Head and neck cancer is the fourth most common referral made by primary care, namely GPs and dentists, comprising 9% of all referrals for suspected cancer in England (NHS England, 2023a). Each year in the UK there are around 12800 cases of head and neck cancer diagnosed (2017–19 figures) and this is projected to increase by a further 3% between 2023–25 and 2038–40 (Cancer Research UK, 2024). At present, the majority of patients being initiated on the diagnostic pathway for head and neck cancer are via the national ‘2-week-wait’ referral, which requires the surgical head and neck cancer team in specialist tertiary centres to review and assess patients. GPs and dentists refer patients with ‘red flag’ symptoms such as unilateral throat pain, a persistent hoarse voice and non-healing mouth lesions. The number of referrals sent for suspected head and neck cancer across England has increased over recent years. The latest figure for 2022–23 was 275354 referrals (NHS England, 2024). When considering this significant increase in referrals, along with a national conversion rate of 2.6% from referral to diagnosis (NHS England, 2024), it is evident that alternative solutions need to be explored within already stretched head and neck cancer services to safely meet this growing demand and the volume of patients requiring assessment for suspected head and neck cancer.
It is widely acknowledged that a delayed diagnosis of head and neck cancer has a direct correlation with survival rates (Schutte et al, 2020). NHS England (2023a) has recognised that capacity and efficiency within cancer pathways needs improvement to meet the ‘62-day target’ from referral to treatment. This need has been further solidified in recent years with the introduction of Faster Diagnosis Standards (FDS), now under the Faster Diagnosis Framework (NHS England, 2019). This highlights the need for cancer alliances to prioritise and streamline the diagnostic pathways for all patients, whether being diagnosed with a cancer or discharged from the services with benign symptoms. The guidance and suggested improvements are particularly relevant to head and neck cancer diagnosis, owing to the pathway experiencing some of the most significant delays in diagnosis in comparison with other tumour groups, with a median of 54 to 75 days between referral and diagnosis (NHS England, 2023a).
There have been previous investigations aiming to solve the increasing capacity issue in tertiary settings such as the National Institute for Health and Care Excellence (NICE) recognition and referral guidance (NICE, 2023), which aimed to standardise the clinical judgements of referrers and referral criteria; nonetheless, the number of referrals has continued to grow. Further innovative ideas to help address the demand have been explored; these have included telephone triage assessments (Rovira et al, 2022); the use of risk calculators to prioritise referrals (Tikka et al, 2020), and one-stop neck lump clinics (Hariri et al, 2023). There has also been ongoing work to validate risk-stratification tools as a way to prioritise face-to-face assessment for patients identified as ‘high risk’, thus allowing better use of diagnostic clinic capacity (Hardman et al, 2021). These interventions are considered safe ways to support the pathway, but owing to exclusion criteria, they are labour-intensive options that are not a solution to overall capacity issues. The compounding issues around diagnostic capacity and innovations to improve the diagnostic pathway for head and neck cancer can also be seen internationally. A nationally implemented fast-track programme in Denmark has been introduced, which uses private ear, nose and throat (ENT) specialists to provide suspected head and neck cancer patients with a review within 48 hours of their GP referral. This has effectively demonstrated improved detection rates and concluded that reducing delays in diagnosis by 1 month has increased survival rates of head and neck cancer in Denmark by up to 61% (Roennegaard et al, 2018).
It is clear that the limitations of the current referral process are multifactorial. However, changing the current referral process would require a national revision to ensure standardised care and to prevent potential delays in diagnosis. It would also require extensive exploration of the behaviour of referring clinicians with consideration of ‘normalisation process theory’ (Bradley et al, 2021).
An advanced nurse practitioner-led service: a pilot study
As a smaller scale alternative solution to these imminent capacity issues in a large London head and neck cancer referral centre at Guy's and St Thomas’ NHS Foundation Trust, it was proposed that the initial face-to-face assessment of suspected head and neck cancer referrals could be performed by a highly specialised advanced nurse practitioner (ANP). The referrals would be sent in the same way and the diagnostic pathway would remain the same, meaning no structural changes to the referral process but significant additional capacity created by having a larger workforce. The proposed responsibility of the ANP was to provide exactly the same service as the senior surgical head and neck cancer team; this includes performing endoscopy and reviewing images to identify any abnormalities and the ability to request all possible diagnostic investigations that may be required, including radiology and biopsies. It was hoped that use of the expanding remit of nurses could be instrumental in increasing diagnostic capacity within the diagnostic pathway without impacting patient outcomes, safety or satisfaction.
