CANCER SERVICES: Primary care groups/trusts have a key role to play in addressing inequitable distribution of cancer services. But a survey shows that commissioning cancer services is being given low priority. Cathy Shipman and colleagues report.

One third of the population in a primary care group/trust are likely to develop cancer at some point in their lives.

Some 400 people may become newly diagnosed with cancer and 280 may die each year.

1The national cancer plan has highlighted the inequitable distribution of cancer, mortality and access to services.

2Primary care groups/trusts have a key role to play in addressing such inequalities. To shape cancer service provision, they can support GP and district nurse professional development and undertake clinical governance activities, based on performance indicators.

There is evidence that two-week referral guidelines on breast cancer, introduced in April 1999, are now bearing fruit, with more GP referrals to specialists reported in the last quarter of 2000 than ever before, and more urgent referrals for attention within 24 hours.

3PCG/Ts also have a key role to play in cancer networks, contributing to the commissioning and provision of cancer services. Lead clinicians, to be funded by the Department of Health with a support and development programme funded by Macmillan Cancer Relief, will facilitate participation in networks, improving the knowledge base of primary care, improving support to patients and families and enabling good communication between primary, secondary and tertiary services and the voluntary sector. In March the Department of Health announced that each PCG/T will receive£5,000 to support the cancer lead project.

4However, the brief of PCG/Ts is wide, and cancer service development has strong competition from other priorities in health improvement programmes, national service frameworks and primary care provision.

5Continuous organisational change has also occupied much time and energy, particularly with the move to trust status. This new status will enhance the commissioning power of PCG/Ts, which will take responsibility for commissioning most of their community and hospital services. But it will be interesting to see what role PCG/Ts will independently play following the cancer network commissioning pilots. The objectives of the national cancer plan are visionary and challenging, but it is important to understand the priority PCG/Ts attach to cancer service development to consider when results can be achieved.

Last year Macmillan Cancer Relief commissioned a survey of PCG/Ts in London, the South East and East Anglia to ascertain intentions regarding trust status, planning and commissioning of cancer services and support needs.

In the survey,130 PCG/Ts were identified. A postal questionnaire was developed following pilot interviews. A total of 93 (72 per cent) of PCG/Ts responded: 13 were PCTs and 34 anticipated becoming PCTs in April. Some 28 of these 34 PCGs have now become trusts.

Sixty five (72 per cent) of respondents identified lead people with responsibility for developing cancer services. Almost half (11/23) of those without cancer leads said that they worked with cancer leads from other PCG/Ts. Identifying a cancer lead did not always indicate work in hand, however. Absence of a lead did not necessarily indicate lack of work, as this commitment could be taken on by another PCG/T member - for example, the commissioning manager.

Most respondents (93 per cent ) said that they were involved in developing plans and three-quarters (78 per cent) were involved in some form of commissioning. But we do not know the extent of involvement: this could be substantial, or it might simply require occasional attendance at meetings.

Commissioning is complex and lead involvement could depend on the configuration and geography of local services. Where services were provided by a hospital outside the PCG/T boundaries, the lead could be taken by another PCG/T.

Commissioning included negotiation with trusts and health authorities (who often continued to maintain a lead) and could be more complex and timeconsuming where a number of hospital services were provided within PCG/T boundaries in inner city areas.

Developing and implementing referral and treatment guidelines was the most frequent focus of work, particularly concerning the twoweek wait for breast cancer referral. But only 19 PCG/Ts described cancer as within their top four priority areas, in comparison to coronary heart disease/stroke (51) and mental health (37). Other areas of cancer-related work included participation in networks, improving the take-up of screening, particularly for breast and cervical cancer, and supporting smoking cessation.

Sixty four (81 per cent) of respondents said that they were working with other PCG/Ts on cancer service provision. Some commented that cancer service provision was too extensive an undertaking for one PCG alone.

Over three-quarters (81 per cent) said that they had representation on some form of cancer network, cancer collaborative or managed clinical network. But there seemed to be confusion over the title and remit of these different groups. For some respondents, representation could be through consultants or indirectly through local cancer implementation groups.

PCG/Ts were asked whether they would like help and assistance in developing cancer services. Thirty five (42 per cent) said yes, 13 said no, and 36 said later. The stage of development of a PCG/T was associated with preference for information. A higher proportion of PCTs and PCGs expecting to become PCTs in 2001 wanted information immediately. The type of support requested included examples of good practice, standards for benchmarking, employing Macmillan Cancer Relief GP facilitators, managing cancer patients and supporting carers at home, and education and training of staff. When asked about topic preferences for attending seminars to support cancer service development, 65 said they were interested in developing services within the community and 53 said they were interested in developing relationships between primary and secondary care.

Forty one respondents said that Macmillan postholders were involved to some extent in cancer service planning. These were mainly nurse specialists. Preference for information, however, primarily concerned learning more about GP facilitators, requested by 39 respondents.

For many PCG/Ts, requirements of the national cancer plan came at a time when they were facing further organisational change. Final comments indicated other obstacles confronting them.

Concerns about the need for adequate funding were raised, together with difficulties arising from having insufficient staff. The enormous agenda of work could be driven by national priorities in competition with local needs. Challenges in developing cancer services included the need to integrate services across disciplines and agencies, to equalise variations in service provision across and between PCG/Ts, and to break down barriers between generalists and specialists.

It is encouraging to see that most PCG/Ts are establishing structures for developing and commissioning cancer services through identifying members with lead responsibility for cancer.

Macmillan Cancer Relief and the DoH are developing the role of lead clinician within PCG/Ts.

These postholders will facilitate improved knowledge about cancer, better communication between healthcare professionals and greater involvement in commissioning, partly through representation on cancer networks.

2It remains to be seen, however, how much influence each PCG/T may wield in what is essentially a large virtual organisation.

There remains some confusion about the title and remit of cancer networks.

More information is needed about the role and potential of cancer networks to maximise the benefits of primary, secondary and tertiary collaborative commissioning. Macmillan Cancer Relief has arranged workshops in the region for cancer leads and networks, to raise the profile and enable cancer development at PCG/T level.

While many PCG/Ts reported some involvement in planning and commissioning, cancer was not a high priority. Priorities appear to be the result of national initiatives and, for many, concentrated on the two-week referral guidelines for breast cancer.

The national cancer plan was published shortly after the survey, and this may stimulate activity.

However, given the onerous workloads placed on PCG/Ts and, for many, the move to trust status, substantive work to implement the core initiatives may still be some time ahead. Many PCG/Ts wanted help and information to develop cancer services, but some preferred to wait for it.

Increasing numbers of PCTs in April will, however, have enhanced overall commissioning power. This may enable substantial progress to be achieved. Whether PCG/Ts will be able to address local needs, given the more global responsibilities of cancer networks, remains to be seen.

Key points

Most primary care groups/trusts have cancer lead posts and have some involvement in planning and commissioning cancer services.

Cancer is not a high priority in comparison to other national service frameworks and the transition to PCT status.

PCG/Ts want help and information about developing cancer services but not all want this now.

Most PCG/Ts have some involvement in cancer networks but information needs exist about their role and potential.