Health funding in Northern Ireland Contents

2Cancer services

Cancer in Northern Ireland

38.Cancer is the leading cause of death in Northern Ireland. Of the 16,036 deaths registered in Northern Ireland in 2017, 4,460 (27.8 per cent) were due to cancer.78 Over the last decade, incidences of cancer have increased 15.1 per cent (excluding non-melanoma skin cancer) from 8,269 cases in 2008 to 9,521 cases in 2017.79 This is mostly due to Northern Ireland’s aging population—63 per cent of cases diagnosed occurred in people over the age of 65 years and incidence rates are highest for those aged 85–89 years.80 It has been estimated that by 2020, almost one in two will get cancer at some point in their lives.81

39.The most common cancers diagnosed among males between 2013 and 2017 were prostate (1,133 cases on average per year),82 lung (680 per year)83 and colorectal (652 per year)84 while the most common cancers among women were breast (1,398 on average per year),85 lung (610 per year)86 and colorectal (532 per year).87

Figure 4: Incidence of cancer in Northern Ireland, 1993–2017

Source: N. Ireland Cancer Registry, 2017 Cancer incidence, survival, mortality and prevalence data, 12 March 2019

40.The standardised incidence rate for cancer is 24 per cent higher in the most deprived communities than in the least deprived communities88 while premature mortality from cancer is 72 per cent higher in the most deprived communities than in the least deprived.89 This gap has remained broadly consistent over the last decade. Incidence rates by cancer type also vary between socioeconomic groups—breast cancer and melanoma tend to be more common in areas of low deprivation while lung, stomach, male-colorectal and cervical cancer are more prevalent in areas with high deprivation.90

41.A patient’s prospects are largely determined by the stage of progression at diagnosis—for example, 99 per cent survive breast cancer for 5 years or more when diagnosed at an early stage but this falls to 18 per cent when diagnosed at a late stage; 98 per cent survive bowel cancer when diagnosed at an early stage but this falls to 9 per cent when diagnosed at a late stage; and 44 per cent survive lung cancer when diagnosed at an early stage while only 2 per cent survive if diagnosed at a late stage.91 Timely diagnosis is therefore essential for a patient’s survival prospects. However, a significant proportion of cases in Northern Ireland are diagnosed at a late stage—20 per cent are diagnosed at stage III and 26 per cent at stage IV.92 These numbers are even higher for men—21 per cent of men are diagnosed at stage III and 31 per cent are diagnosed at stage IV.93 Late diagnosis can be due to a number of factors, including low public awareness of signs and symptoms, hesitation or delay in seeing a GP or delays further in the diagnostic pathway.

Figure 5: Stage of cancer at diagnosis, average number of cases per year, 2013–2017

Source: N. Ireland Cancer Registry, 2017 Cancer incidence, survival, mortality and prevalence data, 12 March 2019

Despite this, advances in cancer care and treatment mean that more people are surviving cancer for longer. According to the most recent statistics one-year net survival for both sexes is 71 per cent and five-year net survival is 56 per cent.94 This compares with 63 per cent one-year survival and 45 per cent five-year survival a decade prior.95

Cancer waiting times

42.Ministerial targets for cancer waiting times were set in 2009 and have not been amended since. These targets are:96

The Department of Health reports on performance against these targets on a quarterly basis. Records show a gradual deterioration in performance against these targets. The 62 day target has never been met since its introduction; the 31 day target has not been met since December 2013; and the 14 day breast cancer target has not been met since March 2018 (though close to target levels were reached in April, November and December 2018).97

43.In addition to these targets not being met, the targets themselves do not capture the full extent of the patient pathway—none of the targets include time spent waiting for a GP appointment; the 31 day target does not capture the waiting time from referral to treatment; and the 14 day target only applies to breast cancer. The total waiting time for patients is therefore likely to be longer than what is captured by these targets. Cancer Focus Northern Ireland told us that:98

It really starts [ … ] with pressure on our GP services where people may have a symptom they are concerned about, [ … ] they try to see their GP, and it is three weeks before they see their own GP. There is where your first delay starts. [ … ] Routinely, if you go to a GP now in Northern Ireland, not a red flag referral necessarily but if there are symptoms that might be cancer, you will be asked, “Can you afford to go privately for an MRI or a CT scan?” If you can, it does relieve pressure on the health service but off you go and you get your scan within three or four days. If you do not have that money—and a lot of people do not—then you are into very long waits.

