Category Archives: Evidence

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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Notes:

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.

Urgent care services are overstretched – we need to fund the cancer strategy now


10 December, 2015
Juliet Bouverie, Director of Services & Influencing  |  @julietbou

This piece first appeared in the Health Service Journal

As the dust settles following last month’s spending review, the NHS has to get down to the nitty gritty of how the precious early investment of £3.8bn is spent.

One area in desperate need of attention is cancer care, which poses a series of stark challenges for the NHS, both now and in years to come, according to Cancer Cash Crisis, a new report out this week from Macmillan Cancer Support.

Let’s start with how money is currently spent. New figures in the report show we are spending more than £500m a year on inpatient emergency care for people diagnosed with the top four cancers alone. Of this, at least £130m is spent on care more than six months after a person’s diagnosis, when initial treatment would usually have finished, but before their last year of life.

After successful treatment, people should be looking forward to getting their life back on track. Instead, many find they bounce back into hospital because they aren’t given the right care and support.

Care beyond treatment

Future prospects are perhaps even more alarming. With more people than ever surviving years or even decades after a cancer diagnosis, the NHS will need enough funding to provide care and support far beyond initial treatment.

As the number of people living with cancer in England rises from 2 million in 2015 to 3.4 million by 2030, this demand will become ever more acute.

New figures in the report show that care beyond treatment for people living with cancer will rise to at least £1.4bn per year by 2020, with £1bn being spent on consequences of treatment, such as side effects from drugs, as well as long term after effects.

Over the next five years, the growth in care beyond treatment amounts to a cumulative increase of more than £600m.

Budget burden

This is a significant chunk out of tight NHS budgets. Unless action is taken now, we will continue to see money being spent inefficiently and we will see the burden on an already overstretched emergency care services grow further.

Our health system cannot continue to assume that the needs of people living with cancer finish when initial treatment does – this is bad for the individual and a false economy for the NHS.

We must place as great an emphasis on supporting people to live well as we do on early detection and survival.

People’s needs are more complex now than ever before. As well as those living with the long term consequences of cancer and its treatment, increasing numbers of people will live with incurable but treatable cancer for several years.

Add in the fact that we currently have an estimated 1.4 million people with cancer in England who have at least one other long term condition, and suddenly providing care and support for this growing number of people starts to look like an almost insurmountable challenge.

Pressing strategy

What is the solution? Early diagnosis is certainly a key component, but it is by no means a magic bullet. For example, new figures released this week reveal that for the 40,000 women diagnosed with early stage breast cancer each year, the cost of inpatient care during diagnosis and initial treatment (£155m) is dwarfed by the £250m spent on inpatient hospital care after their initial cancer treatment ends.

This challenges the notion that patients’ outcomes, as well as the costs of care, can be improved through early diagnosis alone.

If the NHS is to get a grip on this dramatic collision of public spending and public need, the cancer strategy for England must be fully funded and implemented at the earliest possible opportunity.

Recommendations in the strategy, such as the rolling out of a recovery package, including a holistic needs assessment and other key interventions, such as a treatment summary and cancer care review, are vital steps that need to be taken if we are to help people live well beyond a cancer diagnosis.

Wise investment

When delivered together, these interventions can help to contain the rising tide of costs and significantly improve coordination of care and patient outcomes, including better and earlier identification of consequences of treatment, better management of co-morbidities, help with staying at or returning to work, and support with healthy lifestyles.

Funding the cancer strategy for England’s recommendations will not be cheap – it will cost an estimated £400m a year between now and 2020. But it will be a wise investment.

Investing early, followed by delivery of the savings identified by the strategy’s recommendations, would result in a £420m lower cumulative spend by the NHS over the next five years than failing to fund it at all. Worse still, delayed funding and late implementation of the strategy would actually cost about £100m more by the end of this parliament than doing nothing at all.

The cancer story will continue to shift with time and new solutions will constantly have to be found. Through the cancer strategy, the NHS has a chance to shape this story for the near future.

The health service has to be brave and invest now, so that we can improve lives and make every penny count.

Better Data. Better Lives.

As the Data Lead, in Macmillan’s Evidence Department, World Statistics Day is right up my street as a chance to geek out in public for the day! The tag line, “Better data. Better lives.”, of World Statistics Day is also a perfect fit to describe the work of my team and one of the reasons why the Macmillan Evidence Department has been growing since the day I joined over five years ago.

I’ve been working with numbers and statistics all my career from monitoring social trends, interrogating census data and now focusing on cancer and health statistics. Yet it wasn’t until I came to Macmillan and first learnt the startling statistic that – in 2010 there were 2 million people living with cancer (Maddams et al., 2009) – that I really saw the use of data and evidence to make change in action. By the way we now estimate there are 2.5 million people living with cancer in 2015 which is rising to 4 million by 2030 (Maddams et al., 2012).

