Select Committee on Health Written Evidence

Evidence submitted by the Cancer Capacity Coalition (WP 22)

1.  INTRODUCTION

  1.1  The Cancer Capacity Coalition is an expert working party established to consider issues relating to "demand capacity" in cancer drug therapy delivery services and its importance to the provision of high quality cancer patient care. Demand capacity is defined as the resources required for the delivery of optimum care to all patients.

  1.2  Members of the Cancer Capacity Coalition include:

—  Professor Jim Cassidy (Professor of Oncology and Head of Department, Cancer Research UK Department of Medical Oncology, University of Glasgow) (Chair of Coalition)

—  Kathy Corcoran (Nurse Consultant, Southend Hospital)

—  Peter Gent (Cancer Network Manager, North East Scotland Cancer Co-ordinating and Advisory Group)

—  Mark Gilmore (Cancer Network Nurse Director, North West Midlands)

—  Dr Rob Glynne-Jones (Consultant Clinical Oncologist, Macmillan Lead Clinician in Gastrointestinal Cancer, Mount Vernon Cancer Centre)

—  Dr Mark Hill (Clinical Lead for Research, Kent Oncology Centre, Maidstone Hospital)

—  Sir Michael Partridge KCB (formerly a Permanent Secretary in the Department of Health and Social Security)

—  Ian Beaumont (Director of Press, PR and Public Affairs, Bowel Cancer UK)

—  Julia Kennedy (Head of National Service Delivery, Bowel Cancer UK)

—  Joanne Rule (Chief Executive, CancerBACUP)

—  Hannah Saul (Policy and Public Affairs Manager, CancerBACUP)

  The work of the Cancer Capacity Coalition is sponsored by Roche Products Ltd.

  1.3  We have found that workforce shortages are a major explanation for problems in meeting demand capacity in cancer drug therapy delivery. Without effective workforce planning, the impact of these shortages can be expected to be acute given the context of increasing demand for cancer drug therapy delivery.

  1.4  The Cancer Capacity Coalition therefore welcomes the Health Select Committee's decision to launch an inquiry into workforce needs and planning for the health service. This response sets out the:

—  Factors which will influence workforce planning in cancer.

—  Challenges for NHS workforce planning.

—  Impact these challenges will have on Government priorities.

—  Potential solutions to the challenges.

—  Effect of Payment by Results on the NHS' ability to adopt solutions.

—  Recommendations the Committee may wish to consider in relation to cancer workforce planning.

  1.5  If the Committee would find it useful, the Cancer Capacity Coalition would be happy to provide further details of the issues outlined in this response, or to give oral evidence to the Inquiry.

2.  FACTORS WHICH WILL INFLUENCE WORKFORCE PLANNING IN CANCER

  2.1  Demand for cancer services, and therefore the expertise and skills of the NHS Cancer workforce; this looks set to continue.

2.2  Impact of an ageing population

  2.2.1  More than one in three people in England will develop cancer at some point in their life. One in four people in England will die from it. There are over 220,000 new cases per year in England, and 128,000 deaths. Overall cancer incidence increased by 31% between 1971 and 2000, yet cancer mortality has fallen by 12% in the same period. [23]Five year survival rates for all cancers have improved and look set to continue to do so: [24]

Tumour site	Five year survival, 1991-95 (%)	Five year survival, 1996-99 (%)
Breast	72.8	77.5
Prostate	53.6	64.8

Lung	Men:   5.2	Women:   5.4	Men:   5.8	Women:   6.4
Lymphoma	Men: 43.3	Women: 49.2	Men: 47.4	Women: 52.3
Colon	Men: 42.1	Women: 42.8	Men: 46.9	Women: 47.9
Rectum	Men: 40.3	Women: 44.8	Men: 46.8	Women: 51.1

  2.2.2  The NHS is continuing to improve on past performance in tackling most cancers. However, as the population ages, so the number of people diagnosed with cancer will increase, putting additional demand on services. For example, the Scottish Executive estimates that there will be a 28% increase in the number of people diagnosed with cancer over the next 20 years. [25]

2.3  Impact of earlier diagnosis

  2.3.1  In general, the earlier a person's cancer is diagnosed, the better the chances of successful treatment. The variation in the stage at which cancer is presented and diagnosed is considered to be one of the reasons for the continuing inequalities in outcomes. [26]

  2.3.2  Screening programmes for breast and cervical cancer have improved survival rates and evidence suggests that the promised roll out of the National Bowel Cancer Screening Programme from April 2006 will have a major impact on survival, reducing the number of deaths from bowel cancer by 15% and saving approximately 1,000 lives a year in the UK. [27]

  2.3.3  In addition, work by the Government and the voluntary sector to raise public awareness and understanding of the symptoms of cancer and how people can best seek help is likely to increase levels of early diagnosis. For example, in October 2005 the Department of Health announced a pilot awareness programme on the prostate and its function, which can be expected to increase early diagnoses of prostate cancer once it has been rolled out nationally.

