley (00BLFR) 122 120 6.5% 15 12.5% 16.1 13.4% 93.3 52.2 153.8
Breightmet (00BLFD) 114 114 6.2% 11 9.6% 10.7 9.4% 103.2 51.4 184.6
Deane-Cum-Heaton (00BLFJ) 111 108 5.9% 12 11.1% 13.1 12.2% 91.3 47.1 159.5
Horwich (00BLFP) 107 103 5.6% 11 10.7% 9.8 9.5% 112.7 56.2 201.6
Westhoughton (00BLFW) 100 100 5.5% 11 11.0% 7.6 7.6% 143.9 71.8 257.6
Central (00BLFG) 95 93 5.1% 10 10.8% 10.8 11.6% 92.3 44.2 169.8
Smithills (00BLFT) 90 89 4.9% 9 10.1% 8.8 9.9% 101.8 46.4 193.2
Tonge (00BLFU) 90 89 4.9% 5 5.6% 10.4 11.7% 48.1 15.5 112.2
Blackrod (00BLFB) 89 89 4.9% 10 11.2% 8.6 9.7% 115.9 55.5 213.2
Burnden (00BLFF) 89 86 4.7% 7 8.1% 7.9 9.2% 88.5 35.4 182.3
Derby (00BLFK) 88 85 4.6% 8 9.4% 10.0 11.8% 79.8 34.4 157.3
Farnworth (00BLFL) 88 86 4.7% 13 15.1% 10.6 12.3% 122.6 65.2 209.6
Harper Green (00BLFN) 80 78 4.3% 9 11.5% 14.9 19.1% 60.3 27.5 114.4
Hulton Park (00BLFQ) 78 78 4.3% 11 14.1% 8.2 10.5% 134.6 67.1 240.9
Little Lever (00BLFS) 77 76 4.1% 12 15.8% 8.8 11.6% 136.1 70.2 237.7
Bradshaw (00BLFC) 73 73 4.0% 8 11.0% 7.5 10.3% 106.0 45.6 208.9
Daubhill (00BLFH) 68 66 3.6% 15 22.7% 11.9 18.0% 126.0 70.5 207.9
Halliwell (00BLFM) 64 63 3.4% 8 12.7% 8.3 13.2% 96.5 41.5 190.1
Bromley Cross (00BLFE) 60 60 3.3% 6 10.0% 6.9 11.4% 87.4 31.9 190.3
Table ap.
Bolton PCT: All mortality (in hospital) Cancer of bronchus, lung (April 2005 to January 2010)
Percent
Spells in Percent Percent
Spells Superspells of all Deaths Expected RR Low High
superspell (%) (%)
(%)
ALL 1868 1834 100.0% 211 11.5% 211.8 11.5% 99.6 86.7 114.0
1 1776 1776 96.8% 197 11.1% 195.9 11.0% 100.6 87.0 115.6
2 70 46 2.5% 12 26.1% 12.1 26.2% 99.4 51.3 173.7
3 21 11 X% X X% X X% X X X
4 X X X% X X% X X% X X X
Table aq.
Bolton PCT: All mortality (in hospital) Cancer of bronchus, lung (April 2005 to January 2010)
Percent
Length of Percent Percent
Spells Superspells of all Deaths Expected RR Low High
stay (%) (%)
(%)
ALL 1868 1834 100.0% 211 11.5% 211.8 11.5% 99.6 86.7 114.0
End of life treatment is a very personal The following is taken from the Bolton
aspect of a patients care and needs may PCT End of Life Care Strategy and
be different for each patient depending provides a local lung cancer case study
upon physical symptoms and pain whose care was appropriately managed in
management, social situation, emotional line with the Gold Standards Framework
problems, spiritual issues, and family and so represents an exemplar of best
and/or carer issues. The combination of practice.
these factors results in a very complex
stage of the lung cancer care pathway.
“David developed lung cancer in his late 50s. He was treated initially with surgery that
unfortunately was unsuccessful. Secondary cancers developed and David needed palliative
chemotherapy and radiotherapy. Despite this treatment he still had some symptoms that
were managed in conjunction with the Bolton Hospice Team. Another complication for him
was the development of diabetes as a result of some of his treatment. Despite these quite
complex problems, in the last 6 months of his life, David was managed at home (his and his
family‟s expressed wish) where he died peacefully surrounded by his family.
