Recommendation 18

HM Government Acknowledged

Until the 2021 Spending Review and subsequent publication of the NHS Capital Planning Guidance, the responsibility to replace equipment, including radiotherapy equipment, resided with NHS Trusts, using internally generated capital or other financing arrangements, i.e. leasing. Notwithstanding the responsibilities of NHS Trusts, since 2016 NHS England has taken steps to ensure that every NHS Trust delivering radiotherapy has access to modern, cutting edge radiotherapy equipment, enabling the rollout of new techniques like Stereotactic ablative radiotherapy (SABR). This led to the LTP commitment to invest £130m between 2016 and 2018, to which NHS England added a further c£32m in 2021-22. In total, these actions have enabled the replacement or upgrade of over 100 radiotherapy treatment machines. Looking ahead, the 2021 Spending Review set aside £12bn in operational capital for the NHS over the next three years and the recent Capital Planning Guidance states that the following arrangements must be in place for radiotherapy: “It is expected that the majority of radiotherapy equipment, particularly linear accelerators, will need to be replaced at 10 years of age, in order to continue to make progress on LTP priorities, including enabling local access to cutting-edge radiotherapy treatments like SABR. The responsibility to plan for radiotherapy equipment replacement resides with Integrated Care Systems (ICSs), using their system operational capital allocations. ICSs will therefore need to develop replacement plans as part of their multi-year capital plans, in partnership with specialised commissioners, Cancer Alliances and Radiotherapy Operational Delivery Networks, based on an assessment of equipment age, capacity and demand, opportunities to improve access and service risk.” In relation to the current number of LINACs aged 10 or more in routine NHS service, NHS England understands that, as at 31 March 2022, the figure stood at c.20 LINACs, equating to c.7% of the NHS fleet. This information is based on information collected from radiotherapy providers in late 2021 and is therefore subject to change. Over the course of 2022/23, NHS England intends to undertake a capacity and demand review of external beam radiotherapy capacity, which is intended to support local systems to plan radiotherapy provision, including equipment replacement. At the present time, there is no clear case for expanding the radiotherapy equipment fleet in England. This is because: • There has been no clear increase in activity over the last 5 years. • The impact of changing clinical practice, including the use of ultrahypo- fractionated treatments, is visibly reducing the overall number of daily treatments given and is resulting in far fewer patient journeys to hospital. • Investment in new equipment has resulted in greater service efficiency and reliability, reducing the need for ‘back-up’ or ‘contingency’ machines. In relation to the following evidence submitted to the HSCC: “We have a block tariff now, but that means that you cannot have a new machine until you do 9,000 treatments.” NHSEI considers that this evidence conflates two separate issues, potentially generating confusion. Neither the block financial regime in place during the pandemic, nor the current Aligned Payment and Incentive arrangements prevent NHS Trusts or local systems from replacing equipment, rather they set out the basis of payment. The new Capital Planning Guidance makes clear the basis on which local systems and NHS Trusts will need to make capital investment decisions, this includes an assessment of service capacity and demand. generate maximum value for money for taxpayers. The reference to 9,000 treatments is believed to flow from the Radiotherapy Service Specification and is not linked to investment decisions. The specification states that providers must: “Continually review the working arrangements of the service with the aim to improve equipment utilisation rates to meet the national benchmark of 9,000 attendances per year as a service average by ensuring that: • Each machine is available to treat people at least 5 days per week; • That servicing and planned preventative maintenance, quality assurance checks and other key activities (including capacity to accommodate machine breakdowns) do not disrupt Service User’s treatments and should be undertaken on any of the other days of the week; and • Ensure there are contingency plans and arrangements for the management of Service Users during periods of staff shortage and machine maintenance and breakdown should be in place and form part of the Network workforce sustainability strategy” IT and technology Alongside the investment in treatment machines, NHS England has commenced a 3 year pilot programme of new cloud based technology called ProKnow, as recommended in the Digital Playbook for Cancer. The technology provides valuable teaching and training resources and offers a mechanism for: • Clinicians to work togeth