Cancer is changing. The old ‘die or cure’ paradigm no longer holds. There is an increasingly sizeable section of the population who have survived cancer but who are still unwell. Until now the NHS hasn’t been good at supporting cancer survivors to live well after treatment. But all this could change with the publication last month of the Independent Cancer Strategy Taskforce’s blueprint for achieving ‘world class cancer outcomes’. In future the outcomes which the NHS will be aiming to achieve will include quality of life as well as length of survival.
Achieving World Class Cancer Outcomes: A Strategy for England 2015-2020 is a hugely ambitious document which has prompted some critics to question whether, in the current economic climate, the NHS can afford the cost of implementation. A better question would be: ‘Can we afford to do nothing?’ The answer is an unequivocal ‘no’. It’s a scandal that survival rates in the UK continue to lag behind the best performing European nations. It’s also a false economy. If cancers are diagnosed later not only are outcomes likely to be poorer but treatment costs are generally higher. There’s also a powerful economic rationale for improving aftercare. There are 2 million people living with cancer in England, one in four of whom will have treatment-related long-term effects and 70% have one or more long-term health conditions. The increasing numbers of people living with cancer and trying to cope with the physical and psychological effects of cancer treatment will place an intolerable strain on health and social care services unless we can support cancer survivors to live well, manage their own condition and stay out of hospital.
The report proposes a series of measures aimed at preventing cancer and diagnosing patients earlier. These include reducing smoking prevalence to less than 13% by 2020, ensuring that 95% of patients are diagnosed within 4 weeks of GP referral. The new 4-week target is massively ambitious and, in order to realise this ambition, the report calls for an increase in diagnostic capacity, direct GP access to key diagnostic tests and the trialling of new models – such as multidisciplinary testing centres – which can facilitate earlier diagnosis. These measures will require significant investment, as will the proposed replacement of over 100 linear accelerators with new, state-of-the-art equipment.
Inevitably, the headlines have focused on the ambition to save more lives – the report estimates that by 2020 up to 30,000 additional people could survive for 10 years or longer each year if its recommendations are implemented and ambitions met. However, while saving lives is an absolute imperative, what’s really radical about the proposed strategy is the recognition that people with cancer must be enabled, not just to live longer, but to live well after treatment. One of the potentially game-changing proposals in the report is the development of a new ‘quality of life’ metric for cancer. At present the NHS primarily measures the length of survival, not the quality of a person’s life. Why is a quality of life metric important? Firstly, it is a very significant statement of intent; it signals that the job of the NHS isn’t just to treat the disease but also to enable people to live healthy, fulfilling and productive lives after treatment. This isn’t just good news for patients, it makes good economic sense. If people with cancer are equipped to live well and manage their condition, it should reduce downstream costs to the system and provide economic benefits to wider society.
Secondly, a quality of life metric should serve to incentivise the radical overhaul of ‘follow-up’ and the development of new aftercare services envisaged in the report. It is proposed that the NHS rolls-out the ‘Recovery Package’ and ‘risk stratified pathways’ across the country. What this means in practice is that, in future, patients won’t just be abandoned at the end of curative treatment and left to cope on their own. It means that all patients will have a post-treatment care plan; they will be supported to manage the potentially debilitating effects of treatment, such as chronic fatigue or breathlessness, they will be remotely monitored and they have rapid re-entry back into acute care if symptoms reappear. There is strong evidence that this approach delivers better health and well being outcomes without additional cost.
Another strategic priority that will be transformational is the proposal that patient experience should be accorded equal status with clinical outcomes and safety. Why does this matter? One of five patients, surveyed in 2014, said they felt treated like a set of symptoms rather than a person. This is simply not acceptable. The scandal at Mid Staffordshire NHS Trust starkly illustrates the dire consequences of allowing a culture of compassionate care to erode. The report proposes a set of measures to ensure that patient experience is hardwired into the culture of the NHS. This means that the Cancer Patient Experience Survey (CPES), a tried-and-tested improvement tool, will be conducted on an annual basis, and that the survey data will be supplemented by a broader set of patient experience metrics designed to drive continuous improvement.
As I said, the vision is massively ambitious. That’s why there need to be strong ‘enablers’ in place to ensure the strategy is more than just a set of warm words but capable of delivering real change. It’s therefore very encouraging that workforce features prominently in the Taskforce’s six strategic priorities. The current cancer workforce is ill equipped to cope with today’s challenges, let alone tomorrow’s. The Taskforce proposes a more strategic approach to workforce development – something that has been sorely missing in recent years. This means addressing the workforce deficits, for example the shortage of radiologists and clinical nurse specialists (CNS). It means getting the skill mix right and developing new roles, such as 1-2-1 support workers, who can coordinate care and can free up valuable CNS time. And it means equipping the workforce with the skills to work in new ways, i.e. to facilitate shared decision-making and support patients to self-manage.
Another key enabler is boosting local NHS improvement capability. It’s obvious that Strategic Clinical Networks, established in the 2013 NHS restructure, simply haven’t been equipped with the right resources to deliver large scale change programmes, such as pathway redesign care or integration of health and social care. The Taskforce report proposes the creation of new regional ‘Cancer Alliances’ which are ‘properly resourced’ to drive change and ensure local integration of services.
The Taskforce has produced an exciting and ambitious strategic vision which addresses ‘what’ cancer care in England ought to look like as well as ‘how’ we can deliver the key recommendations. The report provides the blueprint for change. Now we must hold the NHS to account to deliver.
‘A Cancer Strategy for England: turning ambitions into reality’ was authored by Duleep Allirajah, Head of Policy at Macmillan Cancer Support.