Gold Standards Framework meant that the practice had a system in place for identifying
people in David‟s position. This allowed a key health professional to be identified and be the
first port of call for David or his family. David was consulted about his care at all times, and
his wishes regarding where he would like to receive care and spend his last days were
sought. At this stage he had time to discuss his wishes with his family and the team were
able to plan for his needs and anticipate potential problems. His care was discussed within
the team regularly; this meant that good continuity was obtained even when his main contact
was unavailable.
The GPs had actively sought education regarding symptom control and so had the skills to
deal with his complex problems and knew where and when to seek help. In the end phase of
his illness, David‟s problems were anticipated so if they arose medicines and equipment
were already available in his home. The Gold Standards Framework meant that there was a
good relationship between the district nurses and the practice team and all worked together
in a co-ordinated way to provide the best standard of seamless care. After David‟s death his
family was able to continue to seek support from the practice, recognising that care needs
for family and carers extend beyond the death to include the period of bereavement.”
Key to this aspect of the strategy is active Pathway are a strong emphasis upon
case management. Active case communication with the patient and their
management is a service targeting family, anticipatory planning including
patients with complex health needs and psychosocial and spiritual needs, effective
who use health services frequently with symptom control, and continuing care
support from a health professional to following death.
manage their own health better. As
identified in the strategy, increasing the The following is taken from the Bolton
number of patients in Bolton who receive PCT End of Life Care Strategy but is an
active case management will greatly example of best practice for lung cancer
improve quality of end of life care in Bolton palliative care in line with the Liverpool
in line with the Gold Standards Care Pathway from a national report.
Framework.
“Emily had been diagnosed with advanced heart failure and lung cancer and although she
had repeated admissions to hospital with similar symptoms, she was significantly weaker on
this occasion and did not respond to the usual interventions. The Specialist Palliative Care
team was asked to get involved in her symptom management.
Although her pain and breathlessness settled with appropriate support and medication, she
remained weak and fatigued and she felt she was too frightened to be nursed at home. The
option of a care home placement was discussed and it was explained that support would be
available at the end of life through the Liverpool Care Pathway.
Emily was transferred to the care home within two weeks. She died three months later.
A few days prior to Emily‟s death, the staff in the care home were able to recognise that
Emily was deteriorating. In discussion with the family, it was agreed that she should not be
admitted to hospital and the LCP was initiated. An assessment of Emily‟s needs was
undertaken which included psychological, social, spiritual and physical aspects, and included
stopping oral medication and prescribing medication by other routes for symptoms such as
pain, breathlessness, nausea and vomiting. Her daughter said, „I think the culture of the
care home was excellent and the Liverpool Care Pathway helped the staff to help my mum
and me. I will miss her terribly but I know her care was the best it could be and that helps.‟
Benefits of using Liverpool Care Pathway in this situation: The LCP provided a structure
within which excellent care could be given in the final days of life without readmission to
hospital. This meant that disruption was avoided for the resident and the LCP gave the care
team confidence to manage the situation.”
The Strategy identifies a reduction of the show the importance of the Preferred
number of deaths in the Royal Bolton Place of Care Plan in the provision of end
Hospital who are residents of a care home of life care.
as key to implementing the Liverpool Care
Pathway.
“Derek was 62 and had been in a care home for three months. He was admitted following a
stroke from which he never fully recovered. He was also suffering from dementia. His wife
Betty had visited every day but had been looking increasingly tired. Derek had his own
business but passed this on to his two sons when he started having difficulties due to
dementia. Visits from their sons were rare as they lived in the South.
Derek had another chest infection for which the doctor prescribed antibiotics. One day Betty
asked to discuss Derek‟s care; she cried as she spoke about her concerns. She asked that
next time Derek developed a chest infection it should not be treated. She did not want him to
be transferred to hospital, as he was last time, as this was traumatic and Derek‟s dementia
seemed to worsen after this. Derek was very comfortable in the home and it was easier for
Betty to visit. She felt that nature should take its course. She said that she had not discussed
this with her sons but felt that after being married to Derek for so long, she knew him best
and that previously when in good health he had talked of not wanting to end his days in
dependence. She added that he would have hated to be like this and for their sons to
witness his demise.
