Memorandum submitted by Macmillan Cancer
Relief (PCT 39)
INTRODUCTION
1. Macmillan Cancer Relief helps people
who are living with cancer. Every day around 740 people in the
UK are told they have cancer. More than one million people in
the UK today have had a cancer diagnosis, and more than one in
three will be diagnosed at some time in their life.
2. Macmillan Cancer Relief works in partnership
with others to improve cancer services and influence change. We
work with a range of partners, including the voluntary and private
sectors, hospices and local authorities, but our main partner
is the NHS, with whom we've been working since the 1970s. In all
of these scenarios, the partner organisations retain responsibility
for staff employment.
3. Macmillan's range of community based
services include more than 2,800 nurses, 360 GPs as well as other
doctors and health and social care professionals, cancer care
centres, a range of cancer information services and centres, practical
help at home, carer's schemes, and benefit advice projects. We
also contribute to the funding and development of cancer facilities.
4. The nature of cancer is changing. Treatments
are more effective, survival rates are increasing and mortality
rates are declining. The five-year relative survival rate for
21 major cancers increased by more than 10% between the period
1971-5 and 1986-90.[25]
The way cancer patients are treated is also changing. Four out
of five cancer patients now receive radiotherapy treatment as
outpatients. While patients undergoing or recovering from cancer
treatment, or else receiving palliative care, will predominantly
be living at home, cancer services are still concentrated in the
acute sector.
RECOMMENDATION: Macmillan believes that
cancer should be seen as a major priority for the primary care
and social care sectors, and not just an acute care, or end of
life, issue.
MACMILLAN'S
EVIDENCE
5. Macmillan Cancer Relief has invested
heavily in developing better cancer services within the NHS over
the last 30 years. Using our "pump-priming" model to
initiate developments we have co-funded major NHS innovations
with the Department of Health for England, notably the clinical
nurse specialist, but also more recently Primary Care Cancer Leads,
the Gold Standards Framework and cancer information centres. Our
developmental model of funding has proven benefits and many of
our innovations are reflected in the cancer service Improving
Outcomes Guidance and the NICE Supportive and Palliative Care
Guidance.
6. Macmillan Cancer Relief is therefore
in the unusual position of being able to convey the views not
only of its staff and people affected by cancer, but also of Macmillan
postholders who are supported by Macmillan but employed by a partner
organisation, mostly the NHS. This submission is based on an informal
consultation exercise, specifically conducted for this purpose,
with Macmillan staff and postholders.
MACMILLAN'S
RESPONSE TO
THE PROPOSALS
7. We welcome the suggestion that "as
a general principle" PCTs will have a clear relationship
with local authority boundaries. We hope this will make it easier
to identify need and to secure the support of both health and
social commissioners (and providers) of local services.
8. We also welcome the Government's recognition
that commissioning is a specialist skill and believe that "Commissioning
a Patient-Led NHS" represents an opportunity to develop a
clearer framework of strategic planning and management based on
population needs and wants.
9. We do have some concerns about the current
reform proposals. Sir Nigel Crisp's letter (dated 28 July 2005)
sets out a number of criteria against which SHAs' proposals will
be assessed. We have used these criteria as the basis for our
submission.
RECOMMENDATION: We ask that the Committee
recommends that the Government takes action to ensure that our
concerns about the possible unintended consequences of "Commissioning
a Patient-Led NHS" are fully assessed and addressed prior
to implementation.
CRITERIA: PCTS'
ABILITY TO
SECURE HIGH
QUALITY, SAFE
SERVICES
10. The current "postcode lottery"
of care must not be made worse by cutting urgently needed services.
We have evidence which suggests that sector uncertainty created
by additional reform, in the context of current financial difficulties,
is resulting in unwillingness by some PCTs to make long-term service
commitments. For example, Macmillan regional services teams and
postholders are telling us that specialist cancer and palliative
care services, and specialist palliative care teams, including
those supported by Macmillan, are being cut, fragmented and/or
current vacancies are not being filled because PCTs will not commit
to long-term funding.
11. Macmillan has made a huge investment
into community palliative care services—all of which has
been raised through public donations which we have a duty to protect.
Over the past five years, in England, we have invested approximately
£230 million in cancer services and created more than 3,000
posts. We are anxious to ensure that this investment is not jeopardised
and to avoid significant impact on people affected by cancer and
post-holders. Given our "pump-priming" funding model,
the reforms present our organisation with a number of questions
about the viability of our on-going funding strategy. Unless our
considerable investment is safeguarded we may be forced to reconsider
our funding strategy.
RECOMMENDATION: Macmillan asks the Committee
to seek assurances from the Government that current and future
funding for cancer services is guaranteed and that NICE Supportive
& Palliative Care Guidance will be fully implemented. We also
ask that assurances are sought that Macmillan's significant investment
in cancer and palliative care services will be safeguarded into
the future.
CRITERIA: PCTS'
ABILITY TO
IMPROVE HEALTH
AND REDUCE
INEQUALITIES
12. We are concerned that, in cutting primary
care services, there will be a growing divide in importance and
resources between primary and secondary care, with hospitals continuing
to enjoy the "lion's share". If this happens, the NHS
is at risk of undermining its policy to reduce unnecessary admissions
to hospital and to improve care in the community. We believe there
is a danger that this will, in turn, undermine Government attempts
to improve primary care through the forthcoming integrated Health
and Social Care White Paper.
13. The evidence described above also illustrates
that specialist palliative care services in the community are
at high risk. We are concerned that if reconfigured PCTs are not
prepared to fund specialist palliative care posts this will undermine
the Government's policy objective of increasing choice in end
of life care. Without access to 24-hour community-based specialist
palliative care services it will be impossible to enable patients
to die at home if this is their choice.
