Last week the government promised a further £370m to reform cancer, with a focus on prevention and shorter hospital stays. But selective fast-tracking plans have drawn criticism. Claire Laurent reports
The Cancer Reform Strategy, published last week, puts prevention at its heart.
Improving education, raising public awareness, further curtailing smoking and increasing access to screening were put forward as the ways to boost prevention (for more background, click here).
The treatment focus will be on radiotherapy and surgery rather than expensive drugs. Patients with cancer can expect to spend less time in hospital, receiving more care at home or in hospital day care. Length of inpatient stays for surgery, already becoming briefer as techniques and management improve, are expected to fall further.
The strategy also calls for a reduction in the time from when the decision is made to treat a patient to the start of treatment. By 2010, no patient should wait more than 31 days for any treatment to start.
The government is investing£370m up to 2010 to back up the strategy. At the same time trusts will be expected to save£320m over the next three years by cutting unnecessary hospital admissions and the length of hospital stays.
Building on success
National cancer director Professor Mike Richards says the strategy is building on substantial progress made over the past seven years. 'It recognises the challenges and new opportunities and it sets a clear direction for the next five years with a commitment to develop world class cancer services.'
However, shadow health secretary Andrew Lansley claimed last week that the publication of the second cancer strategy was an admission that the first had failed. 'The UK is still lagging behind the rest of Europe in cancer survival rates.' He accused the government of 'raiding public health budgets in recent years to fund NHS deficits' -at odds with a strategy of prevention. 'The government must prioritise public health if we are to have improved obesity rates, fewer people smoking and other preventive measures to beat cancer,' he said.
The Conservatives are critical that only breast cancer patients benefit from a two-week referral target - now expanded to include all breast referrals, suspicious or not - while other cancers are not fast-tracked.
NHS confederation policy director Nigel Edwards shares this concern as the benefits of earlier diagnosis grow more apparent.
Levelling the field
The strategy sets out two central ways to improve prevention and achieve earlier diagnosis: an emphasis on good data collection and a concerted effort to address the health inequalities prevalent in cancer, including age, gender, deprivation and ethnicity.
'Inequalities need to be tackled at both a national and a local level,' says Professor Richards. 'It's about access and it's about working in the community to explain, drive and screen and in many cases, let's say with breast cancer for example, explain that the mammography will be undertaken by women. In terms of inequality we do need to collect better data so we can understand where the problems are.'
A national cancer equality initiative will be launched bringing together health professionals, the voluntary sector, academics and equality groups to make the best use of data.
Professor Richards says: 'If we collect good data we can then feed it back to the clinical teams and trusts. There is a lot of evidence that feeding the data back drives up quality. Commissioners need good data as it is fundamental to strong commissioning and if we want to empower patients to make choices we have to have good data.'
Mr Edwards says to meet the challenges of the strategy, primary care trusts have to develop the skills of world class commissioning. As PCTs, other trusts and cancer networks have to work together, he says the strategy 'requires quite a high level of co-operation between organisations that have traditionally regarded themselves as competitors'.
A cancer commissioners' guide is being developed, with an electronic toolkit to provide comparative data on cancer incidence, survival and mortality rates.
Leicester, Northamptonshire and Rutland cancer network director Dr Elspeth Macdonald says cancer networks need more funding to support commissioning. 'Cancer networks are a body of expertise that support a cluster of PCTs. That has to be recognised as a resource that needs support.'
She welcomes the emphasis on data collection but calls for it to be mandatory and as near 'real time' as possible. 'For data to have a real impact it's got to be faster and more timely and it needs leadership.' She says chief executives have to be held responsible for data collection if it is to become a priority.
Professor Richards says national contracts will enforce data collection. Multidisciplinary teams will be required to collect data on case-mix and disease staging and feed this through the cancer registries and audits. 'We are looking for a step change in the quality of data collection and I believe this will be welcomed by clinical groups,' he says. 'It will be defined in the national contracts and so be a part of the commissioning of cancer services.' He says funding to cover this work will be covered by the strategy.
