Alongside my role as Cancer Research UK’s chief executive, I am honoured to have spent the last 6 months chairing the Independent Cancer Taskforce, and we have today published a report setting out how to transform cancer services in England.
If the initiatives in the report are implemented and the ambitions realised, we estimate it would mean 30,000 additional patients surviving cancer every year by 2020.
We were asked to consider how to deliver better prevention, swifter diagnosis and improved treatment and care for all cancer patients and, in so doing, to deliver the vision of the Five Year Forward View (FYFV). The context for the taskforce was that, despite fifteen years of effort and progress, we still have outcomes that do not come close to meeting our aspirations as a society. Our patients deserve world-class outcomes.
What might world-class mean? A significant reduction in the pace of growth of preventable cancers, improvements in survival rates so that our patients have the same outlook as those in comparable countries, and a transformation in patient experience and quality of life.
The report recommends a fundamental shift in how we think about cancer services, with a much greater emphasis on earlier diagnosis and living with and beyond cancer. It has been informed by hundreds of written submissions, nearly 100 workshops and meetings involving around 600 participants, the proactive involvement of patients, and consultation with around 30 cancer charities and almost all relevant professional groups.
The six strategic priorities we have identified are as follows:
1: Spearhead a radical upgrade in prevention and public health
The NHS, working with local and national Government and the public, needs to take a much more proactive approach to public health, with a view to reducing the growth in the number of cases of cancer in the future. There are opportunities to address the range of lifestyle risk factors and also to boost efforts in prevention of secondary cancer.
We need to go further and faster on smoking. We should aim to reduce adult smoking prevalence to less than 13% by 2020.
It is also time to get serious about tackling obesity. A failure to take dramatic action now to protect children means we are condemning many thousands of them to having serious health problems into adulthood, including increasing incidence of cancer.
2: Drive a national ambition to achieve earlier diagnosis
Earlier diagnosis is pivotal, as it enables more patients to access potentially curative treatment options, such as surgery. Earlier diagnosis will only be achieved by being less restrictive in our approach to investigative testing. NICE has recently updated its guidelines to help GPs refer patients with potential cancer symptoms – giving them more freedom to send patients to see specialists.
Delivering this will require us to significantly increase access to diagnostic services, where we currently are under-invested in both people and equipment. Most activity would continue to be funded through normal commissioning processes. However, in addition we propose that a national fund is created and used flexibly to enable local organisations to unlock local solutions.
Speed in diagnosis is of the essence, which is why we are also proposing a new metric – definitive cancer diagnosis or cancer exclusion within 4 weeks. We have recommended that this should be achieved for 95 percent of patients by 2020. Speed can also be enhanced by giving GPs direct access to a range of tests, and trusting them to make use of them appropriately.
3: Establish patient experience as being on a par with clinical effectiveness and safety
Perhaps the most disappointing aspect of the Taskforce’s work has been the countless stories we have heard from patients and their carers of poor communication and suboptimal coordination of care.
First, patients should be properly informed and empowered to be equal partners in their care. We should revolutionise the way we communicate with and the information we provide to cancer patients using digital technologies. From the point of a cancer diagnosis onwards, we recommend giving all consenting patients online access to test results and other communications involving secondary or tertiary care providers by 2020. This could yield substantial efficiencies also, although we have not attempted to quantify these.
Secondly, we should systematise patients having access to a Clinical Nurse Specialist or other key worker to help co-ordinate their care.
Thirdly, we have identified the need for a set of meaningful metrics to encourage providers to focus on patient experience, including the annual Cancer Patient Experience Survey. We expect these to be embedded across the NHS accountability framework to drive further improvement.
4: Transform our approach to support people living with and beyond cancer
Many cancer patients suffer long-term consequences from their cancer or their treatment and are at higher risk of recurrence. Many will suffer psychological or financial hardship. Most will have another long-term condition they are trying to manage in addition to their cancer.
The highest priority should be to accelerate the roll-out of tailored follow up pathways and access to holistic packages of support. The aim should be that, by 2020, every person with cancer will have access to relevant elements of the Recovery Package, and that stratified follow-up pathways should be in place for the common cancers.
We need to develop a national quality of life metric – ideally by 2017 – to ensure that we monitor and learn lessons to support people better in living well after treatment has ended. We should also ensure that end of life care planning and choices are made available to all who have a terminal diagnosis, without delay.
5: Make the necessary investments to deliver a modern high-quality service
Late diagnosis is not the only driver of our poorer survival rates. Over the last five years, we have come to understand that we also do not provide optimal access to treatment. This is in part caused by workforce and equipment deficits. Whether we compare numbers of oncologists or CT machines per head of population, our provision in England lags considerably behind other countries.
We need to upgrade our radiotherapy machines, around half of which are reaching the end of their useful life. Doing so will not only deliver safer care, it will also enable more widespread use of modern radiotherapy techniques, which spare normal tissue and the associated adverse consequences. Furthermore, because we can use modern machines more efficiently, replacing old machines will preclude the need to have more machines or suffer even worse access. This will require significant capital investment.
Secondly, we need to address acute workforce deficits, particularly in oncology, radiology, radiography and endoscopy, as well as in specialist nursing provision. There is also a very strong case to undertake a strategic review to determine future workforce and skills mix needs in cancer.
Thirdly, we should not delay any longer in establishing a modern molecular diagnostics service. We should be doing this already. Not only is its absence meaning patients are missing out on treatment options, but we are also using drug treatments inefficiently and, in some cases, inappropriately. Further delay risks accentuating the UK as a slow adopter of innovation with the consequent implications for inward R&D investment.
Finally, we need to establish a more sustainable model for access to novel cancer drugs. The Cancer Drugs Fund has helped to unlock access to new treatments for a large number of patients. However, its implementation could be adjusted to enable more innovative treatments to be provided in a more sustainable way. The new system should be co-designed by NHS England, patients and NICE.
6: Overhaul processes for commissioning, accountability and provision
Tackling variation in performance across the country represents the final top priority for progress over the next five years. Whilst our best Centres provide care comparable with anywhere in the world, quality is far from uniform. We need to determine how to configure services to deliver the best for all patients no matter where in the country they live. This needs to start with appropriate commissioning to defined national standards.
Secondly, we need to establish sub-regional alliances that provide a forum to bring providers and commissioners together with patients, so that they can co-design services to optimise pathways, ensure effective integration and address variation. This, in turn, will be facilitated by providers and commissioners working to standard dashboards of key metrics, which highlight variation both within a health economy and compared to the national average.
Finally we strongly advocate piloting new models of care and commissioning. This should include, in at least one area, the entire cancer pathway with full devolved budget over multiple years.
The strategic priorities set out above offer the potential to transform outcomes over the next five years. In the absence of implementation, the NHS will be unable to meet demand, resources will be spent inefficiently, costs will escalate, and patients will not receive the standard of care that they rightly deserve.
There are many questions to which we do not know the answers, such as how we can improve outcomes for older people, or what we can do about the long-term effects for adults treated for cancer. We must continue to lead the world in cancer clinical research, enabling us both to evaluate new technology that other countries do not, such as newer radiotherapy techniques, but also to offset NHS costs, for example in free drugs provided in trial settings.
Achieving world-class cancer outcomes is a multi-faceted challenge. No one initiative will fix all the problems, or address all the opportunities. We have tried to steer a course that will create the right conditions and environment for the future, whilst continuing to serve the needs of patients today.
– Harpal Kumar