COMMONS

Improving cancer services and outcomes in England progress report published

12 March 2015

The Department and NHS England have allowed a loss of momentum in the drive to improve cancer services according to the Public Accounts Committee's report published Thursday 12 March 2015.

Chair's comments

"With more than 1-in-3 people developing cancer in their lifetime, cancer touches the lives of all of us at some point, and the Department of Health spends over £6.7 billion on cancer services a year.

That is why it is so concerning that the Department of Health and NHS England have lost momentum in the drive to improve cancer services in the last two years.

More and more people are getting cancer but the resources available to support improvement have gone down.

Previous progress in improving cancer services was driven by strong national leadership but NHS England has downgraded the position of National Clinical Director for Cancer to only a part-time role. The National Cancer Action Team has been disbanded.

Focus on cancer has also been diluted at a local level. Across the country, the 28 regional networks dedicated specifically to cancer have been replaced by 12 'strategic clinical networks' covering both cancer and a wider range of other diseases.

Survival rates for cancer continue to improve, but nearly a third of people still die within a year of being diagnosed and around half do not survive for five years, placing the UK in a poor position when compared with the rest of Europe.

It is also alarming that the NHS is failing to meet important national cancer waiting time standards for patients, with the NHS failing to meet the 62-day target for patients to start treatment for the first three quarters of 2014. This is the first time this has happened since the standard was introduced.

Three-in-five cancers are diagnosed in people aged over 65, but older people are significantly less likely to receive treatments such as surgery and chemotherapy – for example, 70% of patients aged 15 to 54 receive surgery for kidney cancer, whilst only 36% of patients aged 75 to 84 do.

It is unacceptable that NHS England does not understand the reasons why access to treatment and survival rates are considerably poorer for older people.

More generally, there is still unacceptable and unexplained variation in the performance of cancer services across the country – for example in the proportion of people diagnosed through an emergency presentation, in GP referral rates and in performance against waiting time standards.

NHS England does not understand what lies behind the variations and is not using the available data to hold poorly performing local areas to account.

Important gaps remain in information to support improvements in cancer services, for example in the completeness of 'staging data', which record how advanced a person’s cancer is at diagnosis. There are also insufficient data to evaluate properly the impact of the Cancer Drugs Fund on patient outcomes.

The Department and NHS England must seriously consider whether the new arrangements for promoting improvements in cancer care provide the leadership and support required. All the bodies involved must redouble their efforts to regain lost momentum and get improvements in cancer services back on track."

Margaret Hodge was speaking as the Committee published its 45th Report of this Session which – on the basis of evidence from Juliet Bouverie, Director of Services and Influencing, Macmillan Cancer Support, Sarah Woolnough, Executive Director of Policy and Information, Cancer Research UK, Sir Andrew Dillon, Chief Executive, National Institute for Health and Care Excellence, Sean Duffy, National Clinical Director for Cancer, Simon Stevens, Chief Executive, NHS England, Professor John Newton, Chief Knowledge Officer, Public Health England, Jane Allberry, Deputy Director NHS Clinical Services, Department of Health and Una O’Brien, Permanent Secretary, Department of Health – examined Progress in improving cancer services and outcomes in England.

Despite having a good record in improving cancer services, the Department of Health and NHS England have lost momentum in the last two years. The incidence of cancer has grown whilst the resources available to support improvement have reduced. Leadership has been lost, the support for commissioners and providers to support improvement reduced, and fragmentation of accountability has made progress more difficult. The NHS needs to adapt to cope with the growing demand, but it is struggling to meet waiting time standards. Whilst survival rates continue to improve, nearly a third of people still die within a year of being diagnosed and around half do not survive for five years, placing the UK in a poor position when compared with the rest of Europe.

In addition, the inequalities and variations that we highlighted in 2011 persist. Survival rates and access to treatment are unjustifiably poor for older people in particular, and this is especially concerning because three-in-five cancers are diagnosed in people aged over 65. NHS England does not understand what lies behind the variations and is not using the available data to hold poorly performing local areas to account. While the information to support improvements in cancer services is better than it was, important gaps remain, for example in the completeness of 'staging data' (which record how advanced a person’s cancer is at diagnosis). There are also insufficient data to evaluate properly the impact of the Cancer Drugs Fund on patient outcomes.