Nurse-led interventions
There are extensive illustrations of services within UK health care that demonstrate how the expanded remit and application of transferable skills has optimised and expanded services. Examples of this include emergency department nurse practitioners leading triage services; nurse practitioners performing the same tasks as GPs in primary care settings (Torrens et al, 2020); and nurse-led critical care outreach teams improving outcomes of deteriorating patients (Lynch et al, 2021). Although the use of nurses is a novel idea for head and neck cancer diagnosis, it has been previously explored in a nurse-led bowel cancer diagnostic service, which has a similar referral process of ‘red flag’ symptoms (Cock and Kent, 2017). After their pilot project, the colorectal ANP's telephone triage service was deemed to be a safe and effective alternative to the growing demands of 2-week-wait referrals for suspected bowel cancer, with positive patient experience outcomes (Bromley and Cock, 2019).
The roles and responsibilities of nurses are constantly evolving and expanding. NHS England has acknowledged that advanced clinical practice by nurses and other allied health professionals is an effective response to service expansion. A framework was originally created by Health Education England (HEE) (2017) to support the implementation of these extended roles. The framework highlights the need for nurses to work outside of traditional professional boundaries and demonstrates that nurses have the ability to respond to changing demands in services. It has been proved that appropriately trained and supported ANPs can effectively improve both patient outcomes and satisfaction (Htay and Whitehead, 2021).
There is an array of nurse-led models of care within the cancer care pathway once a diagnosis of malignancy has been made. For example, acute oncology nurse-led assessments and personalised follow-up programmes with survivorship support (Ngu et al, 2020). Therefore, with robust training and support, these skills could be transferable to the diagnosis of cancers. Table 1 highlights the existing skills and additional training required for this role.
| Existing skills of ANP | Additional training of ANP |
|---|---|
| Relevant clinical experience of head and neck cancer patients | Flexible nasendoscopy competencies, including training around identifying signs of head and neck cancer |
| Experience of managing a clinical service | Systematic neck assessment competencies |
| Knowledge of existing diagnostic pathway | Advanced assessment skills for non-medical clinicians’ module (including patient history-taking skills) |
| Interpersonal and communication skills | Advanced communication course |
Nurse-led interventions can directly impact detection rates (Li et al, 2020) and early introduction to clinical nurse specialists can directly improve patient engagement with their diagnostic investigations (Bonetti et al, 2022). There are well-established links between nurses and patient education, such as increasing disease awareness during cervical screenings, running smoking cessation clinics and encouraging vaccination compliance (Laurant et al, 2018). Primary prevention for head and neck cancer has proved to be more effective within the 2-week-wait appointment than elsewhere. Considering the low conversion rate and the fact that patients referred under the 2-week wait for head and neck cancer have a higher risk of cancer in the future, this referral is a great opportunity for smoking-cessation referral and cancer-prevention education by the nurse (Blane et al, 2022).
Recruiting and retaining nurses within the NHS is a challenge. Creating new incentives and training opportunities is imperative to enthuse and challenge nurses’ perceptions of their careers, and an increased knowledge base and greater responsibility within nursing roles can significantly increase the engagement levels of nurses (Mlambo et al, 2021). The role provides extensive opportunities for upskilling and ongoing professional development, empowering nurses to apply their own clinical knowledge in a supported environment, while progressing towards autonomous and confident decision-making. The recently published NHS Long Term Workforce Plan (NHS England, 2023b) has emphasised the need to prioritise training and development opportunities for nurses to increase retention. The Aspirant Cancer Career and Education Development (ACCEND) programme is another national innovation introduced by NHS England; this outlines the necessity to provide structured career progression and support to nurses and allied health professionals working in cancer care (NHS England, 2024c). The evidence of national responses to the progression of nursing roles, specifically within cancer care, demonstrates the importance of pushing the limitations and traditional responsibilities through innovative ideas such as diagnostic ANPs.
Training structure
The purpose of this project was to establish a safe and effective nurse-led diagnostic service with bespoke training specific to the role. It was key to ensure the nurse was competent and confident to deliver this service by providing extensive training, while also ensuring an appropriate escalation protocol. The training period was divided into three sections, which required a consultant head and neck cancer surgeon to sign off competence and progression to the next stage of training. This is described in Table 2. The project began in January 2023 and the ANP started seeing patients in April 2023.
