House of Commons - Progress in improving cancer services and outcomes in England

Progress in improving cancer services and outcomes in England - Public Accounts Contents

1 Services and outcomes

1. On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health (the Department), NHS England (including the National Clinical Director for Cancer), Public Health England and the National Institute for Health and Care Excellence about progress in improving cancer services and outcomes in England.[1] We also took evidence from Cancer Research UK and Macmillan Cancer Support. More than 1-in-3 people in England will now develop cancer in their lifetime. In 2012, around 280,000 people were diagnosed with cancer and an estimated 133,000 people died from cancer. More than 3-in-5 cancers are diagnosed in people aged 65 or over, and a third of new cancer diagnoses occur in people aged over 75.[2]

2. Cancer has been a priority for the Department since the publication of the NHS Cancer Plan in 2000. The Department's current cancer strategy, published in 2011, set out an ambition to save an additional 5,000 lives a year by 2014-15 and halve the gap between survival rates in England and those in the best European countries.[3] Survival rates in England have improved: 69% of people diagnosed in 2012 survived for at least one year after diagnosis, up from 65% in 2007; and 49% of people diagnosed in 2008 survived for at least five years, up from 45% in 2003.[4] Data are not yet available to assess progress since 2011 in closing the gap to the best performing European countries.[5]

3. The Department does not have a robust estimate of the cost of cancer care, but the National Audit Office estimated that the cost was at least £6.7 billion in 2012-13.[6] The Department is ultimately responsible for securing value for money for this spending. Responsibility for commissioning cancer services is shared between NHS England, through its area teams, and the 211 clinical commissioning groups. Public Health England takes the lead in providing access to cancer data to inform commissioners and help improve services. The National Institute for Health and Care Excellence reviews new cancer drugs to assess whether they should be available on the NHS.[7]

4. In 2011 we reported that the NHS had made significant progress in improving important aspects of cancer services. A significant increase in resources had contributed to the improvements, but the progress had also been achieved through clear direction and high-profile leadership, underpinned by strong performance management.[8] Since 2013, however, fewer dedicated resources have been available to support the improvement of cancer services.[9] Cancer Research UK considered that there had been a loss of resource, capacity and leadership, which was having a detrimental impact on cancer services. For example, NHS England downgraded the position of National Clinical Director for Cancer from a full-time to a part-time role. In addition, two of the National Clinical Director's four days a week have been funded by Cancer Research UK and Macmillan Cancer Support.[10] NHS England told us that it strongly supported the role of National Clinical Director and that it would fund the post in full itself from April 2015.[11]

5. In addition, across the country, the 28 regional cancer specific networks, which advised and supported the providers of cancer services, were disbanded at the end of March 2013.They were replaced by 12 strategic clinical networks to support commissioners on a wider range of diseases, including cancer.[12] Macmillan Cancer Support said that, while some of the strategic clinical networks were doing an effective job in pulling together different parts of the health and social care system, that was not the position in all parts of the country.[13]

6. Following the reforms to the health system in 2013, the commissioning arrangements for cancer services are more complex and fragmented.[14] Macmillan Cancer Support highlighted its recent research, which had found confusion among commissioners and healthcare professionals about responsibilities and accountabilities for planning and commissioning cancer services in the reformed NHS. In its view, there needs to be one body with oversight of the whole patient pathway.[15]

7. The Department has itself highlighted previously the importance of information in improving cancer services and survival rates.[16] The Health and Social Care Information Centre (an arm's-length body of the Department) has an explicit obligation to disseminate the data it collects to help drive improvements in health and social care. It tightened its data-sharing processes in 2014 after a review by its predecessor body, the NHS Information Centre, found significant administrative lapses in recording the release of data.[17] Cancer Research UK and Macmillan Cancer Support told us that since then they had experienced severe delays in getting access to the data they needed for their research. Public Health England confirmed that there had been problems with the flow of data.[18] The Health and Social Care Information Centre told the National Audit Office that it had simplified the process for applying to access data and was working through a substantial backlog of applications. However, this process is taking longer than expected.[19]

