An undervalued resource: why practice and programme staff hold the key to improving lung cancer screening uptake

Lung cancer is the leading cause of cancer death in England, responsible for around 34,000 deaths each year. Yet more than 70% of lung cancers are still diagnosed at stages 3 or 4, when treatment options are most limited. The NHS's Lung Cancer Screening Programme was designed to change this, offering CT screening to current and ex-smokers aged 55 to 74. But only around 55% of those invited take up the offer. Despite sustained effort, uptake remains low. The default response to underperforming screening programmes has been to do more of the same (more letters, more texts, more reminders), national or local advertising campaigns, and academic and industry-led research into improving uptake. These approaches matter, but they have not yet closed the gap.

There is another resource available. It does not sit in a dataset or a national guideline. It sits in the experience of the people running these programmes every day: practice managers, care coordinators, and clinicians who understand their patient populations in detail. This post explores what happens when that knowledge is taken seriously.

An action research approach

In partnership with the Cambridge Centre for Social Innovation, I carried out research into what drives inequalities and low uptake of the Lung Cancer Screening Programme and what can be done about it. The research followed a participatory action research design, meaning that rather than arriving with a predetermined intervention, we worked iteratively alongside a Lung Cancer Screening programme team in Norfolk, using each phase of research to inform the next.

The approach moved through five phases: Plan, Explore, Analyse, Implement, and Evaluate. We began by analysing data, moved into qualitative research with the staff responsible for delivering the programme, refined our understanding, designed an intervention together, and then tested it. The point was not just to measure impact but to understand why the problem existed and allow the people closest to it to shape the solution.

What the data showed

The first phase of research involved analysing anonymised invitation data for 1,131 patients who had been invited to book a lung cancer screening appointment by Appt Health. One finding stood out immediately: the income-related inequalities in uptake that dominate the academic literature were not present in this dataset. National studies have consistently found that patients in the most deprived communities are significantly less likely to attend lung cancer screening, yet Appt Health's data showed no statistically significant relationship between income level and booking rate. That finding on its own has important implications.

The more pressing question was: which patient groups were not engaging, and why? The initial dataset did not include smoking status, but the interviews that followed pointed strongly in that direction.

What the staff already knew

Seven semi-structured interviews were carried out with clinical, administrative, and commissioning staff involved in the Lung Cancer Screening Programme. Their observations were striking not because they were surprising, but because they were precise. These individuals knew, from experience, that current smokers were harder to reach. They could articulate why.

Two psychological barriers came through clearly. The first was fatalism. As one interviewee explained: "current smokers have less of a hope of being well, and they've got more like fatalistic nihilistic views on their health." The second was shame. Smokers, staff reported, often felt blamed for their situation, and that sense of anticipated judgment made them less likely to walk through the door. "I think a lot of people who do smoke feel kind of a lot of blame and guilt, and quite ashamed of it," one interviewee noted. "And so, I think they're probably then less likely to want to come along to an appointment."

A third barrier seemed to be the most actionable: many invitees simply felt fine. They were not experiencing symptoms and could not connect the urgency of the invitation to their own sense of health. Staff described this as a real and recurring phenomenon: people who had not responded were not necessarily hostile to screening, but had not yet understood why it mattered to them personally.

These insights were then validated quantitatively. When smoking status data was added to the dataset, the analysis confirmed what staff had suspected. In the field experiment phase, current smokers were found to be 66.48% less likely to book a screening appointment than ex-smokers, a finding that reached statistical significance at a confidence level exceeding 99.9%.

Designing an intervention, together

Armed with the qualitative findings and the quantitative confirmation, we moved into the Implement phase. The practice team was presented with the research and asked a direct question: given what we now know, what should the invitation say?

The modified wording they developed addressed the "feeling fine" barrier directly. It was written not to frighten or assign blame, but to give patients a compelling reason to engage that was grounded in what screening could offer them, rather than what their lifestyle might have put them at risk of.

The field experiment compared the standard invitation message with the modified version across a cohort of 992 patients. The results were significant. Patients who received the modified invitation were 43.03% less likely to decline the invitation to book a screening appointment, a finding that was statistically significant at the 99.69% level. Among current smokers specifically, the booking rate increased from 28.57% in the control cohort to 37.88% in the treatment cohort, and the decline rate nearly halved, falling from 25.71% to 13.64%.

These are not abstract percentages. Scaling this improvement across the NHS's ambition to invite 2.5 million people to lung cancer screening annually, an intervention of this kind could translate into over 90,000 additional screening attendances each year. Research suggests that 1.16% of screened cases lead to a diagnosis of lung cancer, meaning, in practice, that thousands more early diagnoses could be made.

Why this is not already happening

The other research question was perhaps the more uncomfortable one: if staff already hold this knowledge, and if the knowledge can be translated into a meaningful intervention, why has this not happened more systematically? We continued the action research cycle and posed this question to the Lung Cancer Screening programme staff.

The interviews identified three overlapping explanations.

1. The weight of established practice. Healthcare professionals had internalised existing approaches (more reminders, more letters) as the correct response to low uptake. Questioning those defaults required a kind of deliberate disruption that the existing system did not naturally encourage. As one interviewee put it: "normally whenever we've had issues with uptake in the past, it's just been a case of sending another invite." That became the way things were done, and it took action research to look beyond it.
2. Capacity. NHS general practice is under significant pressure. Research (looking at data, running interviews, designing modifications, testing their impact) is not something that can be done in spare moments between appointments. Several interviewees were candid about this. "I don't think the practices necessarily have got the time," one said. Another added: "if it's a national screening programme, we are not particularly funded to be able to hugely do much around the uptake." When activity is not funded, it tends not to happen, regardless of its potential value.
3. Incentive misalignment. Some practice stakeholders reported that financial incentives rewarded reaching target thresholds, or invitation coverage, rather than maximising uptake. Once a practice had hit its target, the motivation to do more diminished. Others described competing pressures from national teams that emphasised the volume of invitations sent rather than the quality of patient engagement. As one interviewee put it: "we're being pushed by the national team to do the numbers." When the system measures the wrong thing, even well-motivated professionals end up optimising for the wrong outcome.

Embedding the learning

What this research demonstrated is that the knowledge needed to improve lung cancer screening uptake is often already present in the practice. The staff who run these programmes understand their patient populations, understand the barriers those patients face, and, when given the opportunity, can design solutions that work. What is missing is not insight. It is the structured process to surface that insight, test it, and act on it.

At Appt Health, we are embedding the learnings from this research directly into our approach. That means approaching patient engagement not as a fixed template to be rolled out uniformly, but as something that should be informed by data, refined through collaboration with practice teams, and tested against real outcomes. It means taking seriously the knowledge and expertise that healthcare professionals carry, and building systems that help them apply it.

The early results from this approach are encouraging. We are seeing meaningful increases in screening uptake across the practices we work with, and we continue to learn from each programme we run. Right now, Lung Cancer Screening programmes using Appt Health's software are seeing more than 60% of patients booking through automated channels, without the need for the programme team chasing or calling patients one by one. There is still a great deal to do. But the evidence from this research suggests that one of the most valuable resources for improving lung cancer screening outcomes in the NHS is not a new technology or a new policy. It is in the heads of the people running these programmes.

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This research was carried out as part of a dissertation for a Masters programme at Cambridge Judge Business School, in partnership with the Cambridge Centre for Social Innovation.