The Preferred Place of Care provides a mechanism to facilitate discussions between the
individual and their families earlier in the process of care. It records an individual‟s
preferences and can initiate establishment of advance directives if the person wants to
decline medical treatment. The PPC process includes the opportunity to regularly review
options and to ensure that the difficult discussions about end of life care are recorded and
available to all of the teams involved in the delivery of an individual‟s care.”
The implementation of the Preferred Place cancer is incurable, but services and
of Care Plan is a key aspect in increasing research concentrate mostly on
the number of people in Bolton who, in developing different treatment
agreement with their carers, wish to be modalities91. The caring aspect is where
supported to die at home. For all deaths, deaths at home are important. In order to
the baseline figure is identified in the improve palliative care for cancer patients
strategy as 16% (2004) with the aim to at the terminal stages of life, more patients
increase this figure to 50% by April 2011. should be allowed the choice of dying at
The latest available figure is for 2006/08 home.
and is 18.7%. The comparative figure for
both England as a whole and the North End of life care is an important issue for a
West is 19.5%. Deaths at home due to disease that is often terminal; from
lung cancer is discussed below. previous sections we know that only 7% of
lung cancer patients in Bolton can expect
Deaths at home to still be alive five years after diagnosis.
The Department of Health has identified a
Having an indicator measuring the „mismatch‟ between people‟s preferences
percentage of deaths at home due to lung for where they would prefer to die and
cancer is important if we remember lung their actual place of death. Findings that
cancer services have three main aspects. motivated the Department of Health‟s End
The first is prevention, which is almost
exclusively the reduction of cigarette
smoking as the disease would practically
be eliminated if no one smoked. The 91
second aspect is curative. Most lung Stevens, A. et al (2004) Health Care Needs
Assessments, Radcliffe Publishing Ltd., Oxford.
of Life Care Strategy92 reveal that most
people would probably like to die at home,
but nationally, acute hospitals account for
58% of all deaths. Furthermore, the Care
Quality Commission found that 54% of all
complaints in acute hospitals relate to care
of the dying/bereavement93. Table ar.
shows the percentage of all lung cancer
deaths that occur at home. Bolton is
below both the national and regional
averages, as well as many of its statistical
peers.
92
Department of Health (2008) End of Life Care Strategy:
promoting high quality care for all adults at the end of life,
DoH, London.
93
Care Quality Commission (2010) www.cqc.org.uk
Table ar.
Deaths at home from lung cancer, persons
96
Beacon Dodsworth (2009) P²: People and Places:
95
Health Service Journal (2009) Information for Understanding people by where they live, Beacon
improvement, The IC, London. Dodsworth, York.
The P² tool seeks to understand people in to predominantly white areas.
Bolton by where they live, with a view to
informing strategies that target specific The below map shows lung cancer
local areas. There are two mortality by small areas within Bolton over
geodemographic classifications that do not the period 2002 to 2008.
appear in Bolton at all; these are „B:
Country Orchards‟ and „E: Qualified
Metropolitans‟. The grey area in the
northern part of Moses Gate represents
„U: Unclassified‟. P² describes such
areas: “At each tier of „P² People and
Places‟, there is an unclassified cluster
which describes people whose
characteristics are too unique for them to
fall comfortably into the standard
categories. Those who are unclassified
make up 1.26% of the UK population”97.
97
Beacon Dodsworth (2009) P²: People and Places:
Understanding people by where they live, Beacon
Dodsworth, York.
The average for Bolton as a whole over Morrisons, and Somerfield. With an older
this period is 48.86 (per 100,000). The population and some below standard living
areas with the highest mortality rates (per conditions, many Weathered Communities
100,000) from lung cancer are: have poor general health. Smoking is
common and exercise levels are low and
1. Breightmet N & Withins (79.62); falling.
2. Deane & Middle Hulton (77.16);
3. Halliwell Road (76.96); L: Disadvantaged Households. This is a
young Tree composed mostly of young
4. Lever Edge (71.09);
parent families who are aged 16 to 34 and
5. Sweetlove (70.37); have young children. The proportion of
6. Burnden (67.39); married couples is low, with many families
7. Tonge Moor & Hall i‟th‟ Wood being cohabiting couples or lone-parents.
(67.21); Most people live in terraced houses, flats,
8. Town Centre (66.58). or semi-detached houses which they rent
from the council or a housing association.