  2.3.4  The earlier diagnosis of cancer can be expected to have a positive effect on survival and quality of life but it will also place increased demand on cancer services. For example in 2003-04 the breast cancer screening programme screened 1.2 million women aged 50-64 and identified 8,400 cancers which may not otherwise have been diagnosed at such an early stage. [28]Similarly, the bowel cancer screening programme is expected to increase the numbers of patients needing treatment. It is estimated that, for every 1,000 patients who complete the Faecal Occult Blood test (FOBt), 16 will report a positive FOBt result and will be offered colonoscopy and 12 will actually undergo a colonoscopy procedure. Of these five will be found to have polyps at colonoscopy (and require surveillenace) and one will be found to have bowel cancer.

2.4  Impact of increasing "treatability" of cancer

  2.4.1  As knowledge of cancer increases, so will the NHS' ability to effectively treat the condition, either in terms of curative interventions, slowing progression or mitigating the effects of the disease. Patients with cancer are now being offered a series of often multiple interventions which were not possible only a few years ago. However new treatments are often in addition to, rather than a replacement of, existing options and are given over a prolonged period of time, resulting in increased pressure on cancer services.

  2.4.2  Drug therapy is now being used to treat a rising number of cancers, increasingly at an early stage of the disease, as well as being employed as a second or third line treatment. Developments in this area are likely to substantially increase demand on chemotherapy services over the next few years. Early in 2005 NICE published its guidance on the management of lung cancer and this included a recommendation that adjuvant chemotherapy be offered to lung cancer patients after surgery. [29]This will represent a change in practice and significant additional work in many centres.

  2.4.3  For example, so-called targeted biological therapies are now increasingly being used in addition to chemotherapies, resulting in significant improvements to patient prognosis but also increased pressure on services. Current examples include the use of trastuzumab (Herceptin) in breast cancer, imatinib (Glivec) in gastrointestinal stromal tumours and bevacizumab/cetuximab (Avastin/Erbitux) in advanced bowel cancer.

  2.4.4  Very few types of cancer are now considered to be chemotherapy resistant and the list is diminishing each year. For example, within the last year pemetrexed (Alimta) has become the first drug to be marketed for the treatment of mesothelioma, a cancer associated with asbestos exposure that, until recently, was thought to be insensitive to chemotherapy.

  2.4.5  Our increased ability to effectively treat cancer is leading to significant increases in survival. Dr Frank Lichtenberg has examined the impact of access to new cancer drug treatments on cancer survival rates in the US between 1975 and 1995. His conclusion is that new medicines account for 50-60% of the 25% increase in five-year survival rates seen in the USA over this period. [30]

  2.4.6  There has been much debate about the cost of new cancer medicines. Although drug costs are increasing and can be expected to expand still further, perhaps more significant will be the impact of new treatments on NHS capacity. A report in 2005 by the Karolinska Institute estimated that drug costs form only a small part of the total cost of treating cancer, with inpatient hospital care accounting for approximately 70% of total budget. [31]

  2.4.7  A survey of 42 hospitals published in 2003 found a huge increase in the use of intravenous chemotherapy over the past three years. The average increase was 200%, with some hospitals reporting a 500% increase. [32]Unsurprisingly this increase has had significant impact on the demands placed on the workforce. The same survey concluded that the lack of staff trained in preparing and administering new cancer treatments was a significant rate-limiting factor in making available these treatments to all who could benefit.