The point that patients are having to resort to funding their own care to avoid long waits was made to us by Melanie Kennedy, who was diagnosed with breast cancer in 2014:99

An alarming amount of people are relying on crowd funding and self-funding to get appointments quicker, to get treatments quicker. It is fast becoming a two-tier system. I am a believer in the NHS and it is something I am very, very reluctant to see and I would say it is happening a lot faster than it is in other parts of the UK because of our circumstances.

Waiting for extended periods of time for a diagnosis or treatment can cause significant distress for those made to wait. Melanie Kennedy went on to tell us that:100

People are having scans very, very late. They are not timely enough and they are not being read, and people are waiting a long time for results, which [ … ] impacts mental health for cancer patients. I believe [ … ] that physical and mental health are intrinsically linked, so this cannot be good for anybody—sitting and waiting around for something that could be a life-changing scan result, and you are living in limbo waiting on it.

44.The Committee heard that the Department’s failure to meet its Ministerial targets is linked with a high number of unfilled posts in the workforce. Cancer Research UK told us that:101

Poor performance against cancer waiting time targets [ … ] demonstrates acute pressures in the HSC workforce, with workforce shortages creating delays in the diagnostic pathway. [ … ] A wide variety of staff is required to deliver cancer services encompassing prevention, diagnosis, treatment and care, so staff shortages across the Health and Social Care system impact cancer services at all levels.

The point was also put to us by Prostate Cancer UK:102

It is not always about having the equipment or paying an initial outlay to have [ … ] new scanning equipment. Often the equipment is there but does the hospital or the trust have the capacity to get those scans done? Is the workforce there? Can they cope with the workload with the current workforce they have? At the moment, it is clear to see that they can’t.

45.According to the most recent workforce census by the Royal College of Radiologists, while there has been steady growth in the number of consultant clinical radiologists in England over the past four years there has been no significant increase in Northern Ireland.103 Northern Ireland has the highest vacancy rate for consultant clinical radiologist posts in the United Kingdom at 18 per cent. This compares with 10 per cent in Wales (the second highest) and 9 per cent in England.104 The Royal College’s census on the clinical oncology workforce estimated a similar shortfall in the number of consultant clinical oncologists of 16 per cent, or approximately six whole-time equivalent posts.105 This would require an additional eight trainees to account for rates of attrition in specialty training and less-than-full-time working.106 However, an average of only two doctors per year in Northern Ireland enrol on specialist training for clinical oncology.107 To address this shortfall the number would need to double over the next four years.108 The census also found that most consultant clinical oncologists were working extended hours to help cover for workforce shortages with almost half contracted to work over 48 hours per week and many taking on additional unpaid overtime.109

46.The disparity in unfilled vacancies between Northern Ireland and elsewhere in the United Kingdom has been linked to disparities in pay. The British Medical Association told us that:110

The lack of investment in the permanent workforce means that working in Northern Ireland is not seen as an attractive option. For example, recent pay uplift recommendations from the DDRB [Review Body on Doctors’ and Dentists’ Remuneration] are not certain to be introduced in Northern Ireland, due to the lack of a health minister. Additionally, the failure to run clinical excellence rounds since 2010 has contributed to a reduction in consultant salaries, especially when compared to their colleagues in other UK jurisdictions.

A recent workforce analysis by Cancer Research UK also identified regional disparities in the ability to recruit, quoting a lead clinician as saying:111

The Belfast area tends to be protected as that’s where people go to university, to settle and live. Other Trusts have different challenges around recruitment. Regionally in Northern Ireland we seem to have shortages of oncologists, shortages of haematologists and shortages of radiologists.