| Training stage | Description | Evaluation | Duration |
|---|---|---|---|
| Shadowing | Observing and gaining competency in: |
Completion of summative assessment in rolespecific competency signed off by consultant head and neck surgeon supervisor | 4 weeks |
| Enrol in Advanced Clinical Assessment for Non-Medical Practitioners Level 7 (Master's level) module | 1 study day per week to attend university course | ||
| Supervised practice | Working under close supervision with named consultant for each clinic list, all decision making discussed with consultant | No additional clinic capacity, regular discussions and feedback with consultants | 4 weeks |
| All FNEs performed to be recorded for consultants to review | Nurse able to perform FNE independently and present findings to consultants; patient consultation not ended until consultant reviewed outcomes | ||
| Completion of Advance Clinical Assessment for Non-Medical Practitioners module | Clinical practice portfolio, assignments and Objective Structured Clinical Examination (OSCE) as per course requirements | ||
| Supported independent practice | Patients seen by ANP and discussed with consultant for second opinion if indicated | Progressive increase of additional patients booked; up to 6 new patients per clinic | 4 weeks/ongoing |
| Prospective database and tracking of patients’ outcomes for clinical governance and safety reasons | Nurse to follow the diagnostic results for learning purposes; continuing reflection on decision making in order to shape future practice |
Safety and risk management
The details of all patients who were seen by the ANP after the completed training period were prospectively recorded in a patient database. Variables that were recorded included presenting complaint, length of symptoms and whether they had previously been referred with these symptoms. All patients in this database had demographics recorded as well as their clinical outcomes for audit purposes. Patient details were recorded for tracking purposes only and only accessible by the ANP. Patients seen by the ANP remained under a named head and neck cancer consultant surgeon as per usual referrals, but the ANP was responsible for tracking the patient outcomes and ensuring any requested diagnostics were performed within expected timeframes. If a cancer diagnosis was made, it was the ANP's responsibility to refer for a multidisciplinary meeting and to ensure communication with a named head and neck cancer consultant to ensure a treatment plan was established. Patient tracking by the ANP was imperative to ensure patient safety, as well as being a useful tool for training assurance. Review and reflection on previous practice was essential for informing future assessment and decision making for the ANP. A radiology proforma was available to support the nurse's decision-making by standardising the radiology requests in accordance with presenting symptoms.
Quality assurance
The ANP was responsible for seeing patients at their first consultation and these appointments were to be booked into the appropriate clinic according to the standard 2-week-wait appointments, with the pan-London head and neck cancer referral form available in consultations. All follow-up appointments and results of diagnostic investigations were to be completed by a consultant or senior fellow within the surgical head and neck cancer team as a safety-netting procedure. The ANP had an additional eight patients booked per clinic session, and required a consultant head and neck surgeon running an adjacent clinic to ensure availability for real-time discussion of patients. This meant capacity was occasionally limited by consultant job plans and availability of senior supervision, but there is argument for the clinic to progress onto independent clinics once the ANP has extended experience and competence. All patients that were seen by the ANP required history taking, neck examination, mouth examination and flexible nasendoscopy (FNE) for complete assessment. It is important to acknowledge that along with having a specific competency for the skill of nasendoscope examination, a separate competency was used to ensure the nurse was able to identify suspicious lesions or abnormal anatomy and to assess for any functional issues with the larynx. All FNEs performed by the ANP were completed on recordable equipment, meaning that images could be reviewed by the consultant head and neck surgeon if necessary. Once a full assessment was completed, patients’ outcomes were recorded as one of two options: discharged to GP or diagnostic tests requested by the nurse. Patients who had diagnostic investigations requested were tracked to ensure these were performed and to review the results of the investigations. Patient tracking also meant it was possible to identify potential delayed diagnosis or misdiagnosis.
Clinical audit
The project was registered on the Trust's clinical audit system. When registering the project, it was assessed for ethics compliance; despite the database acting as an auditing tool, it was deemed to be a service evaluation project and therefore did not need any further input from the research ethics committee. The Trust audit number was 14694. Results of the project will be uploaded to the clinical audit system once a complete data set has been collected.
Education and training
The initial training is described in Table 2. The patient database was used for learning purposes once the nurse was out of the structured training period and working in supervised independent practice. As confidence and competence grew, the ANP was able to review the outcomes of diagnostic tests they had requested and reflect on their decision-making skills when seeing future patients with similar presentations. Reflective practice and regular discussions around clinical decisions with the surgical head and neck consultant team were integrated into clinics as well as structured monthly discussion with their clinical supervisors. A level 7 Master's module, which included clinical assessment skills and differential diagnoses, was completed.
