As UK life expectancy increases more people will get cancer and other long term conditions. The NHS needs a radical coordinated response to handle this new pressure, writes Ciarán Devane
Every four years, life expectancy in the UK goes up by one year. Some of this is due to preventing road traffic accidents and the like, but it is mostly down to improving health. In fact it is a spectacular success. We may not be quite up there with Spain, Australia or Sweden as the best of the best, but we are in the pack with Germany and France, and well ahead of our American cousins.
‘There is a perfect storm of pressure on the NHS that will require a Herculean effort to overcome’
You can clearly see the progress made in cancer. Median survival is now about six years. Whereas in the early nineties only one in five of those diagnosed with cancer did not die of it, by 2020 that number will have doubled to almost two in five. Again this is a credit to everyone working in cancer, the NHS and in healthcare more broadly.
Sadly, no good deed or outstanding success goes unpunished. Macmillan’s recent report on mortality trends in cancer shows the knock-on effect of longer lives. By 2020, almost half of those who die in that year will have had a cancer diagnosis during their lifetime, up from about a third in the early nineties. More people getting cancer, being supported through treatment and aftercare for longer, being on average older and potentially with multiple morbidities − all this creates a perfect storm of pressure on the NHS that will require a Herculean effort to overcome.
Hercules needs to start work now. The combined, compound impact of the increase in cancer incidence and survival will mean that the number of people living with cancer in the UK will go up by around 30 per cent between 2013 and 2020. Or if you are talking to a politician, this is by the end of the next Parliament. Not far away at all. Can we realistically expect to treat 30 per cent more people if we do then the same as we do today? Of course not.
The role of the patient
Money is one issue. It will be tight until 2020 at least. But Macmillan has done some economics work in Manchester that shows that simple, not rocket science improvements in coordinated care could save around 10 per cent of cancer expenditure in Manchester.
‘Behaviour change is slow but ultimate success will not come if we, as patients and public, do not change’
Similarly, an economic evaluation of our Midhurst palliative care service (inspired by a Swedish innovation called the Motala model) shows that if it was replicated elsewhere the total cost of care in the last year of life could be reduced by 20 per cent. The first imperative, therefore, is to roll out innovative system redesigns such as these at pace and at scale. That is the job of commissioners.
Workforce is the second issue. Even if it were the right thing to do, we do not have the time or resource to increase our specialist workforce by 30 per cent in seven years. We need to adopt higher quality, cost effective models, complemented by creating semi-specialists in the community who bridge primary and secondary care and by acute based specialists reaching outside the hospital.
We need clinical nurse specialists supporting community services, practice nurses with a special interest in cancer addressing the consequences of treatment, social care coordinators allowing hospitals to focus on their specialisms − all working with GPs and oncologists as one team overseeing cancer pathways for their population. That we should be able to deliver on time.
As individuals we have a role in our own health, but we need to be supported to play that role. Information on cancer prevention and on the signs and symptoms of the disease needs to be available in the right places and in the right format. Care plans need to be co-created so they address the real issues. Services to improve our survival and overall health need to be in place, physical activity being the obvious area to target.
Behaviour change is slow but ultimate success will not come if we, as patients and public, do not change. We know that we can: halving adult smoking over the past 20 years shows what a coordinated, inexorable campaign can do. Next up must be exercise.
All three of the above − system change, workforce development and people helped to take control of their health − need to start now. First, if the area teams of NHS England are, as declared, “the embassies” of NHS England to their patch then they need to provide great ideas, innovations and support for change. Neither the medical directorate nor the nursing directorate have the bodies to get around everywhere.
The area teams of NHS England are change agents and facilitators, not performance managers of clinical commissioning groups or providers. They have to ensure that the NHS is sustainable and must be fixated with the future.
‘We do not have the luxury of delay, of waiting until after the next election, or of not changing’
Second, shared goals with social care and public health are a priority. Demand will only be managed if we find community solutions, and if public health is a success. For the NHS to be affordable, it will ultimately require fewer people getting long term conditions earlier than they should. Smarter interventions will also help the ageing population, many of whom will inevitably have morbidities, to be as fit and well as possible.
Third, we should collectively take a position on what minimum increase is realistically required in health spending to sustain the NHS. We are unlikely to get the 4 per cent inflation-plus of the past, but that does not mean that “flat real” will be enough. To take a position with a solid footing we need a view of what productivity each part of the new system can achieve, which again gets us back to innovation and efficiency. Only then can we say that in the austerity we shall remain in, the public expectation for the NHS to be supported requires a particular level of funding.
For me it is why the strategy process of NHS England is critical. It needs to create not only a genuine dialogue with the public, but one that captures the headlines, sets the agenda and stays in the news. It must engage the part of the public who otherwise would only wake up when someone has made the decision.
If the increase in the proportion of people who will get cancer to almost one in two by 2020 shows one thing, it is that we are well up the exponential demand curve. Getting on with day to day things will make some improvements and release some cash, which will enable the next iterative improvement. But that will not be enough. In parallel we need radical action. We do not have the luxury of delay, of waiting until after the next election, or of not changing.
Ciarán Devane is chief executive at Macmillan Cancer Support