47.When asked by this Committee what steps were being taken to bring down waiting times, the Department cited the following measures:112

48.While the Committee welcome these measures, there continues to be a lack of focused workforce planning specifically to fill those vacancies that are leading to delays for patients. We were told by the Department that “the national shortage of radiologists cannot be alleviated in the short term and work will continue to explore a range of approaches to address this problem.”113 However, it is unclear what further measures have been taken by the Department.

49.The Committee heard of a number of innovative solutions to workforce shortages. These included: fast-tracking remote monitoring and interpretation of scans by radiologists based outside Northern Ireland;114 the use of artificial intelligence to support radiography and pathology;115 and greater north-south cooperation on the island of Ireland.116 Innovative approaches will be essential for mitigating chronic shortfalls in critical staff. However, it is doubtful whether these will be sufficient to bring waiting times down to target levels without a concurrent strategy for recruiting and retaining an adequate workforce.

50.Cancer incidence increases with age and demand for cancer services is likely to rise as Northern Ireland’s population ages. To meet this demand in the long-term a reconfiguration of services under the direction of an overarching strategy will be essential. However, in the medium-term action is needed to slow and ultimately reverse the upward trend in waiting times. The Committee recommends that the Department of Health commit to a baseline assessment to identify where gaps in the HSC workforce are contributing to delays in the diagnostic pathway for cancer patients. The Department should subsequently bring forward a strategy for closing those gaps through the recruitment and retention of an adequate workforce alongside innovations in technology and service delivery, to be published in draft by summer 2020.

Cancer strategy

51.The World Health Organisation recommends a national cancer control programme that is “goal-oriented, realistic, carefully prepared and appropriately funded through a participatory process” to reduce the cancer burden and improve quality of life for cancer patients “no matter what resource constraints a country faces.”117 However, while England,118 Scotland119 and Wales120 each have updated cancer strategies in place, Northern Ireland’s cancer strategy has not been updated since 2008.121

52.The Committee heard unequivocal support for the development of a new cancer strategy for Northern Ireland. Cancer Focus NI told us that the increase in cancer cases would “only be tackled by developing and implementing a comprehensive and well-resourced cancer strategy for Northern Ireland.”122 Macmillan and the Royal College of Nursing called for a “clear commitment” to developing a new strategy.123 Prostate Cancer UK told us that an updated cancer strategy was “imperative”124 and a “number one priority”125 which should aim at providing “a comprehensive top-down analysis of cancer diagnosis, treatment and support in Northern Ireland to point out the nodes at which key investment can be made to improve the situation.”126 Breast Cancer Now told us that an “effective, overarching cancer strategy, sets direction, and would be crucial in helping with investment decisions and plans for the longer-term”127 and that up-to-date strategies had led to advances in treatment and care in England, Scotland and Wales.128 Prostate Cancer UK raised concern that in the absence of an up-to-date strategy cancer services in Northern Ireland would fall behind the rest of the United Kingdom.129

53.The Committee heard that without a cancer strategy in place, long-term planning for cancer services was lacking. Cancer Research UK expressed concern that Confidence and Supply funds were not being deployed strategically in the absence of a joined-up strategy:130

There is an imaging review that is being funded by that money. There is a pathology modernisation project that is being funded by that money. There is a lot of work on general practice. There is a piece of work specific to cancer treatment on delivery of chemotherapy and radiotherapy. [ … ] All those individual pieces are out there being thought about but there is no whole and there also is no long-term thinking. Part of the problem is that we are just putting sticking plasters on things and it results in a system that is inefficient. As soon as one thing gets fixed, something else breaks and you have to fix that. It is indicative of a system that needs a cancer strategy more than anything else, something that analyses all the issues [ … ] from research through treatment, including workforce, research and data. [ … ] We just do not do that.

