Waiting for the tariff
Screening finds the lesions that are hardest to reach

Screening finds small peripheral lesions. Reaching them takes a service that most units in the country do not yet have, and the money to buy it has not arrived.

I wrote in the August SCTS Bulletin about whether the thoracic surgical workforce is configured for the volume that screening is producing. That piece was about surgeons. This one is about the step before surgery, which is where more patients are currently held up.

The starting point is that screening is working. Professor David Baldwin, NHS England's lead clinician for lung cancer, wrote for the UK Lung Cancer Coalition this month that more than 11,500 lung cancers have been identified since national rollout began, over three quarters of them at an early stage, against a historic figure below thirty per cent. Coverage of the eligible population is at around half of the hundred per cent committed for 2030. The National Lung Cancer Audit records forty per cent of patients in England diagnosed at stage I or II in 2024, up from thirty-six the year before and thirty-two the year before that, alongside the highest resection rate it has recorded. Lord Darzi has described targeted screening as the only initiative in recent years to have improved early-stage diagnosis.

Baldwin also writes that screening saves lives only if the diagnostic and surgical capacity is there to act on what it finds. That is the sentence worth sitting with.

A different lesion

Screening does not produce more of the cancer we used to see. It produces a different one: small, peripheral, frequently node-negative, often sub-solid on thin-section CT. That is what the programme was designed to do.

The consequence is that the difficult part of the pathway moves upstream. A four-centimetre central mass is straightforward to sample. A nine-millimetre lesion in a basal segment is not, and conventional bronchoscopy will not reach it. Navigational bronchoscopy will. So the pressure that screening creates lands on the diagnostic list before it lands in theatre, and that is where I see patients waiting.

Where the rollout has got to

It matters to be accurate about what kind of problem this is. Navigational bronchoscopy is early in its rollout. Every year more units acquire the service, and the number is rising steadily.

We have watched this happen before. EBUS was concentrated in a handful of centres before it became standard. Medical thoracoscopy spread the same way. Robotic surgery is still spreading, and so is screening itself, which is at half its committed coverage. New capability in thoracic practice arrives unevenly and then fills in. Nobody is withholding anything. Some units have the service, most do not yet, and the map is changing.

So the honest description of the current position is a transitional one. The question is how long the transition takes, and there is a specific reason to think it will take longer than the pattern would predict.

What is slowing it

The platforms are expensive, and there is no national commissioning policy for them yet. Work to produce one is under way and properly funded. In July last year the NHS Cancer Programme, through SBRI Healthcare and the Accelerated Access Collaborative, awarded £14.4 million across seven innovations in early cancer detection. Guy's and St Thomas' received £2,254,634 for a pathway combining AI-guided nodule risk stratification with robotic bronchoscopy, and NHS England announced in January that the pilot would run for eighteen months before expanding to King's College Hospital and Lewisham and Greenwich, generating the evidence needed to develop a national commissioning policy and support more consistent access across the NHS. That is exactly how a decision of this kind should be made, and the answer will not arrive before the middle of next year.

Every other trust has to decide before then. The routes taken so far describe the position fairly. Oxford University Hospitals installed its system this summer through trust investment and charitable support, with the hospital charity paying for supporting equipment. North Tees was part-funded by the Northern Cancer Alliance. University College London Hospitals acquired robotic bronchoscopy capability through a National Institute for Health and Care Research award for research equipment. The South East London Cancer Alliance publishes a resource page for clinicians setting out the funding avenues a trust might explore for the capital cost, alongside the practical work of building the pathway around it.

None of that is a criticism of the units concerned. It is resourcefulness, and it is why the map is filling in at all. But a trust in financial difficulty, with no charity appeal running and no alliance money available, will defer the decision until the policy exists, and that deferral has nothing to do with how many of its patients need the test.

The knock-on is predictable. A unit that has the service and is running it at capacity will look after the population it is accountable for first, and will limit or stop taking referrals from outside its own patch. That is a reasonable decision locally. Taken together across a region, it means access to a diagnostic test depends on where the patient lives — not because anyone chose that, but because the alternative to choosing it is not funded.

What happens where it is not available

The effect is not simply a slower diagnosis. Two other things happen instead.

The first is percutaneous CT-guided biopsy. It is a good test in the right lesion, and the diagnostic yield is not the issue. McNierney and colleagues compared the two approaches in 638 patients this year, and the yields were statistically indistinguishable: 84.3 per cent for shape-sensing robotic bronchoscopy against 80.5 per cent for CT-guided biopsy. The harm was not close. Pneumothorax occurred in 1.4 per cent of the bronchoscopy group against 29.5 per cent after the needle, chest drain insertion in 1.4 against 4.7 per cent, and pulmonary haemorrhage in 0.2 against 14.1 per cent. It is a single-centre observational series and the groups were not randomised, but the direction is consistent with the pooled data on transthoracic needle sampling, and it is not a small difference.

The second is that the patient goes to theatre without a tissue diagnosis, on imaging and multidisciplinary judgement. That is sometimes the right call and I make it myself. It is a different conversation when the reason is clinical probability and when the reason is that the test was not available locally.

Both of those are clinical consequences. A gap in diagnostic capability does not sit quietly in a queue; it converts into procedures with higher complication rates, and into operations done on less information than the surgeon would have chosen.

The constraints behind it

Two further constraints sit behind the diagnostic one, and both are slower to move.

The small peripheral node-negative tumour that screening generates is the one most likely to be treated by lung-preserving anatomical resection, which in most units now means a robotic approach. Shakir, Francis and Yassin argued in the Bulletin of the Royal College of Surgeons of England this year that robotic training has not kept pace with robotic adoption. That applies here. Robotic competence is a separate constraint from consultant numbers and it does not expand on the same timescale. At my own institution robotic anatomical resection rose from just under twelve per cent of anatomical cases in 2018–19 to over seventy per cent in 2024–25, which is what happens where the training infrastructure is already in place. Most units do not have it.

Then there is the workforce. There are 153 consultant thoracic surgeons across the United Kingdom and Republic of Ireland. Eighteen are expected to retire over the next five years against around twenty-five posts considered for advertisement, and about one in three trainees in the pipeline has expressed an interest in thoracic surgery. Those numbers do not improve on the timescale of the screening rollout. But a patient reaches the surgeon only after clearing the two steps in front, and those are where the current delay sits.

What would help

I am not arguing that screening should slow down. Baldwin's warning is the opposite, and it is the right one: coverage is at half of what was committed, lung cancer screening is still the only national programme without guaranteed funding beyond 2030, and losing momentum now would waste the most significant advance this disease has seen.

Three things would help. The commissioning policy, when the pilot evidence supports it, needs to arrive with a tariff attached, so that the purchase decision comes off individual balance sheets and the rollout follows need rather than fundraising. Diagnostic capacity needs to be planned as part of the screening programme rather than assumed to exist behind it, with provision mapped nationally rather than settled trust by trust. And robotic training capacity needs treating as its own constraint, separate from consultant numbers.

The first of those is already in hand, which is the encouraging part. It is also running eighteen months behind a screening programme that is halfway to full coverage, and that gap is where patients are currently sitting.

Screening has done the difficult part. It has changed the stage at which this disease is found, which the specialty spent thirty years failing to do. The pathway behind it is still being built, and at the moment the pace of that build is set by what each trust can afford.

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