Analysis

NHS Long Term Plan reveals bold cancer strategy, but doubts remain over its delivery

Ambitious plans for improved cancer diagnosis and care welcomed, but concerns remain about workforce shortages

Ambitious plans for improved cancer diagnosis and care welcomed, but concerns remain about workforce shortages


Picture: Getty Images

It is no surprise that cancer features heavily in the NHS Long Term Plan. After all, prime minister Theresa May used her speech at the Conservative Party conference to announce the new plans.

In October, she highlighted the new ambition to detect cancer earlier, saying that by 2028 three quarters of cases should be diagnosed at stages 1 and 2 compared with the half that currently are.

The plan gives further details about how this will be achieved. It says there will need to be greater awareness of the symptoms among patients, a lower referral threshold for GPs, better diagnostic services and an increase in the numbers identified through screening.

‘The risk is that the workforce issue muddies the water with what we are trying to achieve with the cancer strategy’

Susanne Cruickshank, RCN cancer and breast care forum chair

The latter will be achieved, the plan says, by changes that are already in the pipeline, including the lowering of the age at which screening for bowel cancer starts from 60 to 50, as well as through the review of screening that is being done by former chief inspector of hospitals Sir Mike Richards at the request of NHS England.

75%

of cancers to be diagnosed at stages 1 and 2 by 2028

(NHS Long Term Plan)

Lung health checks

That review, which is due to produce initial recommendations by Easter, will look at everything from how the latest innovations can be used to encouraging more eligible people to be screened.

One innovation already being piloted by NHS England is lung health checks in which patients are tested and those deemed at high risk are referred for low-dose computerised tomography (CT) scans in community settings.

The pilot in Manchester increased the proportion of stage 1 diagnoses from 18% to 65%, and the plan says more mobile scanning units will be deployed around the country in the future.

Tests and advice in one place

The plan also confirmed the rollout of rapid diagnostic centres, which have been piloted in ten areas.

These have tended to focus on patients who have presented with non-specific symptoms, allowing them to receive a range of tests and advice in one place.

All this comes as the NHS works towards the new 28-day target for diagnosis, which starts in April 2020 and was a centrepiece of the five-year cancer strategy published in 2015.

The plan also promises to make the use of new technologies and advances in medicine, stating that over the next decade the NHS will start to routinely offer genomic testing where appropriate.

It reiterates the commitment that by 2021 everyone will have a needs assessment, a care plan, and health and well-being support.

Overriding concern

The ambitions have been widely welcomed by charities and cancer experts. But an overriding concern shared by many is the absence of a workforce strategy to tackle staffing shortages to go alongside the NHS Long Term Plan to re-design services. Figures from an audit of the cancer workforce in Macmillan Cancer Support - Cancer Workforce in England 2017 report show one in nine specialist cancer nurse posts are vacant in some areas. 

The government has promised a dedicated workforce strategy, which was meant to be published last year, will be out soon.

Macmillan Cancer Support says without a strategy to tackle workforce problems, the NHS Long Term Plan will not be deliverable, while Breast Cancer Care went even further, describing the nurse shortages as ‘shocking’ and accusing the Long Term Plan of ‘barely scratching the surface’.  

10

rapid diagnosis centre pilot sites in Englan

‘We’re not there yet’

RCN cancer and breast care forum chair Susanne Cruickshank says such sentiments are understandable.

‘The risk is that [the NHS Long Term Plan] muddies the water with what we are trying to achieve with the cancer strategy. We’re not there yet – in fact the current waiting times are really bad.

‘We need to get these things right first. There are serious shortages, and until we resolve these problems the ambitions will just remain aspirational.’

Reaching out

Macmillan director of nursing for cancer and palliative care at Barts Health NHS Trust Barry Quinn shares some of the concerns.

‘There’s an opportunity to take more care and services into the community’

Barry Quinn, Macmillan director of nursing for cancer and palliative care at Barts Health NHS Trust

He says the workforce issues clearly need addressing, but he would have liked to see more attention given to reaching out to ‘under-represented groups’ such as people from black, Asian and minority ethnic backgrounds, and those with learning disabilities and mental health problems.

Shaping the debate

Dr Quinn says healthcare professionals working in cancer have an important role to play in shaping the debate.

‘There’s an opportunity to take more care and services into the community and get away from the hospital-focused approach we currently provide.’

2020

Year when 28-day target for diagnosis starts

He cites expanding the risk-stratified pathway to cancers other than breast, colorectal and prostate cancer and increasing the amount of home-based and community-based chemotherapy.

‘Does all chemotherapy need to be delivered by a nurse? Or is there an opportunity to develop a hybrid role where we give the appropriate training to support workers?’

He also calls for greater engagement with the likes of district nurses, practice nurses and those working with dementia, mental health, cardiac and renal patients.

‘The largest percentage of people with cancer are in the older population. Many will have co-morbidities and may be receiving health and social care. We need to engage with the wider workforce to support those with co-morbidities.’

Priority given to personalised follow-up

The cancer team at University Hospitals Plymouth NHS Trust has made providing personalised follow-up care a priority for breast cancer patients by employing a link nurse and support worker.

The team completes a holistic needs assessment at the beginning of every patient’s journey, at the end of treatment and at other times when relevant or if the patient has requested one.

Once the patients’ needs have been identified they are put in touch with the available support through the trust and other agencies.

Available support through the trust and other agencies

  • Health and well-being events can help patients to better understand their cancer as well as how and when to obtain advice
  • Patients are encouraged to contact a local Macmillan centre where a wide range of services are offered, including information on side effects, financial advice and complementary therapies. They can also meet other patients who are going through similar challenges
  • The local university provides exercise classes developed specifically for cancer patients, Macmillan has walking classes and patients can also take part in subsidised sessions at the trust’s swimming pool. Safely returning to exercise is regarded as very important

Rapid diagnostic centre targets best and quickest care

University College London Hospital opened its rapid diagnostic centre for patients with complex or vague abdominal symptoms in 2016.

Referrals are sent to a coordinator and clinical nurse specialist (CNS), who provide a fast-track diagnosis service.

Assessments are done two or three days after referral. The CNS takes a detailed medical history and completes the appropriate blood tests.

Patients requiring a CT scan will be given an appointment to return within a couple of days.

Those who do not have cancer are given advice about prevention and may be referred elsewhere, while cases where cancer is suspected are reviewed by a multidisciplinary team and treatment is started quickly where necessary.

Clinical nurse specialist Vicky Megias says her role is to be a ‘constant source of contact’ for both the patients and other clinicians to ensure patients get the best and quickest care.


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