These key areas are identified on the Often these properties have no central
below geodemographical analysis and will heating. Most homes are small and many
be discussed in turn. (The Town Centre is are overcrowded, sometimes severely so.
not featured as it is almost entirely „M: There are also a number of vacant
Urban Challenge‟, as is clear on the properties, particularly terraced houses
previous P² map of Bolton). and flats. There is a high rate of
unemployment amongst members of this
Breightmet N & Withins Tree, with around half not having worked
for several years. In many cases no adult
K: Weathered Communities. Most of this members of the household work. They
Tree are past retirement age with many are largely unqualified and those who do
being older than 75 and living alone. work usually have routine, semi-skilled, or
Weathered Communities mainly have unskilled occupations. Incomes have
small homes that they rent from the local remained the same or risen slightly with
council or a housing association. These most having earnings in the lowest income
properties are mostly flats, semi-detached, band and some in the third quartile. Most
or terraced houses. Some are without Disadvantaged Households have no car.
central heating. Many members of this Those who work tend to travel by bus or
Tree are retired and unemployment is on foot, with distances travelled generally
high, with many having been out of work being short. These people have no
for a while. Previous occupations were interest in politics and read tabloid
mainly in construction and it is common for newspapers. They rarely take holidays
no adults in the household to work. Of but frequently listen to commercial radio.
those still working, qualifications are few Internet usage is low. Members of this
and most jobs are of a routine nature or Tree hardly ever eat out. Very few people
are skilled or semi-skilled. Employment in this group have a credit card and they
with utility or manufacturing companies is mainly shop at ASDA, but also at Aldi and
popular. Since many are retired, earnings Lidl. They rarely have any savings.
are in the bottom two income bands. Disadvantaged Households have the
Weathered Communities rarely have a car highest proportion of smokers out of all the
and they get around mainly by bus and Trees, being one and a half times the
some on foot. These people tend to read national average. They take little
tabloid newspapers and have little interest exercise, although this is a habit that is
in politics. Many listen to commercial increasing. There are many very deprived
radio, although internet usage is low. households; as a result, even though they
They take few holidays and eat out are a relatively young group, there is a
infrequently. Weathered Communities high level of ill health with long-term illness
tend not to have a credit card and being common.
generally shop at ASDA, Aldi, Lidl,
J: Urban Producers. This Tree has a high cars and those who work get there by bus
proportion of lone-parent families. Many and some live near enough to walk. The
households are couples aged 25 to 34 proportion of people in this group who eat
who are unmarried and have children. out is the lowest of all the Trees and is
There are also some people aged 16 to 24 decreasing. They mainly read tabloid
with children. The majority of this group newspapers and some have an interest in
live in terraced houses that are rented, politics. Internet usage is the lowest of all
mainly from the local council. Most groups. These people mainly shop at
properties are medium-sized and some ASDA, but may also go to Morrisons,
have no central heating. The Somerfield, Aldi, and Lidl. Few have
unemployment rate is above average and investments. Smoking is above average
some of those over fifty have not worked and exercise is uncommon, although is
for several years. Urban Producers have increasing slightly. Long-term illness is
few qualifications and most have routine, common amongst the working population
unskilled, semi-skilled, or skilled jobs in and this may be due to high levels of
manufacturing. It is common for only the deprivation across the entire Tree.
man in the household to work. Earnings
fall into the lowest income band, although K: Weathered Communities. See above.
this is improving with the number in the
third quartile increasing. Most Urban J: Urban Producers. See above.
Producers do not have a car and many
live near enough to their work to walk D: Rooted Households. This Tree is
there, whilst others travel by bus. These generally an older group but does contain
people have no interest in politics and a wide range of age groups and generally
read tabloid newspapers. Most do not originates from the UK. Most households
take regular holidays and they are are buying or have paid for their homes.
infrequent users of the internet. Eating out Unemployment is low with many having
has become increasingly rare. Urban skilled jobs, frequently in the
Producers are less likely to have a credit manufacturing industry. This is not a
card and shopping is mainly at ASDA, with highly qualified Tree. This Tree has little
Aldi and Lidl being popular and some interest in politics, mainly read black top
visiting Morrisons and Somerfield. Many newspapers, and use the internet. Rooted
people in this Tree smoke and few take Households shop at various
regular exercise, with numbers falling for supermarkets, particularly Tesco.
the latter. Coupled with a relatively high Smoking is uncommon and the majority
number of deprived households, this are in good health with low deprivation
results in many people being in poor levels and health prospects are generally
health. positive.
