Health and Social Care Bill

Memorandum submitted by Macmillan Cancer Support (HS 140)

1. Introduction

1.1 This briefing outlines Macmillan Cancer Support’s position on the Health and Social Care Bill.

2. What does Macmillan think about the proposed changes to the NHS?

2.1 Macmillan cares passionately about improving cancer survival rates, about the quality of care all cancer patients receive throughout their cancer journey, and about the support survivors receive to get their lives back on track after a life-threatening illness.

2.2 We are also very supportive of NHS and social care reform and feel that although there has been significant progress on how cancer care is delivered, there are a number of ways cancer services could be transformed to greatly improve patient experience and outcomes while at the same time make financial savings.

2.3 We know Health Ministers are committed to delivering health and social care outcomes and patient experience which are among the best in the world. We also have no doubt that they are genuine in their belief that GP commissioning is the best way to deliver this result.

2.4 Like many stakeholders in the cancer sector, and no doubt in the health sector more generally, Macmillan does not know whether GP commissioning is necessarily the best way to achieve these changes to the system. We would feel more comfortable if the pilot GP consortia were allowed to report on the pros and cons of the new system, and broader reform was undertaken in light of the lessons learnt.

2.5 We are particularly concerned about the risk that the effective commissioning of cancer services, and consequently the quality of those services, may suffer during the transition period to GP commissioning if current cancer commissioning expertise is not retained.

3. GP commissioning and cancer expertise in the new system

3.1 We want GP consortia to make use of the expertise currently available in Cancer Networks to help in the effective commissioning of high quality and seamless cancer services. During the transition period (until consortia are fully up and running in 2014) we want Cancer Networks to continue to be properly funded.

3.2 There are currently over two million people living with or after cancer in the UK and by 2030 there will be four million. This demographic challenge means that the NHS will need to be more effective and efficient if it is to treat and support rising numbers of cancer patients and survivors . In this context, the principle that GPs can better understand the health and well-being needs of the community in which they work is a good one.

3.3 However, ‘cancer’ is a set of 200-plus different diseases – most of which have highly complex care pathways. Cancer is an acute sector disease dealt with by consultants and nurses in hospitals and, a t the same time, a terminal illness and, increasingly, a long-term condition – both of which require care and support in the community. This means commissioners of cancer services need to understand and be able to ensure that they meet both the clinical and longer-term needs of people living with and after cancer .

3.4 Yet, according to recent NFP research, at the moment only 8% of GPs have a specialism or particular interest in cancer, compared with 25% for diabetes and 16% for mental health. As such, during the transition period – i.e. until 2014 – we would like to see the continued funding of Cancer Networks until GP consortia are in a position to make an informed decision about the support and expertise they require. Without this funding, Cancer Networks will swiftly disband and patient outco mes may be adversely affected.

3.5 In the longer term, w e believe the key functions of Cancer Networks (see below) will need to remain – although we understand GP consortia will need to make the assessment about the exact structure within which this expertise should sit.

Key functions of Cancer Networks

3.6 Good Cancer Networks play a number of roles which Macmillan is keen are not lost during the transition period to GP commissioning :

· Provision of specialist commissioning expertise and advice on cancer services

· Leadership to ensure coordination of services across primary, secondary and tertiary care

· Guidance on how specialist cancer services should be commissioned and which bodies are most appropriate to commission them

· Support in developing cancer user involvement mechanisms

· Support in implementing the wider DH Quality Innovation Productivity Prevention (QIPP) programmes

· Monitoring compliance with Improving Outcomes Guidance ( and Quality Standards when these are rolled out).

3.7 This is not to say that all Cancer Networks are performing at the level of the best. There is always room for improvement which we would like commissioners to address in due course.

Lack of clarity in Improving outcomes: A Strategy for Cancer about the future of Cancer Networks

3.8 The Government said in the new cancer strategy , Improving outcomes: A Strategy for Cancer, published on 12 January 2011, that Cancer Networks will continue to be funded during the ‘transition period’ to GP commissioning. H owever, the strategy does not say how long the ‘transition period’ will last and there is no commitment that all the current funding will continue.

3.9 Cancer Networks are currently funded by:

· PCTs

· Department of Health

· National Cancer Action Team (NCAT) – who provide a small amount for service improvement

· Charities – e.g. Macmillan provides money for some Cancer Network posts.

