The Health Foundation, in collaboration with Professor Sir Mike Richards, has published a major report today assessing progress on cancer care in England over almost two decades. The report sets out recommendations to help close the gap in survival between England and other comparable countries.
The report looks back to the launch of the NHS Cancer Plan in 2000, the first comprehensive national strategy for improving cancer care in England. The Plan noted that cancer patients in England had poorer survival than in other European countries and promised that by 2010 ‘our five-year survival rates for cancer will compare with the best in Europe’.
The report finds that progress has been made on reducing mortality, and improving the chances of survival and the experience of care, for people in England diagnosed with cancer.
Despite persistent ambitions to be the best in Europe and the world noted in successive cancer strategies, the gap in survival rates has not been closed*. For example, a person diagnosed with colon cancer in the UK has a 60% chance of survival after 5 years, compared with 71% for those living in Australia.
Early detection and diagnosis of cancer is critical to improving a person’s chances of survival, as early-stage cancer is more responsive to treatment than late-stage cancer. 5-year survival for bowel cancer is over 90% if caught early, but less than 10% if diagnosed late.
However, the proportion of people being diagnosed with cancer at an early stage remained almost static between 2015 and 2017.
To close the gap, there will have to be radical improvements in the early diagnosis and detection of cancer. The NHS will need to invest significantly in boosting diagnostic equipment and workforce. Although there has been recent investment in equipment to treat cancer, the UK has fallen far behind other countries in the availability of diagnostic equipment per person, ranking 35th out of 37 countries for CT scanners, and 31st out of 36 for MRI scanners. There is also a shortage of staff to operate the machinery and report scan results, leading to delays in diagnosis and treatment.
There will need to be more progress on helping the public understand the symptoms associated with cancer, so they might seek help earlier. It is also vital that primary care is resourced to meet demand for appointments. Research has found that patients in England are more reluctant to bother their GP than people living in other countries. In 2017, Cancer Research UK found that 22% of respondents were worried about wasting the doctor’s time and 45% said they found it difficult to make an appointment.
There should be greater support for GPs to refer more patients for urgent investigation, along with additional staff and equipment in hospitals to meet demand for referrals. In the past, efforts to encourage GPs to refer early for suspected cancer have been met with resistance from commissioners under pressure to limit referrals, and by limited hospital capacity to meet demand for diagnostic tests such as endoscopy.
Improving early diagnosis and closing the survival gap will require generating momentum and supporting collaboration across primary and secondary care to shorten waiting times and improve treatment.
Our report found that the disruption caused by the Health and Social Care Act 2012 led to a loss of momentum that is only recently being rebuilt. It is crucial that local clinicians and managers are supported to work across organisational boundaries to improve care, share experience and learn improvement skills.
To help improve performance, outcomes and survival rates, the report also recommends:
- Measures to improve the screening of bowel cancer, including introducing testing in primary care for patients with low-risk colorectal symptoms and boosting the non-medical endoscopy workforce.
- Offering periodic low-dose CT scans for people at risk of lung cancer, an intervention that has been shown to reduce lung cancer mortality by 26%.
- Accelerating the piloting and evaluation of rapid diagnostic centres, which allow GPs to refer patients with possible cancer to be assessed and diagnosed in as little as a day, rather than weeks or months.
More funding and support for GPs, to enable the investigation of patients who have symptoms that indicate a 3% or higher risk of cancer, as recommended by NICE guidelines.
- Investment in prevention, which will require reversing cuts to public health budgets as well as cross-government effort on the causes of obesity, smoking and excess alcohol consumption – all of which are known to cause cancer.
- Making sure it is clear which NHS bodies are responsible for delivering progress in early diagnosis at national and local level, with regular progress reports using key metrics including: uptake of screening and outcomes; number of referrals; stage of cancer at diagnosis; and number of emergency presentations.
Professor Sir Mike Richards, former National Cancer Director, said:
‘The NHS Cancer Plan in 2000 and all subsequent cancer strategies have set ambitions for England to match the best in Europe or the world in relation to cancer survival. Although progress has been made on many aspects of cancer, these aims have not been achieved. Every year thousands of deaths could be avoided if we achieved these goals. This is the equivalent to a jumbo jet of people falling from the sky every 2 weeks.
‘The Prime Minister’s ambitious target to increase early detection of cancer from one in two people today, to three in four by 2028, is welcome, but if we are serious about moving the dial on early diagnosis, then setting targets and handing out money will not be enough. The NHS must change the way that care is currently organised to make it easier for people to be seen and diagnosed as quickly as possible, as we know this gives them the best chance of survival.’
Ruth Thorlby, Assistant Director of Policy, said:
‘Our report highlights the importance of the infrastructure that needs to be in place to engage and support clinicians and managers to improve a complex service such as cancer. The disruption caused by the Health and Social Care Act 2012 was profound, and financial pressure has compounded this. Although investment is clearly needed in workforce and equipment, the experience of the past 20 years in cancer shows that staff need support, evidence and skills to implement change. Without these, the injection of resources alone will not be effective.’
- The largest international comparative study, CONCORD 3, only gives data at UK level.
- Cancer is responsible for a quarter (25%) of all deaths for women and nearly a third (30%) of deaths for men. The number of people being diagnosed with cancer has increased by 40% over the last 20 years. In 2015, this equated to 822 new cases of cancer registered each day.
- The NHS’s capacity to diagnose and treat patients promptly has not kept pace with need. Nearly one in 11 people wait more than 2 weeks to be seen after an urgent referral with suspicion of cancer. This year, the 93% target for people being referred within two 2 weeks was missed consistently between April and September for the first time in a decade.
- People are also waiting longer to begin treatment: the 85% target for people starting treatment for cancer 62 days after urgent referral has been missed for 4.5 years.
- Across all cancers, one in five people receive their diagnosis after presenting as an emergency. For some cancers, this is far higher. For example, more than half (51%) of people with brain cancer are diagnosed after emergency presentation.
- There is a clear link between being diagnosed after coming into hospital as an emergency and a person’s chances of survival. A person diagnosed with breast cancer in this way has a 57.2% chance of survival after 12 months. Comparatively, a person diagnosed with breast cancer after an urgent referral from their GP, which should take 2 weeks, has a 97.5% chance of survival after 12 months.
- Currently, around 37% of patients have their cancer diagnosed after an urgent 2-week referral for investigation from their GP. A further 25% of patients are diagnosed with cancer after being referred non-urgently by their GP. This group experiences much longer waits for diagnosis and treatment, which is associated with poorer outcomes and chances of survival.
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