Deane & Middle Hulton (Deane & Middle Hulton is a large MSOA,
the southern part of which is Rooted
M: Urban Challenge. Most homes are Households; it‟s northern part shares
small and cramped and most rented from borders with Heaton, Lower Deane & The
the council or a housing association. Willows, and Lever Edge, and it these
Many are overcrowded and some have northern parts which contain the more
shared facilities. Long-term deprived areas classified as Urban
unemployment is common and many Challenge and Weathered Communities
people are retired. Unemployment affects above).
both men and women; those who do work
mainly have routine occupations due to Halliwell Road
lack of qualifications. Others may have
unskilled or semi-skilled manual jobs in M: Urban Challenge. See above.
manufacturing companies. Earnings are
in the lowest income band but are I: Multicultural Centres. This Tree consists
increasing. Urban Challenge do not have mainly of families, some of which are
large, who originate from India, Pakistan, J: Urban Producers. See above.
and Bangladesh (in Bolton). There is a
combination of young parents with I: Multicultural Centres. See above.
children and older parents with teenagers.
The majority are Muslims (in Bolton) and G: Suburban Stability. This Tree covers a
although the parents were born outside wide range of age groups, from young
the UK, their children have been born families with children up to those of 75
here. These people mainly live in terraced years old. Many of the parents are
housing and flats with the majority of the unmarried. They generally live in semi-
rest living in bedsit accommodation. detached or terraced houses that they are
Properties tend to be small and many do buying, or in some cases have bought. A
not have central heating. They tend to few privately rent their home. These are
rent with many residents occupying mainly medium-sized properties and some
housing association or council properties. have no central heating. These people
The unemployment rate is twice the are not highly qualified and mainly have
national average. Of those who are routine or skilled manual jobs, but some
unemployed, half are long-term are semi-skilled or unskilled. Many work
unemployed. Those who work are mainly in manufacturing and unemployment is
in semi-skilled or unskilled manual jobs below average. Most have earnings in the
rather than professional positions. They third quartile with some in the bottom
tend not to have qualifications and their band, although incomes are increasing.
earnings, although rising, are in the Suburban Stability households generally
bottom bracket. Car ownership is low and have one car, which is small or medium-
the majority use public transport. They sized. They often travel to work in the car,
mainly travel to work by train or bus, with a although some walk or travel by bus.
few working from home or commuting by Commercial radio is listened to frequently
car. These people mainly read tabloid and tabloids are the newspaper of choice,
newspapers, but some also read although some read black tops. This Tree
broadsheets. They regularly listen to has little interest in politics and internet
commercial radio and are not inclined to usage is below average. Credit card
take regular holidays or eat out. Internet usage is just below average, whilst
usage is high and growing. Aldi, Lidl, and Suburban Stability have no strong
Sainsbury‟s are the most popular shopping preferences, with ASDA being
supermarkets for regular shopping in this the favourite but others also visited.
Tree. They are unlikely to use credit Smoking is just above average but only
cards. Although mainly a young one fifth take regular exercise. There are
population, many live in households that no major long-term illness problems and
are particularly deprived and so may there is only a small amount of
cause health problems in the future. They deprivation.
are unlikely to exercise and their illness
levels are above average. Burnden
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Glossary
Cancer Network: A system within the NHS to organise the integrated care of cancer
patients across a region. NHS Bolton comes under the Greater Manchester and Cheshire
Cancer Network.
Directly Standardised Rate (DSR): The directly standardised rate (DSR) is the rate
expected in a standard population if the age-specific rates of the study population had
applied.
DSR =
n
Σ Condition count i
i=1 Population i * ESP i
(i represents the 1 to n population groups, and ESPi is the European Standard population for
age band i)
Health Profiler: Small area database with various indicators to identify health inequalities
across the North West.
HES: Hospital Episode Statistics is a data warehouse containing details of all admissions to
NHS hospitals in England.
HSE: Health Survey for England. A series of annual surveys beginning in 1991
commissioned by the Department of Health and designed to provide regular information on
various aspects of the nation‟s health.
ICD-10 codes: The International Statistical Classification of Diseases and Related Health
Problems 10th Revision is a coding of diseases, symptoms, social circumstances, and
external causes of disease or injury, as classified by the World Health Organisation.
