Twelfth Report - Cancer services

We welcome the development of Rapid Diagnostic Centres and Community Diagnostic Centres, particularly in giving GPs more effective referral routes for possible cancer symptoms, especially those which are non-specific but concerning. However, we have heard differing accounts about the impact of the Covid-19 pandemic on the development of Rapid Diagnostic Centres in particular and would be concerned if there was a significant delay to their roll-out.

NHS England has been focusing on encouraging people to come forward with cancer symptoms during the pandemic, which is welcome, and has recently launched a marketing campaign to encourage people to overcome their reluctance to visit their GP to discuss symptoms. However, NHS England should continue to use marketing campaigns to increase public awareness of specific cancer symptoms. NHS England should also work with Primary Care Networks to build on the recent Early Cancer Diagnosis directed enhanced service and explore options to incentivise practices to encourage patients with possible cancer symptoms to consult with them early.

Cancer screening is a vital tool for early diagnosis, but even before the pandemic there were serious concerns about the effectiveness of national cancer screening services, particularly over IT systems and the speed at which innovations have been implemented. New programmes like the Lung Health Check programme offer some reason for optimism, but the pandemic has had a seriously disruptive impact on screening services.

The Government should implement the recommendations of Professor Sir Mike Richards’ review of cancer screening as a priority and ensure that there is a clear plan in place to rapidly conduct appointments missed during the pandemic.

We understand the rationale for simplifying the Cancer Waiting Times standards. It is important that NHS cancer services are given a clear set of targets to achieve and that these targets are the ones that are most important to patients. However, we note that there are no current plans to increase the target for 28-day faster diagnosis standard performance from 75% to 95%, given the importance of providing patients with a quick diagnosis of cancer.

The Government’s recent announcement of a £2.3 billion investment in 100 new Community Diagnostic Centres is welcome and could provide a significant increase in physical diagnostic capacity. However, it is not yet clear how much additional capacity this investment will yield and whether it will allow England to catch up with other countries in terms of numbers of scanners per patient. Moreover, while there is a commitment to invest in diagnostic equipment, there appears to be no detailed plan to address gaps in the diagnostic workforce. (Paragraph 62) 42 Cancer services

The Government and NHS England must set out detailed plans for how the £2.3 billion investment in Community Diagnostic Centres will be utilised, in particular detailing how many additional CT, MRI and PET-CT scanners and endoscopy suites the investment will provide.

The Government and NHS England must also develop a specific plan to address gaps in the diagnostic workforce, setting out how it will address both short-term and long- term shortages in key professions, and particularly what investment will be required to deliver sustainable long-term increases in these key professions.

There is huge potential in NHS cancer data, and a large amount of data from NHS cancer services is already collected and reported. However, there is significant room for improvement, particularly in reducing the two years it takes to collect and publish data on cancer stage. A major overhaul of data collection and timeliness is urgently needed.

Notwithstanding the lag on published data, on the basis of evidence supplied by the Government and the NHS, and Cancer Research UK’s analysis, we do not believe that the NHS is on track to meet the 75% early diagnosis ambition set by the Government. It is clear that there is good work underway to improve early diagnosis, which is welcome, but wholesale improvement is required if the 75% target is to be met. The stated focus on early diagnosis for the Secretary of State’s forthcoming cancer plan is therefore welcome.

The static trajectory in early diagnosis demands that the Government’s new plan for cancer services must include a clear action plan for achieving the 75% early diagnosis ambition which goes beyond current plans and considers much more radical proposals to kickstart progress. (Paragraph 72) Access to treatments

We recognise that the disruption to cancer services during the pandemic was primarily driven by the need to mitigate the risk posed by Covid-19 to patients undergoing cancer treatment. We also recognise the efforts made by the NHS to maintain treatment or offer alternative treatment options. Nonetheless, we remain extremely concerned at the ongoing disruption to cancer treatment and the lives lost prematurely as a result. While NHS England has continued to prioritise cancer services, we are yet to be convinced that there is sufficient recognition of the scale of the issue, and we are deeply concerned that the target for clearing the backlog for cancer diagnosis and treatment has been moved back by an entire year.

The Department of Health and Social Care and NHS England must publish a detailed analysis of the extent of the cancer backlog to support the delivery of the elective care recovery plan. The Department should work with NHS England to set out: a) the latest estimate for how many fewer cancer referrals and treatment starts there have been seen since the beginning of the pandemic; Cancer services 43 b) the latest estimate for how many of these people may still not have come forward for treatment, based on expected referral rates by cancer type, cancer incidence projections, and mortality rates; c) the breakdown of these estimates according to region and cancer type.

Based on these estimates the Department of Health and Social Care and NHS England should set out: a) an estimate of what level of additional capacity in NHS cancer services will be needed to address the backlog in cancer services and treatment by March 2023; and b) an action plan to ensure that NHS cancer services are able to provide this additional capacity above normal levels.