Melanie Kennedy also described the current model as a “sticking plaster approach” and that focus was needed to develop “a long-term plan for the increasing amount of people who are going to be diagnosed.”131

54.The Committee heard of a number of areas in which Northern Ireland was lagging behind the rest of the United Kingdom in the absence of a cancer strategy. Cancer Research UK told us that Northern Ireland had been “very slow” to run awareness campaigns, contrasting the Be Clear on Cancer132 campaign currently running in England with the lack of an awareness campaign in Northern Ireland for over two years.133 Prostate Cancer UK similarly told us that “without a cancer strategy and that top-down direction, things are moving at a much slower pace.”134 Cancer Focus NI told us that Northern Ireland had been “very slow”135 to adopt new systems for diagnosis and treatment and that Northern Ireland was now falling behind the rest of the United Kingdom, remarking that “it is that other people have become better rather than that we have become worse.”136 The Committee also heard criticism of the paucity of data on cancer in Northern Ireland, with calls to improve the scope, collection and sharing of data.137 Cancer Research UK further highlighted problems in the diagnostic system, telling us that a lot of work was needed on:138

Cohesion, better screening programmes, better awareness, organising diagnostic testing, locations, workforce, and making sure we have enough kit [and] machines.

Breast Cancer Now pointed to opportunities to improve earlier diagnosis that had opened up under the direction of England’s cancer strategy, citing the roll-out in England of ‘one-stop shops’ for people with non-specific symptoms to break the cycle of multiple referrals and speed up diagnosis.139

55.We heard that, in line with the World Health Organisation’s recommendation of a “participatory process,” any new cancer strategy should be developed in collaboration with other Departments, Health and Social Care organisations, key stakeholders including the voluntary and community sectors, and guided by the expertise of healthcare professionals and the voice of patients.140 We were also provided by Cancer Research UK with a detailed summary of those areas that any new cancer strategy should cover, informed by an evaluation of cancer services in Northern Ireland conducted in 2016.141 These included:142

56.On 7 March 2019, during the course of the inquiry, the Department of Health announced that a new cancer strategy for Northern Ireland would be commissioned.143 The Department stated that it had looked into the various arrangements that had supported the development of cancer strategies in neighbouring jurisdictions and saw merit in the model used by NHS England, whereby an Independent Cancer Taskforce had been established to work with professional cancer services staff, patients, cancer charities, commissioners, care providers and other key stakeholder groups.144 The Department has since set a completion date for a new strategy of June 2020.145

57.The Department has stated that implementation of the new strategy “would be for a future Health Minister.”146 While the Department told us that recent legislation had helped the Department to progress a new cancer strategy, there remained difficulties in funding its implementation in the absence of a Health Minister, as such decisions could result in cutbacks elsewhere:147

The [Northern Ireland (Executive Formation and Exercise of Functions) Act 2018] has been extremely helpful both on this issue and on a range of issues in terms of our ability to take decisions. On the limitations—this is an issue we will come to when we develop the strategy—taking a decision to approve and implement a new cancer strategy in one sense is easy, in and of itself. The difficulties lie in how we fund that and, particularly, how we fund it within a finite budget. The reality is that, where additional costs would lie and go alongside the implementation of that strategy, a fixed budget will mean that activity elsewhere will have to be scaled back.

58.Northern Ireland is alone in the United Kingdom in not having an up-to-date cancer strategy. Without an integrated, long-term vision for improving cancer services under the direction of a well-conceived strategy, cancer services in Northern Ireland will struggle to keep pace with demand. As such, the Committee welcomes the Department’s announcement that a new cancer strategy for Northern Ireland is in development. However, we recognise that many will be concerned that decisions on a new strategy are awaiting Ministerial approval. We recommend that the Department set out, in response to this report, clear timescales for its programme of work in developing a new cancer strategy and provide regular updates on progress made. This timescale should set out the key milestones where Ministerial decisions should be made.

