Enabling non-medically qualified registered clinicians in general practice to request chest X-ray for possible lung cancer

Lung cancer is the leading cause of cancer death worldwide.1 Screening of asymptomatic individuals using low-dose CT has been shown to reduce mortality and has been approved by the UK’s National Screening Committee.2,3 Although this is a welcome development, it is likely that the majority of lung cancer diagnoses will continue to arise via symptomatic presentation. This is because, of those who are diagnosed with lung cancer, only around half would have been eligible for screening and, of those invited to screening, only around half choose to participate.4,5 In the UK and several healthcare systems worldwide, chest X-ray (CXR) remains the recommended first-line test for symptoms of lung cancer in primary care except for haemoptysis.6,7

Increased frequency of investigations for symptoms of possible lung cancer with CXR is associated with reduced mortality and increased proportions diagnosed with early-stage disease.8,9 Patients who have symptoms of possible lung cancer, such as cough, weight loss, and shortness of breath, commonly first present to general practice. Facilitating prompt investigation of symptomatic individuals is vital to ensure timely diagnosis and improve outcomes.10 In recent years, the composition of clinical staff, particularly in English general practices, has altered dramatically with numbers of full-time equivalent GPs per patient declining and numbers of other non-medically qualified (NMQ) clinicians such as nurses and pharmacists increasing.11,12 NHS England workforce policy has recognised the role of NMQ clinicians as a resource to deliver patient consultations, thereby enabling GPs to focus on complex cases and improve access to care.13

In general practice, NMQ clinicians often conduct chronic disease reviews with patients for conditions such as chronic obstructive pulmonary disease (COPD) or asthma. Meanwhile, referral for radiological investigations is usually restricted to doctors. Therefore, patients presenting with common symptoms of possible lung cancer are increasingly likely to consult with NMQ clinicians who do not have permissions in place to request the recommended first-line investigation (CXR). The need to enable NMQ clinicians to be able to organise CXR has been highlighted by recommendations on improving symptomatic lung cancer diagnosis from the Roy Castle Lung Cancer Foundation.