For patients with limited treatment options the approval of a new drug or therapy can make a significant difference even when the survival benefit is only months. Despite the effectiveness of the Medicines and Healthcare products Regulatory Agency’s regulatory process, and despite some progress by NICE in approving medicines more efficiently for use in the NHS, the whole process is still too slow.

As part of its new cancer plan, the Government should include a plan for how to better align the technology appraisals carried out by NICE with the regulatory process applied by the MHRA, in order to reduce the delay between a drug being approved by the MHRA and recommended for use in the NHS by NICE. The Government should also review the uptake of NICE-approved treatments in the NHS and ensure that its new cancer plan includes measures to improve the pace of adoption of newly-approved treatments in the NHS on a fair and equitable basis.

The Government and the NHS have recognised some of the issues with radiotherapy delivery in the NHS and have made welcome commitments to resolve these, such as investing in new radiotherapy machines and the proton beam centres in Manchester and London. However, it is clear that there are still significant concerns for the sustainability of radiotherapy services, particularly in regard to workforce and equipment as well as the organisation of services.

The Government’s new cancer plan should provide an update to the 2014 radiotherapy vision which should include a long-term rolling investment programme for outdated radiotherapy equipment as well as changes to the national radiotherapy tariff to incentivise the delivery of modern radiotherapy techniques and remove perverse incentives.

Major specialist cancer hospitals have better access to staff, expertise and technology, and patients referred to these sites are more likely to be offered potentially life- saving surgery. During the pandemic, these hospitals were the ones most likely to be able to continue treatment, perpetuating regional disparities. Creating more of these specialist hospitals would ensure that cancer surgery was more resilient in 44 Cancer services the event of future health emergencies and would better spread specialist cancer services across the country. However, disparities may continue with services outside of these sites.

As part of the Government’s new cancer plan, the Government and NHS England should review the organisation of cancer surgery with a specific focus on whether more specialist hospitals should be established to ensure that more cancer surgery is carried out on sites without an emergency department.

As part of the long-term plan for the cancer workforce, the Government and NHS England should develop specific proposals for improving the retention of experienced cancer staff, including targeting burnout and improving the day-to-day working conditions of staff. (Paragraph 115) Variation

Cancer Alliances have had a positive impact on transforming cancer services and sharing best practice, and enjoy strong support from the sector. However, it is clear that while they are having some success, there is still significant unwarranted variation across regions in England and that the ability of Cancer Alliances to address this is limited as a result of underlying factors such as workforce shortages. While Cancer Alliances have limited ability to address demographic factors such as deprivation which are also drivers of some variation, it is unacceptable if people receive inequitable care based on their ethnicity. It is welcome that the Government is developing and publishing more cancer data broken down by ethnicity as this will be essential to highlighting differences in care and outcomes.

To support Cancer Alliances to embed transformation into local cancer services, new Integrated Care Systems must be required to appoint cancer leads, with responsibility for working directly with Alliances to embed best practice into their own systems. Cancer performance should also be Ofsted-rated by Integrated Care Boards as a sub- domain to their main rating so there is clarity and transparency about where best practice is being followed and where support is needed.

Cancer Alliances must reflect on new data provided to them by NHS England and the Department of Health and Social Care about cancer outcomes by ethnicity in their areas. In particular they should review the care provided to people from Black, Asian and minority ethnic backgrounds to ensure that no one is receiving worse care on account of their race.

The new Office for Health Improvement and Disparities should review the drivers of disparities in cancer outcomes and develop a joint strategy with NHS England to address these disparities.

There are specific challenges facing people with rare and less common and less survivable cancers, including that they are often harder to diagnose and that issues with spreading best practice for treating less common cancers are more pronounced. Despite some positive changes such as Rapid Diagnostic Centres, it is not clear that sufficient focus is being given to rare and less common and less survivable cancers. (Paragraph 137) Cancer services 45

The Government must consider rare, less common and less survivable cancers specifically as part of its new cancer plan. NHS England should also produce an action plan for rare, less common and less survivable cancers, containing clear commitments to address key issues around the diagnosis and treatment of those cancers. It should cover raising awareness of these cancers among health professionals and the delivery of optimal treatments. (Paragraph 138) Research and innovation

The impact of Covid-19 on cancer research was significant and it is concerning that trial recruitment has not yet reached pre-pandemic levels. However, the pandemic has provided a model for how cancer research can be conducted more efficiently, in more hospitals, to bring greater benefits to patients.

The Government should set out how it will build on the lessons learnt during the pandemic by making it easier for researchers to: a) access vital patient data; b) access staff needed for their studies, by providing more protected time for research in NHS contracts, and c) get studies open for recruitment swiftly, by streamlining ethics and other approval processes.

The Government should also establish a ring-fenced fund for cancer research infrastructure targeted at NHS trusts which have historically low levels of research activity. (Paragraph 149) 46 Cancer services