Access to cancer treatments

59.The National Institute for Health and Care Excellence (NICE) is responsible for providing the NHS with advice on effective and good value healthcare. The Institute produces technology appraisals guidance which assess the clinical and cost effectiveness of health technologies, including pharmaceutical and biopharmaceutical products, procedures, devices and diagnostic agents, to help ensure that the NHS is able to adopt new developments quickly and consistently.148

60.NICE aim to issue final guidance on all new treatments within 90 days of the treatment being licensed.149 The NHS is then legally obliged to fund and resource treatments appraised by NICE within three months of the date of appraisal.150 The appraisal process results in one of three recommendations:151

Drugs are recommended for use within the Cancer Drugs Fund where NICE consider there to be plausible potential for a drug to meet the criteria for routine commissioning but where significant clinical uncertainty remains.152

61.Until recently, Northern Ireland was alone in the United Kingdom in lacking a mechanism for patients to access innovative new treatments that would be available through the Cancer Drugs Fund. The only option for patients in Northern Ireland to access a particular treatment that had not been recommended for routine commissioning by NICE was for their hospital consultant to submit an Individual Funding Request (IFR) to the Health and Social Care Board on their behalf. In order for the Health and Social Care Board to approve an IFR, the application had to demonstrate that there were “exceptional clinical circumstances” on the grounds that “the patient is significantly different to the general population of patients with the condition in question.”153 This was defined as “an individual whose clinical circumstances are outside the range of clinical circumstances presented by at least 95 per cent of patients with the same medical condition at the same stage of progression as the named patient.”154

62.The consequence of this was that drugs made available elsewhere in the United Kingdom were not made available to patients in Northern Ireland without extended delays, of years in some cases, if at all. We heard that clinicians were reluctant to submit IFRs for their patients due to the strict exceptionality criteria and many patients had to resort to funding their own treatment or lobbying to access the treatments they needed.155 Northern Ireland was also unable to benefit from managed access agreements for CDF medicines, which resulted in significantly higher costs per patient for those who were approved.156

63.Beyond the immediate impact on patients, we also heard that this would make Northern Ireland a less attractive place to conduct clinical trials.157 This in turn would make it more difficult to attract specialist clinicians to work in Northern Ireland.158 The pharmaceutical company Bristol Myers-Squibb described the range of wider benefits that clinical trials bring to the region, which consequently were at risk:159

It allows some patients to receive a potentially life-extending treatment, providing access prior to the medicine gaining market authorisation. There are also financial benefits for the health service from research investment, as well as cost savings due to pharmaceuticals being provided for free. In addition there are a number of wider positive benefits including benefits to infrastructure, the learning and skill development of clinicians, improved quality of care and health outcomes for patients as well as quicker uptake of new treatments.

64.During the course of the inquiry the Department of Health announced that it would be improving access to new medicines for cancers and other conditions. The changes included:160

The Department aimed to implement the changes within the financial year and estimated that the additional cost to the Department would be between £2 million and £2.5 million per annum.161

65.The Committee wrote to the Department in October 2018 to ask when patients could expect to benefit from these changes.162 In its reply, the Department told us that in order to ensure value for money they had asked the Regional Pharmaceutical Procurement Service to confirm the details of each commercial managed access agreement with the pharmaceutical companies.163 The Committee was told that discussions had commenced in mid-October and once confirmed, patients who were considered suitable by their clinical consultant would be able to access the new medicines.164 Until then, clinical consultants were accessing medicines on a cost per case basis, which meant that patients who were unable to apply for an IFR due to the issue of patient cohorts could now access CDF medicines.165

66.The Department stated that the 95 per cent exceptionality clause would be removed and replaced with a term whereby clinicians demonstrate that the patient is more likely to gain significant clinical benefit from the treatment than other patients with the same condition at the same stage. However, until the clinically led Regional Scrutiny Committee was up and running the current IFR panel would continue to make decisions on applications, though augmented with additional, independent clinical input. A meeting with the newly constituted, clinically-led Regional Scrutiny Committee was scheduled for 23 November 2018 with the ambition that the committee would be considering applications from early 2019.166

67.In January 2019, we questioned the Permanent Secretary on the additional cost of implementing these changes. We were told that the initial uplift would be in the region of £500,000 which would increase to approximately £2 million recurrently.167 The Permanent Secretary told the Committee that:168

Given previous ministerial commitments on this point, and there had been a lot of ministerial engagement, there is a pressing need to move the position. We need to move quickly to do that. I am confident that I can manage the costs, which are not that significant, within the churn as we move forward.