We don’t just stop there. We know how many people are living with cancer but we need to use this alongside other evidence, methods and sources to truly understand their experiences and needs, particularly unmet needs.

One example is the research we carried out to explore the social care needs of people living with cancer (Macmillan, 2015) which won a first prize poster award at this year’s NCIN Cancer Outcomes Conference. We found that the social care needs of people with cancer are far more widespread than expected. Macmillan will be using this research to support our programme of strategic engagement and partnerships with local authorities and other partners, with the aim of improving and better integrating the planning and provision of personal, practical, emotional, and financial care and support for people living with cancer.

Our Rich picture on the 2.5 million people with cancer begins to draw together this and  wider evidence on numbers needs and experiences so that we and our partners can use this knowledge to inform our work, strategy and direction and improve the lives of everyone living with cancer.

In this increasingly evidence hungry environment with a demand for more granular data, ‘big data’ analysis and data visualisation we are already making data and statistics work harder for us, for example:

2.5 million - cut

Excitingly there’s so much more we can do and we have big aspirations on how we use evidence and data (described in this short video) to drive service improvement for people living with cancer so watch this space!

Look out for our tweets on World Statistics Day from @Mac_Evidence for some of the key statistics we produce and use.

Author: Hannah McConnell, Data Lead in the Evidence Department at Macmillan Cancer Support.

Image – 1: Maddams et al., 2012; 2: ‘Five-years’ refers to 2010-2015.

References:

Maddams J, et al. Cancer prevalence in the United Kingdom: estimates for 2008. Br J Cancer . 2009. 101: 541-547.

Maddams J, et al. Projections of cancer prevalence in the United Kingdom, 2010-2040. Br J Cancer. 2012. 107(7): 1195-1202. (Projections scenario 1). Macmillan analysis based on  extrapolation of 2010 and 2020 projections that the number of people living with cancer will hit an estimated 2.5 million in 2015.

Macmillan Cancer Support (2015) Hidden at Home – the social care needs of people with cancer. Bright Blue Research commissioned by Macmillan Cancer Support http://www.macmillan.org.uk/Documents/GetInvolved/Campaigns/Carers/hidden-at-home.pdf (accessed September 2015)

The social care needs of people living with cancer

Belfast

We’re back from sunny Belfast and pleased as punch to have won a first prize at the NCIN conference, in the survivorship category, for our poster presentation on the social care needs of people living with cancer.

It comes after almost two years of hard work with expert agency mruk to design and conduct a programme of qualitative and quantitative research which – for the first time – assesses the practical, personal and emotional support needs of people with cancer in the UK, and how well these needs are met.

Until now very little official data has been available on the full extent of these needs and how well they’re being met. Anecdotal evidence and feedback from professionals on the ground has long pointed to these needs being common for people at all points in the cancer journey, and our research confirms just how widespread they are.

Around two in three people with cancer have practical or personal care needs, and four in five have emotional needs. Overall, almost one in three people with cancer have practical or personal needs but do not receive enough, or any, support. And almost half of people have emotional needs but do not receive adequate support. Often these needs are linked. A lack of support in one area can have a profound impact on other aspects of people’s lives. We suspected that family and friends would be the most common source of support. Our research has shown that they are often the only source of support. This can be true even amongst those with severe needs who need help several times a day. And to make things worse, family and friends often receive no support themselves to help them in their caring role.

Info1

The consequences of a lack of support can be devastating, at a time when people need help most. Overall, one in five people with cancer experience a negative impact on their lives. This results from of a lack of support for their practical or personal needs. These can range from being housebound, unable to wash and dress, to experiencing unnecessary hospital admissions.

Info2

We’re pleased to see our research being recognised by the research community and hope this leads to a greater focus on these issues. However, the real test is ensuring more people with cancer receive the right support when they need it.

The impact of the Care Act and new criteria for eligibility for support remain to be seen. However, with further cuts faced by Local Authorities the road ahead is definitely not an easy one. This is why as well as using the research to support our wider campaign work, we’re using it to inform new strategic partnerships with Local Authorities. Macmillan recognises the significant role of Local Authorities in supporting people with disabilities and long term conditions in their communities. They can make a real difference to the quality of life of people living with cancer too.  In partnership with Local Authorities we will invest to develop co-produced solutions and in building community capacity for local people.  There is long term commitment from Macmillan. We recognise that solutions need to be personalised, sustainable, replicable for other long term conditions. They also need to put the individual at the centre of their care and support.