IMD: The Index of Multiple Deprivation combines a number of indicators, chosen to cover a
wide range of economic, social and housing issues, into a single deprivation score for small
areas in England.
Incidence: The rate at which new cases appear in the population over a given period of
time.
Interquartile range: The range of a variable excluding the highest and lowest quarter of the
recorded values.
MSOA: Middle Super Output Area. ONS designed small areas within Bolton.
NRS areas: Neighborhood Renewal Strategy Areas are the 25% most deprived boroughs in
Bolton.
People and Places: A geodemographic classification that uses Census and lifestyle data to
classify people by where they live.
Public Health Mortality File: Database containing information about deaths within different
health authority boundaries.
QOF: The Quality and Outcomes Framework is used for prevalence data. QOF is the
annual reward and incentive programme detailing GP practice achievement results. QOF is
a voluntary process for all surgeries in England. QOF is measured by QMAS, a national IT
system developed by NHS Connecting for Health (CfH).
SMR =
Observed condition count *100
Expected condition count
Synthetic estimate: Synthetic estimates are not estimated counts of the number of people
or prevalence of a behaviour, e.g. smoking. Rather, they are estimates based on a model
and represent the expected prevalence of a behaviour given the demographic and social
characteristics of that area.
Appendices
Appendix a.
The Institute of Public Finance Nearest Neighbour Model (cipfastats.net) has been used to
select peers for Bolton.
The model is local authority based; however it is more recent than clusters based solely on
Census 2001 data and arrives at more specific peers than traditional ONS groups (for
instance, „Centres of industry‟).
This report displays the nearest neighbours for Bolton based on the selected indicators
listed below:
Metropolitan Districts
Population
% of population aged 0 to 17
% of population aged 75 to 84
% of population aged 85 plus
Output area base population density
Output area based sparsity
Taxbase per head of population
% unemployment
% daytime net inflow
Retail premises per 1,000 population
Housing benefit caseload (weighted)
% of people born outside UK and Ireland
% of households with less than 4 rooms
% of households in social rented accommodation
% of persons in lower NS-SEC (social) groups
Standardised mortality for all persons
Authorities with coast protection expenditure
Non-Domestic rateable value per head of population
% of properties in Bands A to D
% of properties in Bands E to H
Area cost adjustment (other services block)
% Ethic Minority
Indices of Multiple Deprivation
Based on these indicators the model arrives at the following „nearest neighbours‟:
Statistical
Pos. Neighbour Authorities
Distance
1. Rochdale 0.0276
2. Tameside 0.0375
3. Oldham 0.0441
4. Coventry 0.0956
5. Walsall 0.0995
6. Wigan 0.1007
7. Bury 0.101
8. Dudley 0.114
9. Kirklees 0.1323
The following is taken from the Bolton PCT End of Life Care Strategy.
Feedback from End Of Life (EOL) Consultation: August 2006 to January 2007
1. The key initial findings are that we ensure that integration between health and social care
is a priority to ensure responsive joint working and robust co-ordination of care. That the
standard of care is agreed amongst all stakeholders and that this is delivered seamlessly
from the patient and carers perspective. End of life care should be planned in a proactive
manner, be person centred, responsive and sustainable to be effective. End of life care
should be seen as a priority and investment should be robust and sustainable based on
realistic costings. The delivery of the strategy needs to be realistic and workable to be
successful. It should be inclusive and involve all partners and stakeholders such as for
example, PPI, voluntary sector, Benefits advice and Housing. Consideration also should be
given to the relationship between Private health insurance and healthcare and that general
awareness is taken into account of the potential impact of other services by changes in
provision. The design of new services should involve partners from secondary care to
ensure the development of an integrated model and to ensure that we don‟t underestimate
the challenge of delivering 24/7 care.
2. We need to ensure that EOL care is truly person centred rather than target driven and that
the education and support needs for families and carers is given priority and that more
carers and people from BME groups are involved in the future commissioning planning and
implementation.
3. A significant element of feedback from the consultation concerned carers. This related to
issues around identifying hidden carers, GPs developing their registers of carers to enable
support to be given when needed. There were issues raised about carers having key
workers as first contacts and also the need to facilitate carer breaks through respite care.
Any support needs to be available over a 24 hour period to be effective and that there
should be a range of support for carers. It is also important that carers are involved in
discussions about care whether directly or from a strategic planning perspective and that
their views are respected.
