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NHS long term plan is a “fantastic opportunity” to reduce variation in cancer care

BMJ 2019; 366 doi: (Published 23 September 2019) Cite this as: BMJ 2019;366:l5687
  1. Elisabeth Mahase
  1. The BMJ

The NHS long term plan is a unique opportunity to reduce variation in cancer care across the country and hold NHS and political leaders to account on their promises, experts have said.

At the Westminster Health Forum on cancer care on 17 September, speakers highlighted the vast variation in cancer mortality, as well as waiting and treatment times across England, and outlined the ways to improve patient outcomes.

They said that a combination of better diagnostics, staffing, and patient pathways, in addition to support for outlier providers, would enable the NHS to achieve the aims laid out in the long term plan.1

The plan, which was announced by health secretary Matt Hancock in January 2019, set two key goals in terms of cancer. The first was that by 2028 the proportion of cancers diagnosed at stages one and two would rise from around half to three quarters of cancer patients. The second was that from 2028 55 000 more people each year would survive their cancer for at least five years following diagnosis.2

However, in 2018-19, only three of the nine cancer waiting time standards were achieved or exceeded. The most significant breaches were seen with the 62 day wait for first treatment following an urgent GP referral, which was 79.1% last year for all cancers, well below the 85% target.3 There was also huge variation between providers, with some starting treatment in just half of patients within the set time, while others hit 100%.4

Are the long term plan goals cancer achievable?

Despite this, speakers at the conference, who came from a variety of medical specialties and organisations, were optimistic that while the long term goals were ambitious, they could be achieved.

Gastroenterologist Rory Harvey, clinical co-chair of the national programme of care for cancer, said, “This is the first time we have had the opportunity to put a marker at a point in the future and say, this is where we want to get to, and this is what we need to do to get there. This is a fantastic opportunity.”

Chris Harrison, executive medical director at the Christie NHS Foundation Trust, agreed. “When our national leaders—political or managerial—talk about long term planning and doing things differently, we should take that and try to make the most of it,” he said. “We should hold them to account. We don’t need knee jerk policy which responds only to the latest figures, we need long term thinking, so I think we should be working with and supporting any leader who is going to do that.”

Changes are needed

However, the speakers were under no illusion that reaching these goals would not be simple. Harvey said, “To deliver the long term plan goals there are multiple areas where we have to do things differently.”

He then outlined how bowel cancer is one area where improved diagnostics could significantly help shift diagnosis to earlier stages.

“We’ve got the faecal immunochemical test (FIT) for the screening programme going live this year. This is beneficial in two ways. A low risk patient who may or may not have bowel cancer can have a FIT test and be risk stratified appropriately. And from a provider perspective, the evidence is that you can actually reduce the demand on your colonoscopy services by doing FIT tests, because it’s such a good negative test,” Harvey explained.

FIT uses antibodies that recognise human haemoglobin to detect and quantify the amount of human blood in a single stool sample. An abnormal results suggests there may be bleeding within the gastrointestinal tract, and shows the need for further testing. Unlike previous screening tests, FIT is specific to human blood, which means it does not also pick up other blood in the stool, such as that ingested through diet. It is also thought to be a more sensitive test.

Lung cancer is another important area. “Lung cancer is the tumour type for which delivering care by 62 days matters most. You go from curable to incurable in two months. Getting it right is really important,” Harvey said.

“The priority is targeted interventions for those at risk. I’m really pleased that in my area (East of England) we have had two sites chosen for the lung cancer health checks pilot. They’re really interesting populations—you have Luton which is ethnically diverse and very deprived, and Thurrock, where lung cancer is the fourth most common cause of death.”

But there is also huge variation when it comes to treatment. “Depending on where you live, there is a three and a half fold variation across the country in terms of access to curative treatment. That is shocking,” Harvey continued.

Spotting outliers

Variation in outcomes is where Mike Zeiderman, a national professional advisor for surgical specialties at the healthcare regulator the Care Quality Commission, believes regulators can help. He has been working on finding and supporting providers that are not performing as they should be.

“We’ve developed an outlier management programme, which identifies when there are outliers who are two to three standard deviations outside the mortality average. A letter then goes to the outlier, asking it to develop an action plan which is then assessed by us and implemented,” Zeiderman said.

“We can reduce variability in provision of care, improve patient experience by trying to regulate pathways so they are referred appropriately, seen on time, and treated on time.”

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