So watch this space. And if you’re interested in finding out more in the meantime, a short report we published earlier this year based on the research is available here, which received a range of media coverage, including the Guardian, Daily Telegraph and Daily Mail

NCIN Conference – meeting our stakeholders

In early June I went to Belfast with around 20 colleagues to the National Cancer Intelligence Network Cancer Outcomes conference. This conference is one of the Evidence team’s most exciting events as it gives us the opportunity to talk to patients, researchers, clinicians, commissioners, allied cancer professionals, policy-makers and third sector organisations all in one go.

We exhibited many pieces of work at the conference, but a few highlights for me include the premier of our new short animated film on the use of data. It was great to see some of my complex job, where I use data and evidence to help understand and improve the cancer journey, boiled down into a three minute summary. However, if, like me, you enjoy the detail, more can be found about Routes from Diagnosis here, the England Local Cancer Intelligence tool here or the CREW study here.

A personal achievement at the conference was when I won second prize in the changing clinical practice/supporting commissioning/audit category for my 3,600 specialist adult cancer nurses: New evidence for workforce planning poster. Colleagues across Macmillan also won prizes in the survivorship/late effects of cancer and treatment poster category:

Yes, we did win all three prize places in this one category!

I was also proud to see Macmillan’s work at the conference in the media. We found almost 80,000 people in the UK were diagnosed before the age of 45 and are still living with one of the top four most common cancers. This was reported in five national newspapers, including three broadsheets and by Nursing in Practice. This story only represents one aspect of the data so I would recommend everyone explores the full data set.

In the Evidence team, we are all looking forward to the 2016 NCIN conference and would encourage anyone who loves data and could use information in their role to improve the lives of people affected by cancer to attend.

Author: Rachel White is an Information and Data Analyst in the Evidence team. She draws on internal and external sources to understand more about the numbers, needs and experiences of people affected by cancer.

Cancer waiting times – ‘target met’?

by James Shield, Projects Manager, Cancer Population Evidence Programme

Cancer waiting times featured once again in last week’s Prime Minister’s Questions. The discussion focused on performance in one local area – but how does this relate to the national picture?

‘Target met’

Ed Miliband used all of his questions in last week’s PMQs to focus on the NHS, including one on the NHS missing the 62-day cancer waiting times target. David Cameron responded:

Let me bring the right hon. Gentleman closer to home—genuinely, to his home in Doncaster. This is the answer. Here are the cancer waiting times for his constituents: 95.2% of patients with suspected cancer were seen by a specialist within two weeks, and the target is 93%—target met; 97.9% of patients diagnosed with cancer began treatment within 30 days, and the target is 96%—target met; and 87% of patients began cancer treatment within 62 days of an urgent GP referral, and the target is 85%—target met.

It’s important here to look in detail at the most recent figures: while 87.5% of people living in Doncaster Clinical Commissioning Group who were given an urgent GP referral for cancer treatment in the second quarter of 2014/15 began treatment within 62 days, above the 85% target, in the third quarter Doncaster has begun to dip below the target:

Two month wait from GP urgent referral to a first treatment for cancer: Doncaster CCG

The story of missed cancer waiting times is also bigger than Doncaster alone, and while the overall trend is the same – a downward one – much of the rest of the country has fared worse.

Looking at the figures by Clinical Commissioning Group (CCG), more than half missed the target in the most recent quarter. England is now a patchwork of missed cancer targets (click below to view our interactive map):

And at a national level, England as a whole has missed the 62-day target for every quarter so far in 2014/15, and four quarters in a row. In the most recent quarter 68 trusts1 in England failed to meet the target, leaving more than 5,000 people waiting more than 62 days to start urgent treatment. That’s thousands of worried patients; thousands of families in unnecessary distress; and thousands of people potentially being treated too late to experience the best possible outcomes.

What explains missed cancer targets?

NHS England has previously said the failure to meet this target is in part explained by an increase in the number of patients beginning treatment for cancer following urgent GP referrals.

While referrals have continued to increase, the NHS maintained performance against the 62-day target for nearly five years despite rising referrals, and there is nothing about the past year of referral trends that is especially unusual. The number of urgent GP referrals has risen quite predictably by between 10-12% a year for the past four years, and 2014/15 has followed a fairly similar trend; annual growth is predicted to be around 14%.2 A more in-depth look will be needed to determine exactly where the bottleneck lies.

Cancer isn’t fixed

Whatever the cause, the government must take serious steps to improve performance against cancer waiting time targets. We know that being diagnosed early is essential if patients are to experience the best possible outcomes, and the UK currently lags behind much of the rest of Europe’s cancer survival rates. Put simply, cancer isn’t fixed. That’s why Macmillan is calling on the next government to commit to delivering cancer outcomes that match the best in Europe by the end of the next parliament.


