Published: 25/11/2004, Volume II4, No. 5933 Page 1 2
On its four th anniversary, The national cancer plan can be satisified that it has won glowing praise for spurring cancer services into excellent improvements, but the report card for PCTs is still a cause for concern.
Rebecca Coombes investigates
Four years after the publication of the NHS cancer plan, there have been major improvements in services for patients. But some people doubt whether every cancer target is really being met and sustained in all areas of the country, and if future targets will be met at all.
Several recent reports have identified key stumbling blocks to national progress. Although strategic health authorities are working hard to improve performance in crucial areas such as usage of National Institute for Clinical Excellence-approved drugs, whole-systems concerns remain. There are doubts, for example, as to whether primary care trusts are up to the task of funding such a specialist service.
A recurrent message is that lack of resources is no longer the main barrier to progress for cancer services. Instead, shortages of staff and NHS bureaucracy are the more likely culprits.
As HSJ reported earlier this month (news, page 9, 4 November), national cancer director Professor Mike Richards has admitted the government may not hit its ambitious target for a maximum wait of two months from urgent referral to treatment for all cancers by December 2005. 'There is no doubt about the scale of the challenge on this one.
About 78 per cent of patients are now being seen in this time... I do not think we will get 100 per cent, but we can do a great deal better.' On the positive side, the NHS is well over half way to meeting a 2010 target to reduce the death rate from cancer for the under-75s by at least a fifth. With six years to go, deaths have fallen by 12.2 per cent since the 1996 benchmark.
Professor Richards points to other key areas of progress. 'I would highlight screening - screen detection of breast cancer has gone up by 13 per cent in the last year. Evidence this summer about cervical screening has led us to revise upwards the number of lives saved. And we have just announced the bowel cancer screening programme.' That programme - aimed at cutting deaths by 15 per cent - will begin in April 2006, a timetable Professor Richards acknowledges as tough but achievable.
There is also no doubt the cancer workforce has grown, although results in areas such as radiology have been disappointing, says Professor Richards. 'We have increased capacity in the system. There is a third more cancer specialists - 925 more. We have a target of 1,000 extra by 2006 so we are very close to that, about two years ahead.' Hopes are being pinned on newly trained staff in areas such as endoscopy (345 new staff by the end of March 2005) and an increase in training places for radiology.
Despite these steps forward, several reports in the last six months have highlighted major obstacles to achieving a uniformly good service for cancer patients.
The latest Breast Cancer Care Listening and Talking bulletin, which pulls together concerns of patients in contact with the charity, found people are still affected by the lack of support services and delays to screening and radiotherapy.
Despite the target to invite every woman aged 50-70 for breast screening every 36 months, in places like east Devon the interval is already up to 42 months. In one reported case in Essex, women are still making 60-mile round trips to access radiotherapy services.
The reasons for such delays were partially explained in last month's report into cancer services by the all-party parliamentary group on cancer. The Future of Cancer Services in England found that the passing of financial control to PCTs has caused confusion while staff learn the systems. MPs criticised PCTs as 'unequal to the task' of spending the vast amount of public money being pumped into cancer services. The group said they were hindering progress towards eliminating postcode prescribing and ending delays in diagnosis and treatment by their lack of experience and expertise.
For example, the task of purchasing specialist radiotherapy equipment was made needlessly complicated and lengthy because up to 16 PCTs could be involved in one purchasing decision.
Funds destined for cancer networks have not always been forthcoming from PCTs because of competing priorities, it found.
It said cancer services needed specialist commissioning and that the job should instead go to England's 34 cancer networks - which have a remit to plan, co-ordinate, deliver and monitor cancer services but do not hold the purse strings.
The government takes the line that it is still early days for PCTs. Health secretary John Reid said he was 'not persuaded that [the report's recommendations] are better than what we are doing.' And Professor Richards pointed out that PCTs 'are young organisations... they have had to learn a lot about cancer.' He went on to say that they are still 'on a learning curve'.
SHA chief executives are currently reviewing how PCTs commission specialist services and are looking at how to strengthen the partnerships between PCTs and clinical networks.
