Conclusions and recommendations
1. 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networks have been replaced by 12 strategic clinical networks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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
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