Monthly Archives: November 2016

Can Cancer Alliances live up to expectations?

In our first look at the state of Cancer Alliances, Niamh Kelleher and Louisa Petchey ask how they can cope with the weight of responsibility that is being placed on their shoulders

24 November, 2016

Map of Cancer Alliances

16 Cancer Alliances have been set up across England to deliver the Cancer Strategy (Source: NHS England)

The UK’s population is getting bigger and it is getting older. That means more people than ever before are being diagnosed with cancer. But thanks to improvements in treatment, more people are surviving.

While this is obviously great news, it doesn’t mean the pressure on our health system is any less, it is just different — and potentially even greater and more expensive.

Eye on the prize

As set out in the Cancer Strategy for England in July 2015, we want our health system to deliver world class cancer outcomes by 2020, not just in terms of survival but quality of life. If this ambitious vision is to be met, there is much to do and it is not going to be straightforward.

There are now an array of ‘place-based’ policy initiatives — new models of care, vanguards, and Sustainability and Transformation Plans — all trying to find a way to improve care for their communities while often significantly reducing costs. It is important that during this challenging time we don’t allow ourselves to lose sight of or compromise the recommendations in the Cancer Strategy.

A long to-do list

That is where we are hoping Cancer Alliances will come in. Cancer Alliances have long been a priority for Macmillan. We view them as a vital for providing effective oversight and co-ordination of the whole cancer pathway at a local level. Among other things, they should:

  • drive the delivery of national strategies and priorities
  • ensure meaningful user involvement takes place
  • promote whole-system coordination
  • provide strategic support and leadership
  • facilitate alignment and support local providers
  • support cost efficiency within local systems

So we were pleased to see in their response to the Taskforce report that NHS England share this view and that Cancer Alliance “footprints” have now been announced.

Will Cancer Alliances deliver?

But how confident can we be that Cancer Alliances will live up to the weight of responsibility that is being placed on their shoulders to deliver the Cancer Strategy?

Their task is no easy one. They are being expected to come up with a plan for the future of cancer care tailored to the needs of their local population, involving local people while also coordinating day-to-day improvements in cancer care and support. This includes working with multiple commissioning bodies, potentially dozens of providers and, most difficult, ensuring the transformation of cancer care and support in their area’s Sustainability and Transformation Plans (STPs); a process that in itself has been fraught with controversy and difficulty. All of this is expected with limited resource or dedicated staff time.

Reasons to be cheerful

But there are several important reasons to be optimistic. For one thing, Cancer Alliances exist. So now at least we have a structure that can focus on driving improvements in cancer care in an ever-changing environment. And amid so much negative publicity about planning rounds with STPs and service transformation, Cancer Alliances now have a unique opportunity to lead the way in working collaboratively with their communities.

We also expect that NHS England will soon make money available to Cancer Alliances so they can make improvements to diagnostics and ongoing support for people beyond the end of active treatment. This will be the first time we get to see Cancer Alliances in action, spearheading the transformation of cancer care in line with the Cancer Strategy recommendations.

Big test

Cancer Alliances will soon need to face their first big test since their footprints were announced. No two Cancer Alliances will be facing the same challenges, from the differing needs of their local cancer population to the impact of STPs on their local area. We will be looking on with expectation and qualified optimism — and as ever, Macmillan will be working with the rest of the cancer community to help make a success of the Cancer Strategy.

Niamh Kelleher and Louisa Petchey are Policy Analyst and Senior Policy Analyst (respectively) at Macmillan Cancer Support

The NHS in England may be struggling to meet even relaxed cancer targets

18 November, 2016
James Shield, Senior Policy Analyst  |  @jshield

The NHS in England has now failed to meet a vital cancer target in all but one of the past 29 months — and on the latest evidence, it is struggling to meet even the relaxed targets set by NHS Improvement this July.

Recognising the problem in hitting the national target to treat 85% of patients within 62 days of an urgent GP referral, NHS Improvement put the previous system of fines on hold. Instead, most trusts now have an ‘improvement trajectory’ to meet, tied to a bit of extra money from a ‘sustainability and transformation fund’. Out with the stick, in with the carrot.

Uphill battle

It’s too early to say whether that approach will work in the medium term. But what we do know is that NHS Improvement appears to have a bigger challenge on its hands than it might have thought.

Here at Macmillan, we’ve been comparing actual performance against this target with the ‘improvement trajectories’ for the first quarter of this new system — July 2016 to September 2016 (the most recent stats available).

Waiting times chart - for twitter.png

The actual picture differs in two important ways from what NHS Improvement wanted to happen by this point:

  • Many more trusts failed to meet the national target than NHS Improvement expected. By this point, just over 20% of trusts were expected to be missing the national target, leading into a period of recovery over the winter. Instead, it was more like half in July, August and September.
  • We may be seeing a divergence among trusts, between those persistently missing the target by a wide margin, and those meeting it by a comfortable margin. Such a wide divergence has implications for the way improvement funds are allocated.
Waiting times table - for twitter.png

Phantom carrot

Previously, trusts were fined for missing these targets. But since July, each individual trust can be rewarded for staying on their improvement trajectory with a pay-out from the £1.8bn Sustainability & Transformation Fund. 5% of that fund (or about £90m) is linked to this cancer target.

The idea is that rather than taking money away from struggling trusts, they should be helped to get back on track — a carrot rather than a stick — and between July 2016 and March 2017, much of the country is supposed to have recovered.

But according to our analysis, more than half of trusts (56%) could be at risk of missing out on this money, at least for the most recent quarter.

The rules go like this: in Q2 of 2016/17 (July to September), trusts need to be within one percentage point of their trajectory to get the pay-out. This then ratchets up to half a percentage point in Q3, until the ‘tolerance’ disappears entirely in Q4.

However, fewer than half (44%) of trusts were near enough to their improvement trajectories from July to September to qualify. Our estimate of the amount of money that might be withheld from these trusts during Q2 puts the figure at around £12.7m, though it’s hard to know for sure.

Reality check

It is too early to say whether this picture will improve as we move further into the winter. Early signs appear to be that the NHS is struggling even to meet relaxed targets. And perhaps more worrying is that these targets are being missed by so wide a margin that many trusts could continue to miss out on the money they need to improve, trapping them in a cycle of missed targets.

Macmillan will continue to speak out on behalf of the thousands of people who continue to wait too long to start treatment. We’d encourage NHS Improvement to keep a close eye not only on the targets, but also on whether its system for supporting trusts to get back on track is working.

With thanks to Samuel Jones in Macmillan’s Evidence department for help with data analysis

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1) Not all trusts have ‘performance trajectories’ in NHS Improvement’s new system. According to a document published by NHS Improvement in July 2016, trusts that had not accepted a financial ‘control total’ were excluded, and at the time of the document’s publication trajectories were subject to change due while they waited for regional sign-off. So for the purposes of this post, and its charts and tables, we only looked at the 133 trusts that had trajectories set for this period.

2) A couple of points on our estimate of the money that might be withheld from trusts: firstly, we only included trusts that had performance trajectories in place and saw at least 5 patients in any given month. Secondly, we estimated the withheld funds as follows: 5% of the Sustainability and Transformation Fund is linked to the performance trajectories for the 62-day cancer target. 5% of £1.8bn = £90m. Assuming this money is spread equally over the four quarters of the year, the amount linked to this target between July-September = £22.5m. We estimate that 56.4% of trusts missed their trajectories by >1% for the most recently reported quarter. 56.4% of £22.5m = £12.7m. If you think we’ve estimated this incorrectly, please do let us know.