  2.4.8  These findings are supported by the work undertaken on access to new cancer medicines by the National Cancer Director in 2003 and the Audit Commission in 2005. Professor Richards found a fourfold geographical variation in access to NICE-approved oncology drugs. The Report identified "constraints in service capacity" as having a major impact on the variation in usage. Specifically, the increased use of chemotherapy was found to have resulted in a lack of suitable space to prepare and administer cytotoxic drugs as well as shortages of specialist pharmacists, doctors and nurses. [33]

3.  CHALLENGES FOR WORKFORCE PLANNING IN CANCER

  3.1  Despite the potential of new technologies to make more efficient use of existing capacity, the factors outlined in Section 2 mean that increases in the cancer workforce will be necessary, mirroring the projected increases in demand for skilled healthcare staff across the NHS. Derek Wanless estimated that the healthcare workforce would need to be increased by almost 300,000 in the period up to 2022. He also noted that demand for healthcare professionals is likely to far exceed supply. [34]

  3.2  Staff shortages will be compounded by at least three factors:

—  Existing staff shortages—as well as dealing with projected increase in demand for staff, the NHS will have to cope with historical under-capacity. Much of the recent increase in staffing has simply compensated for existing deep-seated shortages in skilled staff.

—  Ageing population—as the wider population ages and cancer diagnoses increase, so the healthcare workforce will also age, resulting in many skilled professionals reaching retirement age. The NHS will have to recruit replacements as well as the additional professionals needed to meet demand.

—  Working Time Directive—the full implementation of the Working Time Directive in the NHS will mean that more full time equivalent staff will be needed to provide the same level of capacity as before. For example, one London hospital estimates that, whilst before 1991 three doctors sometimes each working over 100 hours a week were needed on a rota to cover a speciality, by 2009 eight to 10 doctors will be needed to cover a similar rota (on duty up to 48 hours a week). [35]Clearly it is a benefit that staff should not have to work such long hours, but it also poses challenges to capacity planning.

  3.3  These factors will make the swift adoption of capacity-saving measures even more essential.

4.  IMPACT OF CHALLENGES ON GOVERNMENT PRIORITIES

  4.1  Increased demand for cancer services is already impacting upon the ability of the NHS to meet Government priorities.

4.2  Implementation of NICE guidance

  4.2.1  As set out in Section 2.4, the Government has already acknowledged that shortages in capacity have resulted in some cancer networks not fully implementing the recommendations of NICE technology appraisals. Although steps have been taken to address this, evidence suggests that capacity remains a challenge.

4.3  Patient choice

  4.3.1  The Government has made clear its intention to expand patient choice around treatment. The Cancer Capacity Coalition's understanding of choice includes four components: patients should have a choice of where they receive treatment, when they are treated, what they are treated with and how this treatment is delivered. If adequate capacity is not available in drug therapy delivery services, then patients will be denied options from which to make a realistic choice on one or more of these components.

  4.3.2  Choice also impacts on clinicians, who are understandably reluctant to use a treatment that cannot be efficiently and effectively delivered, sometimes resulting in the full range of treatments available not being offered to all patients.

4.4  Waiting times

  4.4.1  The Government has implemented targets of a maximum 62-day wait from urgent GP referral for suspected cancer to treatment for all cancers and a maximum 31-day wait from diagnosis and decision to treat, to treatment for all cancers. Shortages of staffing and equipment capacity remain a challenge for trusts in meeting these targets.

  4.4.2  A CancerBACUP survey of cancer networks published in 2004 found that staff shortages were one of the main barriers to achieving waiting time targets. Forty-five per cent of networks surveyed stated that a shortage of key staff is the biggest single barrier to achieving waiting time targets while only 15% considered lack of funding as the biggest problem. [36]

4.5  Health inequalities

  4.5.1  Although good progress has been made in improving cancer outcomes, health inequalities in cancer remain a significant challenge. Research has found that the gap in survival between rich and poor is wider for those diagnosed during 1996-99 than for those diagnosed during 1986-90 for 12 of the 16 cancers looked at in men and nine out of the 17 cancers in women. [37]

  4.5.2  Shortages in treatment capacity are likely to affect those suffering from health inequalities disproportionately as they are more likely to develop cancer and less likely to be equipped to effectively argue their case for access to the best treatments.

5.  POTENTIAL SOLUTIONS

  5.1  Although the challenges to effective workforce planning posed by trends in cancer incidence and treatment are significant, there are a number of opportunities to make more effective use of existing capacity.

5.2  Opportunities presented by technological changes

  5.2.1  Section 2.4 sets out how technological advances have increased the treatability of cancer and therefore resulted in greater demands being placed on cancer services and the cancer workforce. However new technologies also have the potential to enable the NHS to make better use of its existing workforce capacity.

  5.2.2  Some oral chemotherapies have been developed which enable patients to choose to take the majority of their treatments at home, therefore freeing up chemotherapy capacity in hospital and community settings, as well as saving on nursing and pharmacy time. Such therapies have no need for intravenous equipment and significantly reduce staff time spent on drug preparation and administration.