68.The Committee welcomes the Department’s moves to place Northern Ireland on an equal footing with the rest of United Kingdom in opening up patient access to innovative new treatments. However, there has been a lack of updates on progress made towards realising the full raft of changes announced last year. The Department should update the Committee on what progress has been made so far and provide regular updates on further progress until such time as these changes are fully rolled out, or until the relevant Committee is constituted at Stormont.

69.In the course of our inquiry it was also brought to the attention of the Committee by several organisations169 that Northern Ireland was lagging behind other UK jurisdictions in not committing to adopt screening methods recommended by the UK National Screening Committee, in particular the Faecal Immunochemical Test (FIT) offered to men and women aged 50 to 74 years to screen for bowel cancer170 and tests for Human Papillomavirus (HPV) as the primary test in cervical screening.171 Northern Ireland instead offers the less cost-effective Faecal Occult Blood Test (FOBT) to men and women aged 60 to 74 years172 and routine smear tests as the primary test in cervical screening.173

70.In October 2018 the Committee wrote to the Permanent Secretary to ask the Department to commit to adopting more efficient methods.174 The Department replied that, with respect to FIT, adopting the screening method would require:175

Reviewing patient pathways, drafting a procurement specification for the new test kits, analysing potential issues for colonoscopy capacity, looking at the requirements for a new IT module for the Bowel Screening Information Management System and revising patient and professional information.

The Department also stated that the greatest health gains would be made by rolling out the screening method to people aged 60 or over but that “extending the age range to 50 years remains an option to be considered.”176

71.In January the Committee questioned the Permanent Secretary again on the adoption of FIT. We were told that the issue had been looked into in further detail and preparatory work was now underway. However, the Permanent Secretary wished to “defer the actual decision-making process until we get a budget allocation for 2019–20 and we can consider the financial implications.”177

72.In April 2019 the Department announced that, having reviewed the Department’s budget allocation, FIT would be adopted as the primary screening test for bowel cancer, to be introduced from early 2020.178 However, the announcement made clear that this would be offered to men and women participating in the Northern Ireland Bowel Screening Programme, which is offered to men and women aged 60–74.179 This does not extend the age range to 50 years as recommended by the UK National Screening Committee.

73.The Committee welcome the Department’s announcement that FIT will be adopted as the primary screening test for bowel cancer. However, we are concerned that this will not be extended to men and women aged 50 and over as recommended by the UK National Screening Committee. We are not clear why this decision was made. The Committee recommends that the Department consider extending the programme to men and women aged 50 and over.

74.With respect to tests for HPV as the primary test in cervical screening, the Department told the Committee that the introduction of primary HPV testing was expected to increase demand on colposcopy services, citing the 60 per cent increase in colposcopy referrals in England since introducing primary HPV testing. As a result, they told us that the Public Health Agency was leading work on exploring the impact of HPV testing on cervical screening and developing the optimum implementation strategy for managing demand.180

75.The Committee welcome ongoing work to explore a managed strategy for introducing HPV testing as the primary test in cervical screening. However, there has been a lack of updates on progress made since the Committee questioned the Department in January. The Department should update the Committee on what progress has been made so far and provide regular updates on further progress until such time as primary HPV testing is rolled out fully, or until the relevant Committee is constituted at Stormont.

78 Northern Ireland Statistics and Research Agency, Registrar General Annual Report 2017 Cause of Death, 7 November 2018

79 Queen’s University Belfast, Cancer incidence and survival statistics for Northern Ireland 1993–2017, 12 March 2019, page 2