The number of people diagnosed with cancer in England is increasing by 2% a year on average, driven by better awareness and the ageing and growing population. More than 1-in-3 people will develop cancer in their lifetime. In 2012, around 280,000 people were diagnosed with cancer and an estimated 133,000 people died from cancer. The Department of Health (the Department) is ultimately responsible for securing value for money for spending on cancer services, estimated at £6.7 billion in 2012-13. Responsibility for commissioning cancer services is shared between NHS England, through its area teams, and the 211 clinical commissioning groups. Public Health England takes the lead in providing access to cancer data to inform commissioners and help improve services. The National Institute for Health and Care Excellence reviews new cancer drugs to assess whether they should be available on the NHS.

Conclusions and Recommendations

The Department and NHS England have allowed a loss of momentum in the drive to improve cancer services. Cancer has been a priority for the Department since the publication of the National Cancer Plan in 2000, and we reported in 2011 that the NHS had made significant progress in improving cancer services. These improvements were driven, to a large degree, by high-profile leadership and increased resources. However, since 2013 the resources dedicated to leading cancer services have been reduced and NHS England has downgraded the position of National Clinical Director for Cancer to a part-time role. It has also relied on money from cancer charities to help fund this post, although it committed during our evidence session to fund the post in full itself from April 2015.

Across the country, the 28 regional cancer-specific networks have been replaced by 12 strategic clinical networks covering both cancer and a wider range of diseases. The effectiveness of these new networks has been variable. In addition, organisations, including cancer charities, have experienced delays in getting access to the data needed for research and analysis to support improvements in cancer services. The new Health and Social Care Information Centre has now simplified the process for organisations to apply to access data and is working through a substantial backlog of applications.

Recommendation: The Department and NHS England should review whether the new arrangements for promoting improvements in cancer care (for example, strategic clinical networks and data-sharing arrangements) provide the leadership and support required.

It is unacceptable that NHS England does not understand the reasons why access to treatment and survival rates are considerably poorer for older people. Survival rates for older people are lower than for other age groups, with cancer patients aged 75-99 20% less likely to survive for at least one year after diagnosis than those aged 55-64 (57% survive for at least one year compared with 77%). Older people are also much less likely to receive treatments such as surgery and chemotherapy.

In the case of kidney cancer, 70% of patients aged 15-54 receive surgery whilst only 36% of patients aged 75-84 operated on. NHS England has little understanding of the causes of the variation between age groups. It does not know the extent to which the variations can be explained by factors such as patient choice or the generally frailer condition of older people, or whether older people are being discriminated against in accessing treatment. NHS England has set up an expert advisory group to assess how it can ensure that access to treatment is based on an assessment of physical fitness rather than age, and it has commissioned a national survey on attitudes to cancer.

Recommendation: NHS England and Public Health England should build on existing initiatives to understand better the impact of age on access to cancer treatment and outcomes and the causes of any discrimination. They should establish the extent to which the variation can be reduced, and encourage commissioners and frontline clinical staff to take action to improve access and outcomes for older people.

There is still unacceptable and unexplained variation in the performance of cancer services across the country. As we reported in 2011, there are wide geographical variations, for example in the proportion of people diagnosed through an emergency presentation, in GP referral rates and in performance against waiting time standards. There are examples of neighbouring clinical commissioning groups with very different performance–in North East Lincolnshire, 98.5% of patients were seen by a specialist within two weeks of an urgent GP referral compared with only 87.1% in Lincolnshire West. The Department and NHS England expect that greater transparency, by publishing data on the performance of local cancer services and peer review, will lead to reduced variation. NHS England is responsible for overseeing the performance of clinical commissioning groups and holding them to account, but the persistent wide variations in performance indicate that these arrangements are not working effectively.

Recommendation: NHS England should use the available data to oversee clinical commissioning groups more effectively and to hold them to account for poor performance where it is identified. As part of this process, NHS England should gain assurance that commissioners, both clinical commissioning groups and its own area teams, are using existing benchmarking data and learning from good practice.

The NHS is failing to meet important national cancer waiting time standards for patients. NHS England told us that performance against the standard that 85% of cancer patients should start treatment within 62 days of being urgently referred by a GP is a crucial indicator of the readiness of the NHS. Meeting this standard has been challenging because the number of urgent GP referrals increased by 51% between 2009-10 and 2013-14. The NHS failed to meet the target for the first three quarters of 2014 and, between July and September 2014, some 5,500 patients had to wait longer than 62 days for treatment.