4. More commitment needs to be given to the spiritual care of people at EOL and not
skimmed over as appears at present. This is reflected in the following feedback:
It was felt that the document did not reflect that anyone has been consulted on spiritual care.
It would be inadvisable for a non-spiritual professional to conduct assessments without
extensive training. Parish priests and Religious Leaders generally do not have skills in this
area of work, and may not be appropriate anyway. There is a considerable difference
between normal pastoral visiting and support of the sick, and the liaison with other health
professionals in the extended care of the terminally ill. Using voluntary workers from the
community raises also the problem of communication. Health workers could not share
confidential, but essential information about the progress of the illness or the services
provided to voluntary visitors. Similarly, there would be no formal referral mechanism, or
ongoing return of information from the Religious Leader to the health professionals. The
possibility of 24-hour callouts for spiritual care would not be sustainable by Religious
Leaders on a voluntary basis. Spiritual support should also be available to members of the
various disciplines who have input to these patients/clients. There seems to be no evidence
that spiritual care is provided at any level in the PCT. It is suggested that the PCT consider
funding a whole-time chaplain who would provide that service and expertise and that this
person has a wide expertise in multi-denominational and multi-faith issues and requirements.
The Chaplaincy Dept. at Bolton Hospitals NHS Trust would be willing to assist the PCT in
exploring and developing spiritual care.
5. The education and training for all staff and carers was seen as an essential and that the
success of the strategy will rest on this being implemented broadly. In particular, good
communication and awareness raising and education to promote strategy implementation
was seen as essential. As was the need to ensure carers were recognised as having
relevant knowledge and skills, which needs to be supported practically in the home by
support and education. In relation to staff, it was felt that an audit of existing background
knowledge of long term conditions should be undertaken as well as ensuring that all staff
involved in assessments have good communication skills. Staff feedback related to the need
to have a range of training for all grades, from very practical skills to more academic levels
and that this study time must be protected. There should be a mentorship system for staff
and that training should be developed on a multi-agency basis with adequate and sustained
financial support. The basic education for nurses should include palliative care at end of life.
6. Communication was seen as the other key requirement with emphasis on the use of Gold
Standards Framework etc. across primary care and the links to single assessment process.
The need to have robust information and IT systems that communicate with each other was
also highlighted.
7. From a practical perspective the fundamentals within the draft strategy remain unchanged
following consultation. This hopefully indicates we are approaching end of life in the right
way. Some of the feedback relates to very operational issues such as:
November 2006.
Appendix c.
This appendix details the principal evidence base for this needs assessment.
1. Various bodies were established as part of the Cancer Reform Strategy to help
reduce cancer inequalities:
The National Cancer Equality Initiative (NCEI): to develop policy and research
proposals for tackling cancer inequalities;
The National Cancer Intelligence Network (NCIN): to improve the collection
and co-ordination of data on cancer patients;
The National Awareness and Early Diagnosis Initiative (NAEDI): to co-
ordinate activities and interventions, including those at a local level, aimed at
raising public awareness of the early signs and symptoms of cancer and
encourage people to seek help sooner;
The National Cancer Survivorship Initiative (NCSI): to improve the care and
support provided for people living with or after a cancer diagnosis.
2. The Manual of Cancer Services Standards – Lung Cancer Measures, NHS National
Cancer Action Team (2004)
8. Our NHS, Our Future: NHS Next Stage Review, Department of Health (2007)
11. The NHS cancer plan and the new NHS: Providing a patient-centred service,
Department of Health, (2004)
12. NHS Cancer Care in England and Wales. National Service Framework Assessments
No.1., Commission for Health Improvement (2001)
13. Cancer ten years on: improvements across the whole care pathway, Department of
Health (2007)
19. NICE Lung Cancer Diagnosis and Treatment Guidelines, NICE (2005)
21. Forever cool: the influence of smoking imagery on young people, British Medical
Journal (2008)
22. Cancer is our number one fear but most don‟t understand how many cases can be
prevented, Cancer Research UK, (2007)
23. Public Priorities for Health in Britain, MORI for Cancer Backup (2003)
Appendix d.
This appendix shows the report of a social marketing initiative undertaken by Doncaster PCT
which aimed to increase early detection of lung cancer at primary care. The report is
publicly available from the National Social Marketing Centre (http://www.nsmcentre.org.uk/).