8. The increase in the number of people being diagnosed with cancer each year is being driven by population growth, the ageing population, and increased public awareness of cancer signs and symptoms. However, survival rates for older people with cancer are considerably worse than for other age groups. For example, just 57% of cancer patients aged 75-99 survive for at least one year after diagnosis, compared with 77% of those aged 55-64. Older people are also less likely to receive treatments such as surgery and chemotherapy.[20] For example, Cancer Research UK told us that the proportion of patients aged 75 to 84 with kidney cancer who have surgery is almost half that of patients aged between 15 and 54.[21] And analysis by the National Audit Office shows that patients aged 60 and over are much less likely to receive chemotherapy than those aged under 55.[22]

9. Some of the variation in survival rates and access to treatment will be explained by the fact that older people are more likely to be frailer or less fit for treatment, to have comorbidities or to choose not to have treatment.However, Macmillan Cancer Support told us that it believed there was under-treatment of older people and that there was some evidence that clinicians were prescribing based on chronological age rather than fitness to receive treatment. More research was needed to understand why outcomes were poorer for older people. NHS England acknowledged that it was not able to explain the disparities in access and outcomes between age groups.[23]

10. NHS England told us it has set up an expert advisory group involving elderly-medicine doctors and oncologists to assess how it can ensure that access to treatment is based on an assessment of physical fitness, rather than age.[24] It highlighted that attitudes had changed in places where these groups of clinicians had worked closely together. NHS England also recognised that it did not know enough about the attitudes of older people to cancer. It needed to listen more to the preferences of individual older people, and had commissioned a national survey on attitudes to cancer.[25]

11. When we reported on cancer services in 2011, we raised concerns about unexplained variations in the performance of cancer services across the country.[26] These geographical variations persist. For example, the National Audit Office found that, for every newly diagnosed cancer patient, the average number of urgent referrals by GPs varied across clinical commissioning groups from 3.9 to 6.2 in 2013-14 (after excluding the highest and lowest 10% of groups), indicating that GPs make variable use of this referral route.[27] And in 2012, the percentage of cancers diagnosed through emergency presentation varied from 13% to 30% across the 211 clinical commissioning groups. This is important because people diagnosed in this way are around twice as likely to die within a year of diagnosis as those diagnosed via an urgent GP referral.[28]

12. In some cases neighbouring clinical commissioning groups are performing very differently against waiting time standards. For example, in North Lincolnshire, 98.3% of patients were seen by a specialist within two weeks of an urgent GP referral between July and September 2014, compared with 87.1% in Lincolnshire West.[29] In addition, the percentage of patients who started treatment within 62 days of an urgent GP referral for suspected cancer was 89.3% in North Lincolnshire, compared with 73.7% in Lincolnshire West.[30]

13. NHS England acknowledged that such variation was unjustified, and the Department stated that unacceptable variations should not be tolerated.[31] NHS England is responsible for overseeing the performance of clinical commissioning groups and holding them to account. However, the National Audit Office found that it was unclear how in practice NHS England was monitoring the performance of clinical commissioning groups against cancer-related outcomes indicators.[32] The Department and NHS England told us that they expect that greater transparency—collecting and publishing data on the performance of local cancer services—and peer review by commissioners and clinicians should lead to reduced variation.[33]

14. The NHS has an important target that 85% of cancer patients should be treated within 62 days of being urgently referred by their GP. NHS England described this target as 'a weather vane of system readiness'.[34] However, the NHS is struggling to cope with the growing number of cases—the number of urgent GP referrals for suspected cancer increased by 51% from around 900,000 in 2009-10 to 1.36 million in 2013-14, and the number of people being diagnosed with cancer is also rising.[35] For the first three quarters of 2014, the NHS failed to meet the 62-day waiting time standard. This meant that, for example, between July and September 2014 some 5,500 patients had to wait more than 62 days for treatment.[36]

