Written evidence from Cancer Research
UK (COM 95)
1. BACKGROUND
INFORMATION
1.1 Cancer Research UK is the world's largest
independent organisation dedicated to cancer research; in 2009/10
we spent £334 million on research. Our vision is that "Together
we will beat cancer". We carry out world-class research to
improve our understanding of cancer and to find out how to prevent,
diagnose and treat different types of the disease. Around 300,000
people are diagnosed with cancer in the UK every year. And every
year more than 150,000 people die from the disease.
1.2 Cancer Research UK supports the principle
of decision-making close to patients, which is underpinned by
clinical insight and knowledge of local health needs. If implemented
correctly, the proposals contained in Liberating the NHS: Commissioning
for patients could potentially incentivise and raise the quality
of cancer services at a local level and be responsive to the needs
of the local population. However, because of the very complex
nature of cancer treatment, how and at what level cancer services
are commissioned is key to the delivery of world class cancer
treatment. This is particularly important for rarer types of cancers
and specialised cancer services and treatment.
1.3 GP consortia will require access to
relevant and up to date information, data and good quality cost
metrics to improve the planning and procurement of services and
commissioning decisions. To facilitate more robust planning and
commissioning, analytical capability must be improved.
1.4 In the response below, we have focused
our efforts where we feel our expertise is strongest.
2. CLINICAL ENGAGEMENT
IN COMMISSIONING
2.1 How will commissioners access the information
and clinical expertise required to make high quality decisions
about the shape of clinical services?
2.1.1 Liberating the NHS: Commissioning
for patients presents an opportunity to put in place a commissioning
framework for cancer services which is robust and can deliver
world class treatment for patients. Cancer Research UK has recently
published a report entitled Improving cancer outcomes: An analysis
of the implementation of the UK's cancer strategies 2006-2010
which critically appraised the implementation of cancer policy
across the United Kingdom. As part of the research, we interviewed
healthcare professionals and commissioners who stated that there
needed to be more measures and better data to improve the planning
and procurement of cancer services. In particular, there is a
need for good quality cost metrics to improve the quality of commissioning.
2.1.2 To facilitate more robust planning
and commissioning, analytical capability at regional and local
level must be improved. In practice this means ensuring that more
public health consultants and health economists are analysing
local data. Better measures, audits and data to facilitate improved
commissioning are needed and these should show clearer links to
outcomes. Additional work is needed to measure patient experience
and then plan and make effective changes in this area. Priorities
need to be based on evidence of improved outcomes.
2.1.3 Commissioning for cancer services
is particularly complex because of the range of services and treatment
a patient may have. A patient may seek an appointment with their
GP with symptoms which may indicate cancer. The GP will refer
them for further investigation or diagnosis requiring pathology
services. The patient may then require a range of treatments which
could include either radiotherapy, surgery or chemotherapy or
a combination of all three and each of these treatment options
could be delivered at either an outpatient clinic or a specialist
cancer centre. The patient may require social care services during
or following treatment and then either end of life care or ongoing
psychological or specialist nursing. It is therefore particularly
important that cancer commissioning is coordinated across a network
of care, based on patient care pathways rather than organisational
boundaries.
2.1.4 Some complex cancer treatment is best
commissioned at populations of several million because of the
critical mass required to provide effective care. GPs will be
well placed to commission many other services for example diagnostic
services.
2.1.5 Cancer networks have been an important
organisational model to coordinate services and ensure compliance
with clinical standards. During the period of transition from
PCT commissioning to GP commissioning it will be important that
similar coordinating support is available.
2.1.6 There is a strong need for a mechanism
to be put in place, whether on the current network model or by
a new model, to provide advice and expertise on cancer commissioning.
2.1.7 It will be important that the commissioning
outcomes framework joins up with public health and NHS services.
In order to prevent people dying prematurely from cancer, further
steps need to be taken to prevent more cancer. The commissioning
outcomes framework will need to include a range of indicators
to inform commissioning agreements for different parts of the
patient pathway.
2.1.8 As cancer treatments develop, so must
structures for commissioning and provision. It is essential that
there is sufficient capacity in the right setting to ensure that
all those patients who could benefit from new treatments are able
to access them. Commissioners will need to commission a plurality
of services to ensure that patients are able to access the services
that they require and to improve patient experience. Providers
will need to ensure that there are appropriate services and sufficient
capacity in place to give patients choice in the setting and type
of treatment they wish to receive.
2.1.9 Quality standards will play a vital
role in the development of the commissioning capability for cancer
services by GP consortia. However, the Government have committed
to developing a library of 150 Quality Standards over the next
five years and we would welcome further information about how
and when quality standards will be developed. Further thought
should be given about how to develop the quality standards for
cancer as there are over 200 types of cancer which require different
treatments and services. In the interim period, existing guidance,
including Improving Outcomes Guidance (IOG) should be used to
inform commissioning decisions.
2.1.10 Clinical guidelines have also been
developed or are under development by NICE for several of the
most common types of cancer. These guidelines should assist GP
consortia with advice on the appropriate diagnosis, treatment
and care for patients with particular conditions. They are developmental,
reflecting the fact that they cannot be delivered in their entirety
overnight but are something that the NHS should be working towards
delivering.
2.2 How will GPs engage with their colleagues
within a consortium and how will consortia engage with the wider
clinical community?
2.2.1 Services should be commissioned and
delivered nationally or locally based on the evidence of effectiveness.
Consortia should be encouraged to develop structures for stable
joint commissioning where these would best serve their population.
These will often include city-wide and regional commissioning.