Patient involvement
To ensure a complete evaluation of the service, a patient feedback questionnaire was created to assess patient satisfaction and to ensure satisfaction levels were maintained when introducing the new model of care. The questionnaire prompted patients to select the type of clinician they saw, creating the opportunity for comparative analysis of professions. The questionnaire underwent multiple revisions to ensure that useful and measurable data would be collected. A 5-point Likert scale was used, to ensure accuracy of responses, and some free text questions were included to ensure qualitative data were collected. There were questions around overall satisfaction with the service, confidence in care received and understanding of discussions that had taken place. The survey was presented to a patient involvement group, which comprised patients who had previously been treated for head and neck cancer in the Trust. They were asked to consider whether the survey was appropriate to be given after the initial appointment and whether it was user-friendly and easy to follow. All members of the group gave approval for the questionnaire to be used and did not highlight that any adjustments needed to be made. This opportunity was also used to obtain patients’ thoughts on the project and whether they would have any reservations about being assessed by a nurse on their initial appointments. All members of the group unanimously agreed that they would not have any objections to this project.
The approved questionnaire was sent via the Trust's text message reminder system, in the same way patients received appointment reminders. The text was sent to all patients after their initial appointment and they were not sent the form at any other point in the pathway to ensure that responses were specific to the 2-week-wait referral process.
Information and IT
The patient database was only available to be edited and reviewed by the ANP. Patient hospital numbers were recorded for tracking purposes only. No patient details were shared when analysing the full data set. All clinic appointments required the ANP to compose a clinic letter to summarise the outcome of the consultation, which was sent to the GP and the patient and uploaded to the electronic patient record system.
Ionising Radiation Medical Exposure Regulations (IRMER) training was completed, and clinical governance gave approval for the nurse to be added to the Trust's non-medical referrers’ ordering policy. This allowed the ANP to independently request radiology investigations during consultations.
Clinical effectiveness
Analysis of the results is essential to be able to determine the clinical effectiveness of this project, which will be performed after 12 months of independent practice by the ANP. There will be an extensive analysis of the results to determine whether this is a safe and effective alternative to the current diagnostic set up. This will include discussion around conversion rates for the ANP, missed diagnoses and patient experience. This position was initially funded by the South East London Cancer Alliance for a 12-month pilot. The post is now funded by the Trust. There will also be a cost-effectiveness analysis of the ANP in comparison with employing and training new medical staff; this will include consideration of job plans.
Job plan for the ANP
The ANP was initially booked to see six patients per clinic, which was increased to eight. Limitations on the number of patients included availability of senior colleagues to supervise, the availability of additional clinic space and Trust-wide reduced activity owing to the implementation of a new electronic patient record system. Apart from direct clinical care, the time was allocated for patient tracking, clinical admin tasks and data collation for the pilot project. In each clinic the ANP worked with a different head and neck cancer consultant, meaning capacity was increased for all members of the surgical team. All patients were new referrals booked by the Trust's 2-week-wait referral team. There was discussion around whether referrals should be triaged before being booked into the ANP's clinic. However, it was agreed by the team that it would be safer to ensure competence of the nurse to see all presenting symptoms than for the referrals to be triaged by non-clinical staff. Owing to the nature of maxillofacial referrals and the necessity for these surgeons to be dual trained in dentistry, it was decided that the ANP would not support those clinics. The ANP was, however, trained to appropriately identify oral cavity lesions as these patients were also seen by the wider consultant team.
It is hoped that, in the future, there can be an expansion of the nursing team with a shift towards an entirely nurse-led diagnostic service. It is therefore important to consider the succession planning of this role and the feasibility of the time investment required to ensure a sufficient level of competence for the nurses taking on these roles. At present, the model has a single point of failure if the existing ANP is unavailable to provide the service. It is projected that reflection on the training period will result in a refined and supported training programme that can be implemented by the existing ANP to share experience and knowledge, while ensuring patient outcomes are not affected by missed or delayed diagnosis. There are arguably similar pressures within the cancer nursing workforce as in the medical teams; nonetheless this is a completely new and exciting career progression for nurses that should create enthusiasm and an incentive to engage in the training programmes. As part of the evaluation of the project, interviews with doctors will be conducted to assess their views on the time investment required to train the ANP and their overall views on the feasibility of this innovation.
Conclusion
The rapidly increasing referral rate for suspected head and neck cancer undoubtedly demonstrates that there needs to be change within the model of head and neck cancer diagnosis in order to meet the growing capacity issues. The demand on these services will continue to grow and it is therefore imperative that consideration is given to who the most appropriate clinicians are to help meet this demand; whether it be head and neck cancer consultants, general ENT consultants, nurses or allied health professionals. It is hoped that the clinical outcomes of this project will demonstrate that this new model of cancer diagnosis is safe and effective, without compromising patient safety or impacting conversion rates. It will also be important to consider patient satisfaction and confidence in the new service. If these outcomes can be demonstrated as anticipated, then there is potential for expansion to an entirely nurse-led model of care, eventually removing the dependence on head and neck cancer consultants to supervise and support.