15. The NHS also failed to meet two other cancer waiting time targets at points during 2014. First, it did not achieve the standard that 93% of patients should be seen by a specialist within two weeks when referred urgently with breast symptoms (where cancer was not initially suspected) between April and June 2014. This was the first time this standard had not been achieved since early 2010.[37] And second, it did not meet the expectation that less than 1% of patients should wait 6 weeks or longer for a diagnostic test, including those for cancer, in 2014. At the end of September 2014, just under 16,200 patients had been waiting more than 6 weeks for diagnostic imaging tests, up from just over 11,900 at the end of September 2013.[38]

16. NHS England told us that one reason why the waiting time standards were not being achieved was the 'diagnostic bottlenecks' that exist in the health system. It suggested that, although the NHS was providing more diagnostic tests, in some parts of the country there was a shortage of sonographers (healthcare professionals who specialise in diagnostic imaging), whereas in other areas there was insufficient access to diagnostic equipment.[39] NHS England told us that trusts that struggled the most to meet the waiting time standards were usually those which diagnosed and made decisions to treat patients late in the 62-day waiting time period, meaning they had less flexibility to cope with increases in demand.[40] NHS England told us that it has established a waiting times taskforce, led by the National Clinical Director for Cancer, to improve understanding about the reasons for the variation across the country and identify how performance can be improved.[41]

17. Radiotherapy is one of the main types of treatment for cancer. Research indicates that between 40% and 50% of patients could benefit from radiotherapy treatment at some time during their illness. 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.[42] Those hospital trusts with a low percentage of patients in their catchment area receiving radiotherapy in 2010-11 continued to have low rates in 2013-14. NHS England said that there could be valid clinical reasons why some areas might make less use of radiotherapy, but acknowledged that there may have been less focus on radiotherapy compared with cancer drugs, an imbalance that needed to be redressed.[43]

18. England has 5.2 radiotherapy machines per one million people, fewer than most other high-income countries, including Belgium (14.5), Denmark (12.6) and Iceland (12.6).[44] This analysis does not consider the efficiency with which radiotherapy machines are used in different countries, and the Department and Public Health England suggested that the machines in England may be used more intensively than those in other countries. However, within England there has been wide variation in the use of machines between trusts. For example, in 2013-14 the average number of attendances per linear accelerator varied from just below 6,000 at the five trusts with the lowest usage to more than 9,000 at the five trusts with the highest usage.[45]

19. NHS England highlighted that the current stock of linear accelerator radiotherapy treatment machines is coming to the end of its life, and that machines would need to be upgraded or replaced around the country over the coming years. NHS England told us that, as the national commissioner for radiotherapy services, it would be seeking to achieve a nationally consistent approach to procuring radiotherapy machines. It expected to save up to 20% of the cost of new machines by procuring them centrally.[46] It said that the procurement would be supported by the radiotherapy clinical reference group, which would provide expert advice on the configuration of radiotherapy services around the country. For example, there could be a smaller number of centres to deliver complex treatment, supported by a network of local services providing more general treatment.[47]

1 C&AG's Report, Progress in improving cancer services and outcomes, Session 2014-15, HC 949, 15 January 2015 Back

2 Q 126; C&AG's Report, para 1 Back

3 C&AG's Report, para 2 Back

4 C&AG's Report, para 3.3 Back

5 C&AG's Report, para 3.9 Back

6 C&AG's Report, para 2.7 Back

7 C&AG's Report, paras 4, 1.10 Back

8 Q 173; HC Committee of Public Accounts, Delivering the Cancer Reform Strategy, Twenty-fourth Report of Session 2010-11, HC 667 1 March 2011 Back

9 C&AG's Report, para 1.7 Back

10 Qq 3-14, 17-24 Back

11 Qq 173-174, 176 Back

12 Q 2; C&AG's Report, para 1.7 Back