For parts of 2014, it also failed to achieve the standard that 93% of patients should be seen by a specialist within two weeks of being urgently referred with breast symptoms (where cancer was not initially suspected), and the expectation that less than 1% of patients should wait 6 weeks or longer for a diagnostic test, including those for cancer. NHS England acknowledged that there are diagnostic bottlenecks in the health system, including capacity issues caused by a shortage of sonographers. It has set up a waiting times taskforce to understand better variations across the country.

Recommendation: NHS England should ensure that it’s waiting times taskforce pinpoints why cancer waiting time standards are not being met, including assessing whether the NHS has sufficient diagnostic services. The taskforce should set out the action needed to meet the standards, and the date by which it expects the NHS will achieve the standards again.

Progress in improving patients’ access to radiotherapy treatment has been slow, and the NHS’s current stock of radiotherapy machines now needs replacing. Although access to intensity modulated radiotherapy treatment, an advanced form of radiotherapy, has improved, the overall proportion of patients receiving radiotherapy has remained at around 35% since 2009-10. This is some way below the estimated 40% to 50% of patients who could benefit from radiotherapy treatment at some time during their illness.

Hospital trusts with a low percentage of patients in their catchment area receiving radiotherapy in 2010-11 still had low rates in 2013-14. England has five radiotherapy machines for every one million people, fewer than most other high-income countries, although the Department suggested that our machines may be used more intensively. The current stock of linear accelerator radiotherapy treatment machines is coming to the end of its life and will need to be replaced in the near future. NHS England has set up an expert group to advise on how to configure radiotherapy services around the country. It plans to procure new machines on a national basis and estimates that around 20% of the cost of new machines could be saved through central procurement.

Recommendation: NHS England should set out how it will ensure a coordinated national approach to procuring replacement radiotherapy equipment, so that sufficient capacity is available in the right places. It should also set out how it will work with trusts to ensure that the procurement generates the expected savings.

The completeness of staging data still varies significantly across the country and has not met the level we recommended in 2011. Staging data record how advanced a patient’s cancer is at diagnosis, with early diagnosis greatly improving the chances of survival. The data are important for improving outcomes for cancer patients and informing the better use of resources. The proportion of newly diagnosed cancer cases with staging data improved from 33% in 2007 to 62% in 2012, but this was still below the level of 70% we recommended in 2011 and to which the Department committed. The completeness of staging data varied from 24% to 83% across the 211 local clinical commissioning groups in 2012. At the time of our hearing, Public Health England had not finished processing cases for 2013.

Recommendation: Public Health England and NHS England should set out when they expect all clinical commissioning groups to have staging data for at least 70% of new cancer cases. Public Health England should also provide an update on staging data completeness for 2013 in its response to this report. This should include both the national position and the extent of local variation.

The Department and NHS England did not have sufficient data to evaluate the impact of the Cancer Drugs Fund on patient outcomes before deciding to extend the Fund until 2016 and increase its budget. Some 60,000 people have received drugs through the Cancer Drugs Fund, which the Department set up in 2010 to enable patients with cancer to access drugs that are not routinely funded by their local commissioners. We heard that 87% of the drugs currently available through the Fund have previously been assessed by the National Institute for Health and Care Excellence and rejected on the grounds of clinical and cost-effectiveness.

Before April 2014 trusts were not required to collect data on patients receiving drugs paid for by the Fund, and around half of these patients were not recorded in the main chemotherapy dataset in 2013-14. This means that it has not been possible to evaluate in a meaningful way the impact of the Fund on patient outcomes. Despite the lack of evaluation, the Department extended the Fund until 2016 and NHS England increased its budget from £200 million a year in 2011-12 to £280 million for 2014-15 and £340 million for 2015-16. NHS England confirmed that data would be available in April 2015 for patients supported by the Fund in 2014-15.

Recommendation: NHS England should set out how it will use the new data (for 2014-15 patients) to evaluate the impact of the Cancer Drugs Fund on patient outcomes. It should also include in its response a report on the completeness of the data for 2014-15 and, if the data are not complete, it should take action to ensure that trusts comply with the requirement to record data.

Further information

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