Breast Cancer Care joint chief executive Christine Fogg says the charity, together with 'a growing group of patients living with incurable breast cancer', would welcome plans for better data collection.
'Currently secondary incidence of cancer is not recorded and we have been campaigning for this to change,' she says.
She also welcomed the emphasis on specialist cancer nurses: 'Our research has found that the emotional and practical support these nurses can provide is invaluable,' she says.
The commitments of£100m for digital mammography, with promises for new radiotherapy equipment and staff (£200m) have been widely welcomed by patient groups and professional organisations. Professor Richards says that these will be funded through the comprehensive spending review and will be 'available out there in the NHS'.
The£320m efficiency savings trusts are expected to make over the next three years are 'absolutely possible', he says and 'in many cases this is not about closing beds'.
Pilot programmes in 40 trusts have all shown benefits for patients in streamlining care, he says. Reduced inpatient days for women's breast cancer surgery is a case in point: breast cancer service activity levels have risen by 35 per cent but bed days have risen only by 1 per cent,' says Professor Richards.
Other patients would benefit from 'dedicated day units' where patients could be started on antibiotics or have their pain brought under control with the aim of going home within hours.
Dr Macdonald says multidisciplinary team discussions have improved decision making for individual patients and she would like to see them properly remunerated - at present they are not covered by a tariff.
Professor Richards says there is a commitment to review tariffs where necessary. 'We don't want centres that are taking on the complex surgery for cancer to be disadvantaged,' he says. However, 'at the moment there is a disincentive to manage patients outside hospitals'. For example, there is no tariff for following patients up by telephone.
Professor Richards is clear that tariffs will be changed to reflect the wider aims of the strategy. 'We want to make sure the tariffs help to drive care in the most appropriate settings.'
Cancer strategy: key points
Consultation during 2008 to increase tobacco controls. Possible ban on cigarette machines.
Sunbed regulations review.
A campaign to improve public understanding of the effects of alcohol.
Vaccination for young girls against the human papilloma virus.
£100m investment in digital mammography to extend women's breast screening from age 47.
Bowel screening extended to all aged 70-75 from 2010.
Research to be commissioned into the feasibility of a UK trial of CT screening for lung cancer.
£200m investment in radiotherapy equipment and staff.
New cancer drugs to be appraised by the National Institute for Health and Clinical Excellence and approved for licensing simultaneously.
Waiting times for any treatment to come down to 31 days.
Awareness campaign: cancer equality
July 2008 will see the first black and ethnic minority cancer awareness week. Organised by Cancer Equality, a charity that works to address the inequality in cancer care experienced by those from black, ethnic minority and refugee (BMER) groups, the week will be about raising awareness of cancer among these communities and providing information and education about signs, symptoms and prevention as well as access to services.
Cancer Equality chair Madhu Agarwal, who is also Macmillan cancer information manager at the Homerton Hospital, Hackney, says work is needed at all levels to reach people. 'BMER communities are presenting with cancer late due to various reasons,' says Ms Agarwal. 'These may be socio-economic: they may have employment issues, housing problems, childcare problem or resettling issues and as a result health is on the back burner. Screening uptake is low among the BMER communities for the same reasons.'
In addition, she says, 'services are not always culturally appropriate'. For example, she says in some communities people are not allowed to cut their hair so coping with loss of hair due to chemotherapy needs to be understood by staff and patients.
Ms Agarwal says that sustained funding is essential. 'There is a lot of excellent work but when the funding dries up we lose it [the education provision].' She gives the example of a palliative care video that is no longer funded by her PCT. 'We are still struggling with end-of-life issues for BMER communities because often services are not culturally appropriate for them. We have a copy to show people but can no longer give them a copy to take home.'
She welcomes the emphasis on data collection: 'If we don't have the data we don't know which areas to be aware of but at the same time we need to deliver.'