Published: 13/05/2004, Volume II4, No. 5905 Page 10 11
The spotlight on NHS waiting times shines particularly brightly on cancer services.
But research by Cancer BACUP, revealed exclusively here, shows deep fears that staff and funding shortages could play havoc with next year's targets.
Last month HSJ revealed that the government is considering proposals to replace existing access targets with 'total wait' targets, setting out a maximum four-month wait between point of referral and treatment.
The idea is ambitious and designed to tackle claims that current waiting lists do not reflect the reality of the patient experience, disguising 'hidden waits' to see consultants and receive nonsurgical treatment.
But there is one area where the NHS is facing up to some of its hidden waits. Cancer services already work to a maximum twoweek wait for urgent referrals from GP to consultant. By the end of next year all cancer patients should have started to receive treatment within one month of diagnosis, and all urgent cancer patients within two months of referral.
So could the NHS at large use oncology care as a blueprint for reducing waits? Cancer charities are sceptical: they fear that the December 2005 targets may not be met and that they disadvantage non-urgent patients who have yet to be diagnosed (see box).
Here HSJ exclusively reveals research by cancer information service CancerBACUP, which demonstrates that blockages in the patient journey persist.
The research gives grounds to doubt that next year's targets can be met.
CancerBACUP researchers approached all of the country's 34 cancer networks to examine how well the service was progressing towards next year's two-month target and to discover the main obstacles to success. Replies were received from 20 of the networks.
The report did not look at progress on the one-month targets, as CancerBACUP wanted to examine the entire patient journey.
A range of obstacles to the success of the targets were identified, including lack of funding, problems in data collection and a failure among some services to redesign appropriately.
But chief among them is the workforce issue: basic shortages in the groups of staff needed to deliver the targets. Forty-five per cent of network leaders who responded to the survey said workforce shortfalls were the key obstacle to reducing waits.
The shortage of radiographers was highlighted. The report says: 'The worst staff shortages are in radiotherapy, radiography and pathology, causing bottlenecks at the vital diagnostic stage.'
Reasons for radiographer shortages are many and varied, say cancer experts.Not only have training numbers been historically low, but student attrition rates are estimated at 30 per cent. Experts say the field's low status - and low salaries - are key factors.
Audrey Patterson, Society and College of Radiographers director ofprofessional policy, says the new pay system Agenda for Change will mean an hourly pay cut for all radiographers and will not help the situation.
She is optimistic, however, about the government's recruitment and retention drive, which includes the introduction of postgraduate courses: 'Earn and learn schemes that certain strategic health authorities have been running will have some impact.'
Cancer 'czar' Professor Mike Richards acknowledges that the workforce shortage is 'absolutely a key problem'.
He tells HSJ: 'We have not had enough radiographers or radiologists in place. We have increased the numbers in training, but it takes years to train them.' But he adds: 'I am confident that numbers will continue going up.'
In headcount terms, there has been a 7.8 per cent increase in diagnostic radiographers since 1999 and an 11.1 per cent increase in radiotherapists. But what this means in terms of whole-time equivalents is unclear.
Workforce statistics are not the only grey area. Forty per cent of those polled by CancerBACUP described poor-quality data as the main barrier to meeting next year's targets. Fewer than 10 per cent of cancer networks believe that the data currently being collected meets all their service development and planning needs.
Professor Richards claims he is working hard to solve this. 'We have been developing a new cancer database. It takes people from referral through to diagnosis and treatment.
'This allows us to look at the whole system, ' he explains. 'It tracks information between trusts. So if a patient is diagnosed in one hospital but is treated at another, we do not lose them in the system.'
He adds that information should be sufficient for comparison towards the end of this year. Local trusts and networks will only be able to see their own information but will be able to compare it against national averages.
These figures will not be put in the public domain until the targets 'go live' at the end of 2005.
CancerBACUP chief executive Joanne Rule says: 'We are anxious that these details are made publicly available sooner.'
Statistics on two-month breast cancer waits and one-month waits for four cancer groups (breast, children's, testicular and acute leukaemia) are already published, with compliance ranging from 9597 per cent.
Then there is the age-old bugbear: funding. So it is surprising, perhaps, that just 15 per cent of cancer networks thought lack of funding was their biggest hurdle.
The charity's report says: 'The underlying problem now appears to be not the amount of money available for cancer care, but how it is spent.'
But Ms Rule fears the networks 'have not woken up and smelt the coffee' - they have not grasped the implications of the fact that the three-year funding programme from the national cancer plan ended in March. 'If we did the same survey in a year's time, they might be saying something different, ' she says.
She blames the 'ideology' of localised decision-making in primary care trusts for inconsistencies in spending, urging SHAs to take a more top-down approach.
She praises the example of Trent SHA, which she says has ruled that if 75 per cent of PCTs are prepared to commission a particular cancer service, 'that decision is binding on everybody else'.
The CancerBACUP report also stresses the need for service redesign. Sixty per cent of respondents to the survey said they had redesigned services in order to support waiting-list reduction.
Many such examples are described in the report.
Professor Richards also believes that service redesign is key, citing endoscopy as an example of successful waiting list reduction.
Nobody interviewed by HSJ, however, is confident enough to answer one question directly: will the cancer targets be met by December 2005?
Professor Richards says: 'I fully hope and want to meet these targets. The barriers are that some of the patient care pathways are proving difficult to sort out. They are very complex.
'Take oesophageal cancer, for example. There might be six different tests - It is not as if they can be done all at the same time.'
Ms Rule says cautiously that 'there has been more progress in some cancers than in others'.
While unwilling to predict those cancers where progress is slow, her words match Professor Richard's concern about oesophageal cancer (an upper gastrointestinal cancer): 'People have talked about upper GIs, ' she says.
Institutions that fail to sufficiently accelerate the cancer patient's journey in time could find themselves in trouble, however. Professor Karol Sikora, visiting professor of cancer medicine at Imperial College School of Science, Medicine and Technology, has this stark warning.
'If I were a patient waiting for three months for radiotherapy, I would be suing the NHS, ' he says.
He points to lower waiting times in other parts of Europe, adding: 'In the US, there are no waits.'
An international precedent has already been set. In March, 12 hospitals in Quebec, Canada, were presented with a mass lawsuit on behalf of 10,000 breast cancer patients who had waited more than eight weeks for radiotherapy.
If it goes to court, the case could be one for the UK to watch.
Charity case: are cancer targets the right ones?
CancerBACUP's document follows Left in the Dark, a report published by charity Breakthrough Breast Cancer which focused on the two-week wait target for urgent cancer referrals.While urgent breast-cancer patients can expect to see a specialist within two weeks and hopefully have treatment within two months as 2005 draws to a close, Breakthrough estimates that 10,000 nonurgent cases per year could wait months even to reach secondary care, as the universal onemonth rule kicks in only after diagnosis.
Breakthrough chief executive Delyth Morgan says: 'We need to look at the fact that some women are waiting as long as 17 weeks to see a consultant.'
Macmillan Cancer Relief medical director Dr Jane Maher says the one and two-month waiting targets may not pick up lengthy waits for follow-up treatment.Patients suffering from cancers of the breast, prostate, lung and cervix, for example, will not be monitored for radiotherapy waits beyond the 'first' treatment, as recorded under the targets.
Concern over issues like this has sparked a decision by the Commons all-parliamentary group on cancer to launch an inquiry into cancer services, beginning next month.