One problem the Department of Health is alert to is the need for SHAs to be clearer with PCTs about the importance of meeting national targets, and to help 'unblock' things that get in the way of that.
One area where SHAs have been spurred into action recently is in the usage of NICE-approved cancer drugs. A report by Professor Richards in June showed unacceptable variations in approved oncology drugs. It found a lack of capacity, variation in prescribing by clinicians and the need to improve commissioning. There was also little information collected by the DoH on local prescribing patterns.
Six months on and SHAs that underperformed in the report have reviewed their position and are developing action plans. 'So far the SHAs are confident that inequalities are being reduced and that appropriate patients will be getting the NICE drugs, ' says Professor Richards.
For example, Shropshire and Staffordshire SHA performed well in the report, but for three NICEapproved oncology drugs it scored below the national average. The drugs were gemcitabine, used for lung and pancreas cancer; and pegylated liposomal doxorubicin hydrochloride and topotecan, both used in cases of ovarian cancer.
Barbara Newns, head of clinical networks and SHA cancer lead, has just completed the authority's review and says it was interesting to find that there were no financial restrictions on using these drugs in any of the regions it is responsible for. Instead, it appeared that variations were the result of prescribing decisions. This has in part been remedied by recruiting an extra oncology consultant in north Staffordshire, since when the use of gemcitabine has risen.
Ms Newns adds that a new oncology pharmacy group is to draw up network-wide protocols.
'There will be a dedicated pharmacist, who has yet to be recruited, and representatives from NICE implementation groups in the SHA area.
'The pharmacist's job will be ensuring equality of access to treatment for all cancer patients. The group will audit usage of drugs, so we know who is prescribing what. They will also agree standards on how to implement NICE drugs. So one consultant can't say, 'I am not going to use that drug.'' At a national level, the DoH is developing a capacity model to help local areas gauge the impact of NICE guidance on pharmacists, nurses, oncologists and capacity in oncology suites.
Professor Richards adds that, 'to the best of my knowledge' electronic prescribing for chemotherapy will be achieved by 2006. This will provide better information on which patients are getting chemotherapy for which conditions.' Only half a dozen areas are currently using electronic prescribing in limited form. In the meantime SHAs such as in Surrey, West Sussex and Hampshire have secured Macmillan cancer network pharmacy posts to gather better data about local prescribing patterns. Royal Surrey county Hospital trust oncology pharmacist Jackie Turner said the big improvement would come with electronic prescribing.
Professor Richards is keen to emphasis that 'overall' progress on the cancer plan is good. 'You must think of it in its entirety, ' he says. 'It is worth remembering how much work has been done.
Look at breast screening. With the new targets we have seen a 40 per cent increase in screening.
It is a very big change.'
THE ROYAL MARSDEN FOUNDATION TRUST
LOCAL ACTION TO MEET CANCER TARGETS
Breast cancer clinicians responsible for one of the country's largest chemotherapy practices at the Royal Marsden foundation trust, expressed a wish to transfer part of their intravenous-based chemotherapy practice to an oral form of chemotherapy in line with new evidence.
This evidence suggests oral-based chemotherapy treatment has several advantages for patients - reducing the amount of time a patient spends in hospital receiving treatment and reducing the need for minor surgery (intravenous chemotherapy involves the surgical insertion of Hickman lines).
Nicky Browne, director of strategy and service development, said the introduction of this treatment had an additional advantage for the trust - freeing up theatre capacity.
She says: 'This was particularly important since the Royal Marsden sees approximately 500 patients with newly diagnosed breast cancer each year and has been seeing a marked growth in the number of new patients being referred with suspected breast cancer due to rationalisation of breast services within our area.
'The extra theatre capacity was sufficient to enable the trust to provide an additional theatre list for breast surgery, which in turn helped the trust to meet the new cancer plan targets - offering newly diagnosed breast cancer patients treatment within 31 days of the decision to treat and within 62 days of an urgent GP referral.'
Key points
Despite progress in some areas, major obstacles to achieving a uniformly good service for cancer patients remain.
PCTs' lack of expertise is holding back progress on ending delays in diagnosis and treatment.
SHAs need to be clearer with PCTs about the importance of meeting national targets.
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