The cancer care pathway is in a state of confusion, with various organisations responsible for different elements. NHS England urgently needs to to clarify and allocate responsibility to make sure no patient is forgotten, argue Mike Hobday and Katharine McDonald
Over a year on from the major restructuring of the NHS, new qualitative research from Macmillan Cancer Support and the OPM shows that cancer commissioning is in a state of confusion and uncertainty.
‘It is inefficient that commissioners at CCG and specialised level are not working together’
One commissioner told us: “It’s hard to say what’s going on… I don’t think anyone has an overarching view or overall control [of commissioning anymore]”.
Worryingly, this seems to be a common response from clinical commissioning groups, health and wellbeing boards and local area teams alike.
Under the old system, each primary care trust established specific roles responsible for commissioning cancer care. Alongside these, cancer networks existed to provide additional expertise, focus and oversight of the whole patient pathway, from cancer prevention to end of life care.
Today, the picture is much more complex. A number of different organisations are responsible for commissioning different aspects of cancer care. Early stages of treatment fall to CCGs, although in some areas they devolve much of their responsibilities to commissioning support units.
Specialist services are commissioned by local area teams and the responsibility for prevention and awareness raising falls largely to Public Health England.
Unblock the pathway
We think it is inefficient that commissioners at CCG and specialised level are not working together and this is likely to have a severe impact on cancer patients. Our research shows that CCGs are concerned this splitting up of commissioning responsibilities makes it more likely that patients will face unnecessary delays in diagnosis and accessing treatment.
For example, information about a patient’s needs could get lost in communication between professionals in two different organisations, or one organisation might fail to pick up a patient’s referral from another in a timely manner.
One commissioning and planning director said: “If a patient has cancer today… their journey will have followed [PHE] all the way through to my services, all the way through primary care – which I don’t commission – all the way to generalist care, which I do commission. But for certain specialist parts of that it’ll go to… NHS England. So to have a neat pathway for care is a challenge at the moment.”
Commissioners hold the power
Within this context of fragmentation and the narrowing area of responsibility that each commissioner has, there is also confusion among many CCGs about what their role and responsibility covers. A CCG chief operating officer said: “What bits of cancer services are we actually responsible for commissioning? What is our responsibility? In all honesty, we don’t really know.”
Macmillan is concerned this confusion means some parts of the pathway are being neglected. In particular, the vital parts of patient support that come before and after cancer treatment: prevention, screening, aftercare and end of life care. For example, screening drives are sometimes neglected due to confusion about whether they fall under the remit of PHE or CCGs.
It is concerning that some CCGs even hold the view that all, or most, cancer treatment will be commissioned by others.
Britain currently has some of the worst cancer survival rates in Europe and we cannot afford to see cancer neglected.
We want NHS England to:
- urgently clarify cancer commissioning responsibilities;
- allocate responsibility to a person or body to have oversight of the whole cancer pathway; and
- provide adequate resourcing to ensure cancer commissioning is at a high standard.
Most important are the changes that commissioners can make on the ground. Despite the current confusion, it is within their powers to make a change.
Our findings also show that commissioners that have established a network of stakeholders – meeting regularly to discuss cancer with people from multiple CCGs, acute providers, public health, CSUs, relevant charities, their local area team, and Macmillan GPs and nurses – felt their cancer commissioning was more effective. They also had a better understanding of their role and how to make the best impact in their local health system.
‘People affected by cancer have told us they want support on all aspects of the impact of cancer’
We are encouraging CCGs, area teams and local authorities to follow the lead of these areas and establish strong co-commissioning relationships. It is essential commissioners speak to each other and ensure all aspects of the cancer pathway are being covered so no aspect of treatment - and no patient - is forgotten.
It is vital we see this commitment and action happen sooner rather than later. The number of people living with cancer is growing rapidly – it is expected to double from 2 million to 4 million by 2030, and the NHS budget is tightening.
People affected by cancer have told us they want support on all aspects of the impact of cancer, and we cannot continue to fail a growing number of people. Commissioners, decision makers and politicians have a responsibility to make sure this happens.
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Mike Hobday is director of policy and research, and Katharine McDonald is senior policy analyst at Macmillan Cancer Support