These commissions should be made on a time-scale that will allow
stable service planning and delivery, for example multi-year or
rolling contracts. Cancer commissioning should be coordinated
across a network of care, based on patient care pathways into
these services, rather than formal organisational boundaries.
2.2.2 GPs will need to commission services
as part of pathway commissioning with advice and expertise from
specialists. Typically, a GP will see one new case each of breast,
lung, prostate and colorectal cancer each year, one case of less
common cancers such as ovary or pancreas every five or six years
and some rarer cancers such as testicular cancer about once every
20 years. Even for a common cancer such as breast cancer, a GP
may find it very difficult to spot the signs and symptoms and
refer as there are many different presentations of breast cancer.
It is unrealistic to expect that a GP will have sufficient knowledge
and expertise on the most appropriate and effective commissioning
arrangements for such a small cohort of their patient list.
2.2.3 A challenge relating to commissioning
for cancer services will be ensuring that they are commissioned
at the appropriate level. In cases of very rare cancers, GP practices
may not have sufficient numbers of patients to make efficient
and effective commissioning arrangements. It will be important
to ensure that arrangements for these types of cancer are carefully
developed to ensure the delivery of high quality treatment for
all cancer patients.
2.2.4 GP consortia will need to work in
close partnership with the NHS Commissioning Board to develop
specialised commissioning arrangements and take strategic decisions
to shape how and where care is best delivered. They will need
to work together to secure comprehensive services for cancer,
ensure that services are coordinated across the care pathway including
health promotion, social services, preventative and other services
jointly provided with local authorities.
2.3 Will commissioners be free to access new
commissioning expertise?
2.3.1 Due to the complexity of treatment,
we strongly support the proposal for commissioners to access specialist
expertise about the commissioning of cancer services. External
providers of commissioning support will need to demonstrate knowledge
and expertise in the delivery of cancer treatment and care across
the whole pathway including prevention, through to treatment and
end of life or survivorship services.
2.4 How will GPs engage with their colleagues
within a consortium and how will consortia engage with the wider
clinical community?
2.4.1 The involvement of primary care dentists
and ophthalmic providers will be particularly important in developing
commissioning arrangements for cancer as dentists and ophthalmologists
will refer patients who they suspect of having cancer for further
investigation. Dentists and ophthalmologists should be involved
at the appropriate level for commissioning these services. This
should include developing formal links with local GP consortia
to input into contractual arrangements with providers, to ensure
services for oral and eye cancers are included.
2.4.2 Consortia should demonstrate to the
Commissioning Board that they and their constituent practices
have proper processes in place to ensure that they are playing
an active and evidence based role in population health improvement.
3. ACCOUNTABILITY
FOR COMMISSIONING
DECISIONS
3.1 How will patients make their voice heard
or their choice effective?
3.1.1 Effective user involvement should
have a central role to play in improving the quality of patient-centred
care and treatment for cancer in the NHS. GP consortia and the
NHS Commissioning Board should ensure that they have appropriate
user involvement when making decisions about service provision.
As part of this they should consider how best to assist HealthWatch
in engaging with current user involvement structures in cancer
networks (such as partnership forums and user involvement facilitators).
3.1.2 Consideration should also be given
to ways of facilitating user involvement from those who do not
join groups or attend meetings but have valuable experience of
services. This could be done by mail, phone or email, with professional
support for those with specific needs.
3.2 What will be the role of the NHS Commissioning
Board?
3.2.1 The NHS Commissioning Board must ensure
that GP consortia work in close collaboration with their local
Director of Public Health to ensure that public health measures
such as tobacco control interventions, obesity, physical activity
and alcohol harm reduction initiatives are delivered at the appropriate
city-wide or regional level. Where joint commissioning structures
are established to provide more effective and efficient services
for large population areas, the Commissioning Board should ensure
that Directors of Public Health are involved for maximum population
health gain.
3.2.2 The Commissioning Board must have
expertise and access to data to inform the development of commissioning
arrangements for specialised and rarer cancers.
3.2.3 The Commissioning Board should also
ensure that each GP consortia has access to specific advice about
commissioning for cancer services which will be commissioned at
GP consortia level and that local commissioning is undertaken
with due regard to public health and with the active involvement
of Directors of Public Health.
3.3 How will commissioning interface with
the Public Health Service?
3.3.1 Ensuring that the public health service
and health care service work together effectively must be a high
priority.
3.4 How will commissioning interface with
Health Watch?
3.4.1 Any changes to the system of engagement
must be responsive to patients' needs.
4. INTEGRATION
OF HEALTH
AND SOCIAL
CARE
4.1 What will be the role of local authorities
in public health and commissioning decisions?
4.1.2 One of the biggest challenges to the
NHS will be putting prevention at the heart of the service. This
will be particularly important as the new structure will put health
care and prevention into separate organisations with different
outcome frameworks, geographical boundaries, cultures and systems
for accountability. The combined cost to the NHS of smoking, alcohol
and obesity is estimated to be £11 billion which equates
to around 10% of the NHS budget, with half of that cost attributed
to smoking alone. Failing to engage primary care effectively in
preventative medicine will impose burdens to the public in terms
of ill-health and the NHS as a whole in terms of increased workload
and cost.
5. SPECIALIST
SERVICES
5.1 What arrangements are proposed for commissioning
of specialist services?
5.1.2 A challenge relating to commissioning
for cancer services will be ensuring that they are commissioned
at the appropriate level. In cases of very rare cancers, GP practices
may not have sufficient numbers of patients to make efficient
and effective commissioning arrangements. It will be important
to ensure that arrangements for these types are carefully developed
to ensure the delivery of high quality treatment for all cancer
patients.
October 2010
| 
