Across the “Clinically-led review of NHS access standards” and the NHS’s Long Term Plan, there are important changes in cancer care, as summarised below:
These two documents commit the NHS to achieving a dramatic improvement in cancer survival, primarily through increasing the proportion of cancers caught early (at stages 1 or 2 rather than stages 3 or 4) from 50% now to 75% by 2028. Improvements in survival overall will also be helped by prevention, most particularly of lung cancer:
Collectively, these documents remove the 2-week wait standard and introduce a new 28 day faster diagnosis standard: from the moment a patient is referred for diagnostic tests for suspected cancer by a GP or based on a screening test, to the moment they receive a definitive diagnosis (cancer or no cancer), should be no more than 28 days.
The removal of the 2-week wait target offers significant opportunities for Trusts and Cancer Alliances to re-design their care pathways using “straight-to-test” techniques that can deliver diagnosis earlier in the pathway. This removal is also culturally unusual (and beneficial) – it is very rare for targets or standards in the NHS to be removed.
The change from 2-week wait to the 28-day referral to diagnosis standard is important because the time between referral and diagnosis is currently the only part of the cancer treatment pathway that is not specifically measured, and it is clear that much of the (often anxious) delay patients experience in receiving cancer care stems from this early part of the pathway.
This approach is also supported by work 2020 Delivery has done with a leading trust across five tumour sites, which showed that patients who didn’t receive a definitive diagnosis within approximately this timeframe were 5-8 times more likely not to receive treatment within 62 days of initial referral.
Equally, as diagnostic techniques continue to develop, so diagnostic pathways need to keep evolving, often making increased demands on diagnostic resources. Since 2020 Delivery was founded 13 years ago we have seen multiple improvements in diagnostic techniques: for example through the introduction of multi-parametric MRI for prostate cancers, and of CT as a first-line diagnostic tool for patients referred with potential lung cancer. So alongside this faster diagnosis standard, there will be increased funding for scanning and radiotherapy equipment.
The plan also sets out changes that aim to increase innovation and modernisation in cancer care:
- New Rapid Diagnostic Centres will be set up to enable faster access to diagnostic services
- More personalised care, enabled by technology and support locally within the community, as well as a new focus on follow-up care and a ‘quality of life’ metric to assess the long-term impact of cancer
- Innovative therapies will be made available, including CAR T-cell therapy, personalised therapy based on genetic analysis, whole-genome sequencing for children, and Proton Beam facilities in London and Manchester
There is much to celebrate in the Long Term Plan’s ambitions for cancer care. But there are also important areas where further attention would be valuable.
- Threats to funding for stop-smoking services. Smoking is the single biggest preventable cause of cancer, and programmes to help people quit are proven to work. The Long Term Plan’s commitment to offer stop-smoking support to all inpatients who smoke is a fantastic development (and one that has been shown to generate net cash savings for the NHS), but the Public Health Grant, which enables Local Authorities to provide stop-smoking services in the community, is at risk of losing its ringfenced status, and therefore of becoming a victim of Local Government cuts. Protecting this ringfencing status would ensure that funding continues to go to these services.
- Weak financial incentives: NHS organisations have financial incentives written into their contracts to encourage them to support primary prevention; but these are much weaker than those relating to timely access to care for those who have a diagnosis. (These ‘access’ measures are very important for people’s experience of care; but they are less effective at improving patient outcomes).
- Delayed reporting on cancer staging: “What gets measured, gets managed”. The National Cancer Registration and Analysis Service (NCRAS) publishes data about what proportion of cancers were diagnosed early, but it has a 1-year delay, which reduces the power of this data in driving changes in how health systems perform. Alongside the commitment to more early diagnoses it would be good to see more timely publication of staging data to make this possible.
Uncertainty about Cancer Alliance funding:
Cancer Alliances have a key role to play in coordinating regional strategies to improve cancer care, so making them coterminous with Integrated Care Systems (ICSs) and Sustainable Transformation Partnerships (STPs) is a welcome development. However Cancer Alliance core funding is only guaranteed until the end of March 2019, leaving them in an uncertain financial position. Longer-term funding commitments would invigorate Cancer Alliances to provide strategic leadership for regional cancer care.
No clear commitments on cancer workforce (for now):
There are a number of critical shortages in cancer workforce, especially in oncology and radiography, as well as other areas. The Long Term Plan acknowledges that 1,500 more clinical staff will be needed across 7 cancer specialisms. Even if this goes far enough, though, a detailed plan to address these workforce shortages won’t be available until the Workforce Implementation Plan is published later in 2019: until then, all we have is the promise to extend a credentialing scheme to allow clinicians to develop recognised capabilities in cancer care.
Of course, the devil is always in the detail, and the Long Term Plan is light on the specific measures that will deliver its big promises. But behind the eye-catching headlines there are commitments that will materially improve cancer outcomes, including among groups that are harder to reach with traditional hospital- and GP-based services. However, there is more that can be done to improve primary prevention and enhance the impact of Cancer Alliances: and without enough trained specialists, none of the Plan’s ambitions will be achievable.