3.10 In the Second Reading debate, Andrew Lansley said that central funding from Department of Health and NCAT would only continue until April 2012. There is no commitment from PCTs to continue their funding. Macmillan understands that some PCTs have already called for networks to make up to 55% cuts in overall management costs within 2-3 years.

3.11 The Government has also so far not taken the opportunity t o give its backing to the importance of the networks’ key functions in supporting effective cancer commissioning. Improving outcomes: A Strategy for Cancer says: " i t is very likely that GP consortia will wish to purchase support from a new style of cancer network " although what this means in practice is not made clear.

How can the Government assuage concerns within the cancer community?

3.12 We would like the Government to confirm that financial support from both PCTs and the Department of Health will co ntinue until 2014 – i.e. the full transition period.

3.13 We would also like the Government, and NHS Commissioning Board when it is established, to actively encourage GP c ommissioners, including P athfinder C onsortia, to either set up their own networks or procure the services of existing networks as soon as they start to form . This is particularly vital as they start to allocate their commissioning budgets to health services and begin to procure management expertise to adminster the commissioning they are required to carry out .

3.14 Suggested questions to be posed during the Public Bill Committee stage

· Will the Government ensure Cancer Networks are funded throughout the entire transition period – i.e. until 2014? And will this include funding Cancer Networks receive from PCTs as well as directly from the Department for Health and National Cancer Action Team ?

· How will the Government ensure that the functions currently provided by Cancer N etworks a re not lost and that standards are not compromised under the new commissioning regime ?

· W ill GP consortia be incentivised to ensure the functions of Cancer Networks are carried out as they commission cancer services?

4. Our concerns about a fall in the quality of cancer services, outcomes and experience

4.1 Macmillan is seeking early assurance that the new commissioning processes being set up through the Health Bill will lead to improvements in survival rates and patient experience for all cancers and for all cancer patients

4.2 Macmillan warmly welcomes the Government’s focus on improving patient outcomes – including patient experience – through the Health Bill. Improving cancer survival rates was cited by Andrew Lansley in the Second Reading debate as one of the main goals of the NHS reforms.

4.3 As with the NHS reforms more broadly, we would feel more comfortable if the move to a new model for improving quality was evidence-based and the benefits had been shown to clearly outweigh the costs through piloting.

Limited number of cancer-specific measures in the NHS Outcomes Framework

4.4 We are particularly concerned by the limited number of cancer-specific improvement measures in the NHS Outcomes Framework . For example, the NHS Outcomes Framework only asks for improvements in 1 and 5-year survival rates for three cancers – lung, breast and colorectal cancers – when there are actually over 200 different types of cancer, most of which require dramatic improvements in their survival rates if we are to achieve the goal of having survival rates among the best in the world. The lack of cancer-specific outcomes is particularly important because the Government said in the Command Paper that the NHS Commissioning Board will "translate the national outcomes into outcomes and indicators that are meaningful at a local level in the Commissioning Outcomes Framework". We are concerned that the lack of cancer-specific outcomes measures at a national level may mean a lack of prioritisation in the Commissioning Outcomes Framework and hence by GP consortia at a local level.

Role of Quality Standards

4.5 The NHS Commissioning Board will also draw upon new evidence-based Quality Standards when it develops the Commissioning Outcomes Framework and commissioning guidance for GP consortia. However, very few cancer Quality Standards will be ready at the point when the new NHS Commissioning Board is developing its Commissioning Outcomes Framework and commissioning guidance. There is a worrying lack of detail in the Government’s plans about what will happen during this transition period. Unlike the current Improving Outcomes Guidance (IOGs) for cancer, which Quality Standards will replace, it will also not be mandatory for commissioners and providers to adhere to NICE Quality Standards. We are looking for Ministerial reassurance that this change will also not impact on quality.

4.6 Suggested questions to be posed during the Public Bill Committee stage

· Why are there so few cancer-specific outcome measures in the NHS Outcomes Framework and what impact will this have on the prioritisation of cancer in the Commissioning Outcomes Framework?

· Why are Quality Standards not mandatory when the Improving Outcomes Guidance for cancer was mandatory? What impact will this have on quality?

· What will the NHS Commissioning Board base its Commissioning Outcomes Framework and commissioning guidance on given that Quality Standards will not be ready in time?

April 2011