Government sets new cancer targets as trusts in England struggle to meet existing ones
Is there a risk of being railroaded by too many targets in cancer care?
With some targets not being met in cancer care, are services at risk of being railroaded by too many targets?
At times, it can seem like there are two parallel worlds. Cancer waiting times have slipped to their worst ever levels, yet ministers keep talking about their ambitions for more and faster services, setting new targets in the process.
Prime minister Theresa May repeated these ambitions at the Conservative Party conference in Manchester, when she announced there would be a new cancer strategy in England off the back of the yet to be published ten-year NHS plan on how the extra funding for the health service is to be spent.
She said that by 2028 she wanted the early diagnosis rate – cancers spotted at stages one and two – to increase from 50% to 75%.
This comes just three years after the existing cancer plan was launched and services are still working hard to achieve the new 28-day target for diagnosis by 2020.
of patients started treatment in July within 62 days of urgent GP referral, the worst on record
Further, waiting times for the cancer target – the 62-day goal for treatment to start following an urgent GP referral – has been missed by a record margin in England.
Recording against the target began in 2009. In 2018, June, July and August have all been the worst on record at 79.2%, 78.2% and 79.4% respectively.
The 62-day target to meet in England is 85% however, less than one third of trusts are currently meeting it.
Only time will tell if the decline has bottomed out. While cancer services are not as susceptible to seasonal fluctuations as areas such as emergency departments and elective treatments, recent years have tended to show that the worst performance does happen during winter when the NHS is under the most pressure.
Patients are waiting longer than they should. Since the target was last met – at the end of 2015 – just over 72,000 patients have waited more than 62 days for treatment.
Cancer related targets
The problems are not confined to the 62-day measure either. There are another seven targets covering cancer care. Three of them, including the two-week wait for a consultant appointment following an urgent GP referral, are also being missed.
So what has gone wrong? Mark Foulkes, UK Oncology Nursing Society board member and Macmillan lead cancer nurse at Royal Berkshire NHS Foundation Trust, says the major emphasis on quick diagnosis has created a real ‘bottleneck’.
‘We’re seeing lots more referrals. All these have to have the diagnostics done and we simply don’t have the capacity in terms of staff and equipment to keep up.
‘The targets may be a bit of a blunt instrument, but they do drive improvement’
‘There’s quite a variation in performance when you look below the national figure. The Thames Valley – where I work – is particularly challenged. That is hard on staff. We are always looking to see what we can do differently to try to improve performance.’
Mr Foulkes would not like to see the targets go or be lowered. ‘They may be a bit of a blunt instrument, but they do drive improvement.’
South Tees Hospital NHS Foundation Trust chemotherapy nurse Wendy Anderson says access to treatment is also a ‘well-recognised challenge’, but one that is not always reflected in the waiting time statistics, because the waits can happen after the clock has been stopped by the initial treatment. ‘These waits can be frustrating and affect patients,' she adds.
patients in England have waited longer than 62 days for treatment since the target was last met in 2015
Ms Anderson says there are several factors that contribute to delays, including the time it takes to obtain lab results, assess patients and prepare treatments while battling nursing shortages.
Fundamental workforce challenges
The biggest task facing the government, according to Macmillan Cancer Support, is trying to recruit more staff. The charity's cancer workforce census earlier this year found vacancy rates of 11% for cancer specialist nursing posts in some areas.
Macmillan director of policy Moira Fraser says the prime minister is right to focus on early diagnosis as it has the ‘real potential’ to improve and save lives, but says it will fail unless she addresses the ‘fundamental challenges’ facing the workforce.
'I find it odd we are talking about a new plan when the old plan hasn’t yet achieved what it was meant to'
‘Without a costed plan to grow and sustain the numbers of doctors and nurses to deliver these aims, it simply will not be possible.’
RCN cancer and breast care forum chair Susanne Cruickshank predicts early diagnosis will be difficult without a significant change in approach.
‘Cancer used to be where people wanted to work. It didn’t struggle as much as other areas, but that’s changing. It is a consequence of austerity and the bursary going.
‘There’s not a hospital that hasn’t got vacancies – and the problem with specialist staff like cancer nurses is that you can’t just go and get cover from the bank or agencies.
‘I find it odd we are talking about a new plan when the old plan hasn’t yet achieved what it was meant to.’
What about the rest of the UK?
England may have just recorded its worst-ever cancer waiting times, but the picture across the rest of the UK is better.
4 out of 8
cancer targets in England are now being missed
Northern Ireland, Scotland and Wales each have a 62-day target – although the three countries have a higher target to achieve of 95%, compared to the 85% in England.
All are missing their targets. In fact, Northern Ireland has never met it since it was set in April 2009 with the latest figures showing just 70.4% of patients started treatment within 62 days.
In Wales you have to go back to the end of 2008 for the last time it was met. Meanwhile, in Scotland it is coming up to six years since the target was hit. Both nations are hovering around the 85% mark.
Are rapid diagnostic centres the answer?
NHS England is placing a lot of emphasis on rapid diagnostic centres helping to drive up the identification of early-stage cancers.
A number of different models are being piloted across the country. One is at Guy’s and St Thomas’ NHS Foundation Trust in London. It actually started back in 2016, but has recently been expanded to cover a wider area across south London. Its rapid diagnostic centre aimed at patients who have presented to their GP or at an emergency department with vague, but worrying symptoms.
Within seven days of a referral being made, a patient will attend an initial 45-minute appointment with a consultant and advanced nurse practitioner.
A detailed medical history will be taken, investigations completed and the patient will also be screened for frailty, mental health and social needs. Scans and endoscopies can be done on the day or within a week at most. A second appointment will then follow to discuss the results. If needed, they will be placed on an urgent cancer pathway unless other treatment is more appropriate.
Results so far are promising. One in 11 patients have been diagnosed with cancer – one quarter of which were diagnosed at stage one or two.
Meanwhile more than half of cancer patients have been diagnosed with other serious conditions, including cirrhosis of the liver, heart failure and multiple sclerosis.