  5.2.3  One such example is capecitabine (Xeloda). During the NICE appraisal process for capecitabine in advanced bowel cancer (NICE Appraisal No 61), the independent technology assessment group model estimated substantial NHS budget-impact savings if all eligible patients were treated with oral chemotherapies (net savings of £17 million were identified if all metastatic bowel cancer patients were treated using oral alternatives to IV). Similarly the current appraisal process for capecitabine in early stage bowel cancer has indicated that substantial savings are possible (net £16.5 million if all early stage bowel cancer patients were treated using oral alternatives to IV). These savings were calculated using the cost of drug, plus an estimate of the resources required for preparation and administration, as compared to the cost of purchasing, preparing and delivering a standard IV drug alternative.

  5.2.4  There are examples of how using oral therapies is leading to significant capacity savings in practice. For example, the Mount Vernon Hospital in Middlesex reports that the introduction of oral chemotherapy has been the factor which has had the most impact on maximising capacity to date.

  5.2.5  Similarly, the Beatson Oncology Centre in Glasgow offers a nurse/pharmacy led chemotherapy (in this case capecitabine) service, avoiding patients being admitted to in-patient beds/day areas for infusional chemotherapy. Other centres in Scotland have followed the example of the Beatson Oncology Centre. Within Grampian, the development of out-patient based capecitabine services has saved around 2000 bed days each year. This has resulted in the abolition of oncology treatment waiting times for other tumour groups and the removal of the need for a larger cancer unit. The main pharmacy area in Aberdeen has significantly benefited from the increasing use of oral chemotherapy by avoiding the reconstitution of around 2,800 litres of IV chemotherapy annually. This is significant when we consider their workload over five years has more than tripled without a matching increase in their staffing establishment.

  5.2.6  Some newer cancer drugs also have a longer shelf life, resulting in less demands being placed on pharmacy staff to be present to make it up. Such drugs can help support distant and remote administration services to patients.

  5.2.7  Other areas where technological change can minimise demands on staffing include the development of less invasive surgical techniques, resulting in shorter hospital stays, and the greater use of telemedicine.

5.3  Opportunities presented by role and service redesign

  5.3.1  Redesigning staff roles to make the best use of different skill sets can result in much greater use of existing capacity. Derek Wanless' first report suggested that nurse practitioners could undertake at least 20% of the work of doctors while maintaining the safety and quality of care. However for such a move to be effective, responsibilities would then have to be devolved from nurses to healthcare assistants, resulting in additional demand for an estimated 70,000 additional healthcare assistants, on top of the extra 74,000 Wanless forecasted would be required. [38]

  5.3.2  In relation to "demand capacity" in cancer drug therapy delivery, there are best practice examples of how role redesign is resulting in more effective use of existing capacity. The Cancer Services Collaborative "Improvement Partnership" with Maidstone and Tunbridge Wells NHS Trust has focussed on role redesign as a way of reducing patient waits and improving quality of care. The work incorporated developing new ways of working and the reallocation of tasks to suit the skill mix of the team. Over an eight-week period it was found that the chemotherapy nurse spent on average 14 hours a week on non-chemotherapy tasks. A non-chemotherapy nurse or a health care assistant could perform procedures such as applying dressings or removing the cannula, allowing the chemotherapy nurse to give treatments, attend pre-assessment clinics or perform technical tasks such as the chemotherapy line insertion.

  5.3.3  The review suggested that developing the roles of nurses to perform nurse review clinics would improve the continuity in patient care, as well as making the nurses' careers more rewarding. This would also release consultant time allowing them to see more new patients. It also concluded that additional capacity could be realised by re-structuring the scheduling system, reducing the variation in patient pathways and introducing a secure drug storage system.

  5.3.4  Other ways of improving the use of existing capacity include:

—  Up-skilling of primary care based staff so that they are able to safely evaluate toxicity problems using appropriate grading tools and refer patients appropriately to the cancer centre, avoiding unnecessary assessment and admission to beds and reducing the number of chemotherapy patients requiring hospitalisation.

—  Increasing the availability of cancer drug therapy training courses to support the theoretical component of administration for nurses. This would broaden the number of nurses skilled not just to administer drug treatment but also to manage toxicities competently and encourage the development of nurse-led services.

—  Maximising pharmacy delivery time by providing sufficient staff for departments to continue to operate through lunchtime and other breaks.