14. We are also concerned that the reorganisation
of PCTs should not threaten the future of cancer networks. Sir
Nigel Crisp's letter makes no mention of the importance of cancer
networks despite the National Audit Office recommendation that
such networks should be strengthened. Strong cancer networks are
essential to ensure that cancer services are well co-ordinated,
that services are reconfigured in line with the NICE Improving
Outcomes Guidance, and that commissioning of cancer services is
not fragmented. However, unless the new PCTs are committed to
funding the infrastructure (ie network management posts, user
involvement facilitator posts, etc) these networks will be further
weakened.
RECOMMENDATION: We ask the Committee to
urge the Government to take action to ensure that PCTs recognise
the value of specialist cancer and palliative care services and
clinical networks in co-ordinating and planning cancer services.
15. Effective commissioning, planning and
provision of services must be supported by good quality public
health information. We believe there needs to be clear lines of
responsibility for ensuring accurate intelligence about demographics
and patient need. We are unclear where such responsibility will
sit within reconfigured PCTs.
RECOMMENDATION: Macmillan asks the Committee
to recommend that there is greater clarity over the responsibility
for public health information to ensure future commissioning is
based on demographics, prevalence and other trends.
CRITERIA: PCTS'
ABILITY TO
IMPROVE THE
ENGAGEMENT OF
GPS AND
ROLLOUT OF
PRACTICE-BASED
COMMISSIONING WITH
DEMONSTRABLE PRACTICE
SUPPORT
16. We note that the current version of
the GMS contract places little emphasis on cancer. The current
NHS Cancer Plan also focuses predominantly on improving access
to secondary care.
RECOMMENDATION: Macmillan would like the
Committee to seek assurances from the Government that Practice-Based
Commissioning and the updated GMS Contract will give greater priority
to improving cancer and palliative care in the community.
CRITERIA: PCTS'
ABILITY TO
IMPROVE PUBLIC
INVOLVEMENT
17. While the Government has recently undertaken
a considerable consultation exercise about the principles of patient-led
care ("Your Health, Your Care, Your Say"), there has
been little patient or public involvement in the actual proposals
set out by Sir Nigel Crisp to reconfigure primary care structures.
Macmillan Cancer Relief has been, and continues to be, a major
charitable funder of NHS cancer services and we would very much
welcome the opportunity to engage with Government on these vitally
important reforms.
18. We believe user involvement posts and
structures in cancer care at PCT and network levels must be maintained
and that the current precarious and fragile funding for such posts
needs to be resolved. It is vital that these structures remain
and flourish if commissioning and provision of services is to
be based on patients needs in the future.
RECOMMENDATION: We ask the Committee to
recommend that voluntary organisations are more involved in the
future development and implementation of proposals, that service
users are fully consulted, and that funding for existing mechanisms
for user involvement are guaranteed.
CRITERIA: PCTS'
ABILITY TO
IMPROVE COMMISSIONING
AND EFFECTIVE
USE OF
RESOURCES
19. We understand the policy intention behind
"Commissioning a Patient-Led NHS" to increase contestability/the
range of service providers and thereby increase choice for patients.
However, people affected by cancer already experience lack of
coordination, which in turn leads to inadequate care, and are
confused about which services are available and from whom. A more
mixed market of care may create more uncertainty and confusion
for people affected by cancer, and may increase the risk of poor
communication between the different professionals and agencies
involved.
RECOMMENDATION: Macmillan asks the Committee
to urge the Government to ensure that, in a mixed market of care,
more emphasis is given to high quality patient information about
available services, and that patients are supported and helped
to interpret this information, so that they can make informed
choices and decisions. We believe that cancer patients need a
single key contact (a navigator) throughout the patient journey
to help them navigate the maze of health and social care services.
CRITERIA: PCTS'
ABILITY TO
MANAGE FINANCIAL
BALANCE AND
RISK, AND
DELIVER AT
LEAST 15% REDUCTION
IN MANAGEMENT
AND ADMINISTRATIVE
COSTS
20. We recognise the need to reduce costs.
However, as outlined above, we are concerned that specialist care
and roles will be cut as a consequence.
21. We are also concerned that the drive
to reduce management costs will be passed on to providers which
will have an impact on services commissioned from the voluntary
sector who may not be in a position to absorb management costs.
RECOMMENDATION: Macmillan asks the Committee
to recommend that the Government confirms its commitment to specialist
services in primary care, including the role of the clinical nurse
specialist in cancer and palliative care.
CRITERIA: PCTS'
ABILITY TO
IMPROVE COORDINATION
WITH SOCIAL
SERVICES THROUGH
GREATER CONGRUENCE
OF PCT AND
LOCAL GOVERNMENT
BOUNDARIES
22. While we welcome greater co-terminosity
of health and local authorities, we do not think that co-terminosity
alone will guarantee joined up services. Given the complexity
of the cancer journey, we believe a whole patient pathway approach
must be taken. We see the potential for fragmentation of existing
services which work across organisational boundaries and are concerned
that there is the potential for breakdown in communication between
professionals. The benefits of collaborative work may then be
dissipated. As we have emphasised earlier, cancer networks provide
the key to ensuring that cancer services are commissioned according
to need and are well-co-ordinated.
RECOMMENDATION: We recommend that the Committee
seeks assurances that cancer networks will be sustained to ensure
that care planning and management happens across whole patient
pathways.
Macmillan Cancer Relief
7 November 2005
25 Coleman M et al, Cancer survival trends in England
and Wales 1971-1995: deprivation and NHS region (1999). Back
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