  1. The 68 trusts are based on providers who give first treatment to more than 5 people with cancer in Q3 2014-15.
    http://www.england.nhs.uk/statistics/2015/02/18/provider-based-cancer-waiting-times-for-q3-2014-15/
  2. Based on data from Q1 to Q3 2014/15 and estimate of Q4 2014/15. Q4 2014/15 estimate is based on previous proportions of the annual referrals in Q4.

When it comes to cancer and health awareness are women really from Venus and men from Mars?

Having recently carried out an evidence review examining needs of men with cancer and barriers to accessing health and social care services I was stunned to discover that, when looking at cancers affecting both men and women, men are 60% more likely to be diagnosed with cancer and 70% more likely to die from the disease.[1] When compared to women, cancer mortality is consistently higher in men across all ages and comparable cancer types.[2]

CancerMortality

From ‘The Excess Burden of Cancer in Men in the UK’1

Why is this?

No one knows for certain but one theory is that men lead unhealthier lifestyles, they drink more alcohol, they smoke more cigarettes and they eat unhealthier food. In fact 42% of men die prematurely (before the age of 75).[3]

But whilst these facts may be true for some it is certainly not true for all men. For example we are seeing dramatic declines in numbers of men smoking and, despite efforts to encourage women to don jogging bottoms and get active, men still generally do more exercise.2

Another important factor could be late presentation. Men are more likely to be treated in hospital as an inpatient for cancer and reasons include a lack of recognition and awareness of cancer signs and symptoms. In a recent interview for Third Sector, Owen Sharp CEO of Prostate Cancer UK, makes the point that ‘Men’s health inequality is just a big, big issue. There’s no biological or social reason now for us to sit here and say it’s all right that men die seven or eight years earlier than women do. We all just kind of accept that as the way it is. But it’s so often about late diagnosis and not having early interventions.’ [4]

And the issues don’t stop at the prevention and early diagnosis stage. Across all cancer types and all stages of the cancer journey men are less likely to report unmet needs than women with the exception of sexual health needs. Is this because they have fewer needs or do these needs just go unreported? How does a health and social care system know where to direct services if they don’t know what needs are unmet?

What if men are already at a disadvantage when it comes to accessing health and social care? Does it concern us that some studies have shown that men perceive subconscious (and unfortunately sometimes conscious) discrimination within healthcare settings, especially GP surgeries? ) [5],[6] The historic stereotype of the macho male is so engrained in us that it’s hard to unpick the myth from reality. The truth is men do care about their health; they just need approaching in the right way, at the right time.

Our evidence review has found that there are three main areas of need among men with cancer. These are in relation to sexual health, social isolation and financial support. Financial support services are generally well established and well used by men but this is not the case for sexual health or social isolation.

Men are not a homogenous group, their needs, attitudes and behaviours are as diverse as they are. Engaging men in positive health behaviours is possible and is being done successfully in small pockets across the UK. Take ‘Men’s Sheds’[7] and ‘Man MOT[8] for example, which have started to tackle some of the areas of unmet need amongst men.

Cancer does not discriminate – if we want to improve the lives of people affected by cancer EVERYONE needs to be included in cancer services and strategies. Let’s make sure services appeal to and cater to the needs of both men and women.

Societal culture is changing; let’s make sure we all change with it.

Rebecca Robertson is a Strategic Analyst in the Knowledge and Strategic Insight Team at Macmillan Cancer Support. This blog was based on an evidence review examining the needs and unmet needs of men with cancer and barriers which may prevent them accessing health and social care.

[1] White A, Thomson C and Forman D. The excess burden of cancer in men in the UK. London: National Cancer Intelligence Network; 2009.

[2]http://www.cancerresearchuk.org/prod_consump/groups/cr_common/@nre/@sta/documents/generalcontent/crukmig_1000ast-2748.pdf

[3] Men’s Health Forum. Engaging with men to improve their health. http://www.menshealthforum.org.uk/sites/default/files/pdf/mhf_vcs_toolkit.pdf (Accessed July 2014)

[4] http://www.thirdsector.co.uk/interview-owen-sharp-prostate-cancer-uk-importance-blokey/management/article/1329773

[5] Men’s Health Forum. Haringey Man MOT Project. A review of the literature: Men’s health –seeking behaviours. http://www.menshealthforum.org.uk/sites/default/files/pdf/mens_health_literature_review_dec2013_final.pdf (Accessed July 2014)

[6] Men’s Health Forum. Slow on the uptake? http://www.menshealthforum.org.uk/sites/default/files/pdf/mhf_bowel_cancer_project_report_2011_web.pdf. (Accessed July 2014)

[7] Men’s Sheds. http://menssheds.org.uk/ (Accessed December 2014)

[8] Man MOT http://www.menshealthforum.org.uk/Haringey (Accessed December 2014)