—  Increasing unit operating times, for example earlier opening and manufacturing in aseptic suites permits patients to commence treatments earlier in the day, thus maximising capacity. At Southend Hospital, nursing and pharmacy staff shifts ensure all day working from 8 am through to 6.30 pm allowing treatment to commence at 8.30 am.

—  Implementing flexible working practices. For example staff at the Royal Marsden Hospital, London have divided the day into morning and afternoon sessions so that unit beds can be used twice in one day.

—  Demystifying the role that cancer treatments can play by encouraging greater education and understanding amongst non-"specialist" staff, therefore in time extending the structures and opportunities for oncological drug interventions to take place.

5.4  Opportunities presented by providing care closer to home

  5.4.1  Devolving care to community settings when it is clinically appropriate can free up specialist centres for patients who require that level of attention. For example, the use of palliative care centres to administer bisphosphonate therapies to patients for whom all lines of chemotherapy have been exhausted can free up oncology out-patient/day care capacity in specialist centres.

  5.4.2  There is no clinical reason why the delivery of many different cancer treatments (oral or IV) cannot be devolved to community hospitals. Remote clinics can be linked to a main centre using new communications technology. For example a capecitabine clinic which is video linked allows staff in remote locations such as Orkney and Shetland to conduct remote reviews in parallel with the main clinic in Aberdeen. Using the link, patients can speak to the consultant on the mainland. More than 150 admissions are avoided annually as a result of this service. In addition NHS Boards save around £100,000 annually on flight and ferry travel costs for patients. The limiting factor in developing this work further in the Islands is the preparation of particular drugs, and then the subsequent shelf life of these treatments. Additional treatments could be offered if this was overcome. Similarly, satellite chemotherapy clinics have been set up to deliver chemotherapy in Merseyside and Cheshire.

5.5  Opportunities presented by improved capacity modelling

  5.5.1  The work undertaken by the National Cancer Director has demonstrated that effective capacity planning is essential if demand for cancer treatments is to be effectively catered for. In his report on uptake of NICE-approved drugs, Professor Richards called for the Department of Health to develop a capacity planning model for chemotherapy. This initiative has been led by the Cancer Services Collaborative "Improvement Partnership" as part of their work with the National Chemotherapy Advisory Group. The model has been incorporated into a broader toolkit entitled Modernising Chemotherapy Services—A Practical Guide to Redesign. It aims to form a basis for the multidisciplinary redesign of chemotherapy services within Oncology and Haematology and is set out as a series of challenges, each with a recommended approach, which if followed, will enable units to take a structured approach to service improvement.

  5.5.2  The pharmaceutical industry can play a role in assisting with capacity planning. The Pharmaceutical Oncology Initiative (POI) is a cross industry collaboration that has been developed under the auspices of The Association of the British Pharmaceutical Industry (ABPI) with the objective of developing an integrated capacity management and planning toolkit to:

—  Assist cancer networks in undertaking demand-led capacity planning allowing optimum exploitation of current capacity.

—  Enable networks to identify the rationale for expanding capacity and assist them in developing business cases for expansion.

—  Build on existing work already undertaken by the NHS.

  5.5.3  Such collaborative approaches can help mitigate the effects of not having sufficient capacity planning expertise within NHS organisations.

6.  EFFECT OF PAYMENT BY RESULTS ON NHS' ABILITY TO ADOPT SOLUTIONS

  6.1  The Cancer Capacity Coalition welcomes the Government's commitment to encourage, wherever clinically appropriate, the devolution of care to community settings as we believe that this has the potential to maximise the effectiveness of existing cancer workforce capacity.

  6.2  However, anecdotal evidence suggests that perverse incentives are preventing Trusts from adopting capacity saving measures such as the use of oral chemotherapies as a result of the existing Payment by Results (PbR) tariff. Hospital trusts can face a substantial loss in short term revenue by using oral chemotherapies as they require a significant drop in the required number of patient out-patient visits (for which hospitals are renumerated under the tariff). One such example is a major northern cancer centre which has calculated that, for every 100 patients it switched from IV to oral chemotherapy, it would lose over £1.5 million in revenue. This calculation is based upon the hospital only being reimbursed for eight outpatient visits per patient when being treated with oral chemotherapy, as opposed to 30 visits to a chemotherapy unit when being treated by IV chemotherapy.