80 Ibid., page 1

82 N. Ireland Cancer Registry, Prostate Cancer, accessed 14 May 2019

83 N. Ireland Cancer Registry, Lung Cancer, accessed 14 May 2019

84 N. Ireland Cancer Registry, Colorectal Cancer, accessed 14 May 2019

85 N. Ireland Cancer Registry, Breast Cancer, accessed 14 May 2019

86 N. Ireland Cancer Registry, Lung Cancer, accessed 14 May 2019

87 N. Ireland Cancer Registry, Colorectal Cancer, accessed 14 May 2019

88 Department of Health, Health inequalities annual report 2019, March 2019, page 21

89 Ibid., page 19

92 N. Ireland Cancer Registry, 2017 Cancer incidence, survival, mortality and prevalence data, 12 March 2019

93 Ibid.

94 Ibid.

95 Ibid.

96 Dr Lesley-Ann Black and Keara McKay, Cancer: Northern Ireland, 28 June 2017, page 21

97 Ibid., pp. 22–24; Department of Health, Northern Ireland Waiting Time Statistics: Cancer Waiting Times January—March 2019, 28 March 2019, page 5

101 Cancer Research UK (HTH0017)

103 The Royal College of Radiologists, Clinical radiology UK workforce census 2018 report, 5 September 2018, page 12

104 Ibid., page 19

105 The Royal College of Radiologists, Clinical oncology Northern Ireland workforce census report 2018, 1 July 2019, page 3

106 Ibid., page 6

107 Ibid., page 6

108 Ibid., page 6

109 Ibid., page 3

110 BMA Northern Ireland (HTH0018)

111 Cancer Research UK, Where next for cancer services in Northern Ireland?, September 2016, pp. 51–52

117 World Health Organization, National Cancer Control Programmes (NCCP), accessed 3 June 2019

121 Northern Ireland Assembly Research and Information Service, Cancer: Northern Ireland, Briefing Paper No. 32/17, 28 June 2017, page 7

122 Cancer Focus Northern Ireland (HTH0015)

123 Macmillan Cancer Support (HTH0012); Royal College of Nursing (HTH0037)

124 Prostate Cancer UK (HTH0042)

126 Prostate Cancer UK (HTH0042)

127 Breast Cancer Now (HTH0005)

130 Ibid.

132 NHS, Be Clear on Cancer, accessed 14 August 2019

136 Ibid.

137 Q152; Cancer Research UK (HTH0017)

140 Macmillan Cancer Support (HTH0012); Royal College of Nursing (HTH0037)

141 Cancer Research UK, Where next for cancer services in Northern Ireland?, September 2016

142 Cancer Research UK (HTH0017)

144 Ibid.

145 Northern Ireland Executive, New strategy will help us meet cancer increase challenge, 10 May 2019

146 Ibid.

148 National Institute for Health and Care Excellence, What we do, accessed 31 August 2019

150 National Institute for Health and Care Excellence, NICE technology appraisal guidance, accessed 31 August 2019

151 Ibid.

152 Ibid.

154 Ibid., pp. 7–8

155 AbbVie (HTH0011); Bowel Cancer UK (HTH0047); Bristol-Myers Squibb (HTH0030); Northern Ireland Assembly All-Party Group on Cancer (HTH0016); Prostate Cancer UK (HTH0042)

156 Association of the British Pharmaceutical Industry (HTH0024)

157 Association of the British Pharmaceutical Industry (HTH0024); Bristol-Myers Squibb (HTH0030); Cancer Focus Northern Ireland (HTH0015); Cancer Research UK (HTH0017); Northern Ireland Assembly All-Party Group on Cancer (HTH0016); Q143

158 Bristol-Myers Squibb (HTH0030)

159 Ibid.

160 Department of Health, Department Announces Improved Access to New Drugs, 12 September 2018

161 Ibid.

164 Ibid.

165 Ibid.

166 Ibid.

169 Bowel Cancer UK (HTH0047); Cancer Research UK (HTH0017)

170 Public Health England, Current UK NSC recommendations, Bowel Cancer, accessed 2 September 2019

171 Public Health England, Current UK NSC recommendations, Cervical Cancer, accessed 2 September 2019

172 Public Health Agency, Overview of the NI Bowel Cancer Screening Programme, accessed 2 September 2019

173 Public Health Agency, Overview of Cervical Screening Programme, accessed 2 September 2019

176 Ibid.

179 Ibid.

180 Ibid.

Published: 2 November 2019