  6.3  We therefore welcome the Department of Health's White Paper commitment to review the Tariff so that it is based on best practice rather than standard national practice:

"Medical science, assistive technology and pharmaceutical advances will continue to rapidly change the way in which people's lives can be improved by health and social care. It is important that the organisation of care fully reflects the speed of technological change . . . [the Tariff] was first introduced in the context of the reform of the hospital sector. For this reason, not everything about the current structure of the tariff aligns with the radical shift that this White Paper seeks to achieve. So we will improve it." [39]

  6.4  It will be important that this opportunity is seized to incentivise capacity saving measures such as oral chemotherapies.

7.  RECOMMENDATIONS THE COMMITTEE MAY WISH TO CONSIDER

  7.1  Through its work on demand capacity planning, the Cancer Capacity Coalition has developed a number of recommendations about how cancer capacity and workforce effectiveness could be maximised, which the Committee may wish to consider as part of its Inquiry:

—  The NHS should base workforce capacity modelling on "demand capacity" (the resources needed to provide optimum care) rather than "current capacity" (the resources that are currently employed to deliver therapy) so that service planning reflects the realities of modern care and patient expectations.

—  As recommended in the Audit Commission report on Managing the financial implications of NICE guidance, horizon scanning of future NICE guidance should be undertaken by all NHS bodies. Local consultation on the potential implications of implementation should include a robust assessment of the impact on local capacity.

—  Regular audits of available chemotherapy capacity (IV seats and trained personnel) should be undertaken at both a national and local level. These should be used to identify any capacity shortfalls which exist and to plan provision accordingly.

—  Given the expected increase in demand for cancer treatments, NHS organisations should prioritise expanding cancer capacity. This should focus on building capacity to deliver the predicted treatments of tomorrow as well as those of today.

—  A national strategy is needed for the education and training of chemotherapy nurses and primary care teams on all aspects of cancer drug therapy to ensure best use of capacity. Currently the role of cancer drug therapy staff varies nationally, making career progression difficult and compromising the ability of the NHS to establish clear care pathways which can be used across organisations.

—  Initiatives such as using oral cancer drug treatments as an alternative to intravenous therapy should also be used wherever possible to free capacity.

—  The adoption of capacity saving measures should be incentivised through mechanisms such as the PbR Tariff. Any perverse incentives inhibiting the uptake of capacity saving treatments should be identified and addressed through primary care trust monitoring of local contracts with providers.

—  NICE's role in assessing the potential capacity implications of new treatments should be strengthened so that NHS organisations can be made aware of, and advised on, capacity measures they will need to take to implement guidance.

—  In addition to the existing recognition of potential cost savings brought about by freeing up capacity, the NICE appraisal process should take into account and advise PCTs of any impact on capacity that adopting a new treatment will have.

Cancer Capacity Coalition

March 2006

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23   National Audit Office, Tackling cancer in England: saving more lives, March 2004: http://www.nao.org.uk/publications/nao-reports/03-04/0304364.pdf Back

24   National Statistics, Cancer Survival: England and Wales, 1991-2001: http://www.statistics.gov.uk/statbase/ssdataset.asp?vlnk=7091 Back

25   Scottish Executive (November 2004) Cancer in Scotland: Sustaining Change (2001-02). Back

26   National Audit Office, Tackling cancer in England: saving more lives, March 2004. Back

27   Department of Health. Back

28   Department of Health (February 2005) Breast Screening programme, England 2003-04. Back

29   NICE (February 2005) Lung cancer: The diagnosis and treatment of lung cancer. Back

30   Lichtenberg FR. Measuring the health impacts of medical innovation and expenditure. Presented at the Health Services Research Seminar Series, University of Minnesota, Minnesota, USA, 2002. Back

31   Wilking N, Jo­nsson B. A pan-European comparison regarding patient access to cancer drugs. Karolinska Institute and Stockholm School of Economics, Stockholm, Sweden 2005. Back

32   Summerhayes M (2003) The impact of workload changes and staff availability on IV chemotherapy services. Back

33   Department of Health (June 2004) Variations in usage of cancer drugs approved by NICE: report of the review undertaken by the National Cancer Director. Back

34   Derek Wanless, Securing our Future Health: Taking a Long-Term View, 2002. Back

35   3Healthy Hospitals: Creating a secure future for Barnet and Chase Farm Hospitals-a discussion paper, July 2003. Back

36   CancerBACUP (May 2004) Living with cancer: waiting for treatment. Back

37   37 Coleman MP et al (2004) Trends and socio-economic inequalities in cancer survival in England and Wales up to 2001. Back

38   Derek Wanless, Securing our Future Health: Taking a Long-Term View, 2002. Back

39   Department of Health, Our Health, Our Care, Our Say, January 2006. Back

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Prepared 9 May 2006