Cancer bureaucracy’s costing lives

The Government needs to address the bureaucracy that exists around cancer spending, says John Baron. 

Nine years at the helm of the All-Party Parliamentary Group on Cancer (APPGC) has afforded me a good overview of changes in cancer policy, particularly in terms of the many reforms to cancer services over the years, but some key facts nevertheless stay the same. Survival rates in England, whilst improving, still lag well behind international comparisons – in 2009, the Government estimated we could save an extra 10,000 lives each year if we matched average cancer survival rates in Europe. Indeed, it remains an inconvenient truth that, despite all the talk of survival rates improving and despite the extent of process targets applied over decades, there is no material evidence that the UK is catching up with international averages. Fresh thinking is required.

It is well-established that the principle reason why our survival rates fall behind other countries’ performance is because the NHS is slower to diagnose cancers in the first instance. Catching cancers in their early stages greatly increases the chances of successful treatment, and in many cases can do much to stop the disease in its tracks. Conversely, late diagnosis makes for more difficult, more onerous and sadly less successful treatment, with the attendant poor survival rates. Such invasive treatment is also more costly.

It should be a source of national shame that between 20 – 25% of cancers are first diagnosed as a result of an emergency admission, such as at A&E. In 2013, the OECD was damning in pointing out that survival rates in England rank near the bottom when compared to other developed economies, for some cancer types only faring worse than Poland and Ireland.

For this reason, campaigning to improve earlier diagnosis has been the APPGC’s main focus for most of the last decade. Working alongside the cancer community, we have notched up some considerable successes. Persuading the NHS to put one- and five-year survival rates into the accountability frameworks of the post-Lansley reforms gave greater visibility to figures which had previously gone almost unremarked. Successfully campaigning for one-year cancer survival rates to be placed in the ‘Delivery Dashboard’ has resulted in Clinical Commissioning Groups (CCGs) being held accountable for their local one-year survival rates – which can only be improved by earlier diagnosis.

However, despite this dogged campaigning, there remains a structural issue which is hindering greater improvements in increasing survival rates. This is that in recent decades the NHS has been beset by numerous so-called ‘process targets’. Instead of measuring the success of treatment, these targets instead measure the NHS’ performance against process benchmarks – A&E waiting times being one such example.

These targets have a role to play, but all too often become a blunt tool offering information without context which hinders rather than help access to good treatment – especially when financial flows are linked to them. Furthermore, these targets, which being understandably ambitious have a tendency not to be met, can easily become a political football between the parties eager to score short-term points. In this, all sides are guilty.

Cancer services are no stranger to process targets – the House of Commons Library has identified no fewer than nine that currently apply, most notably the ‘two-week wait’ (to see a specialist following a referral) and the ‘62-day wait’ (from urgent referral to first definitive treatment). Whilst CCGs are held accountable for their one-year survival rates, in practice, they pay greater attention to process targets as they are invariably the key to unlocking extra funds. NHS England needs to be addressing this blinkered approach.

Moreover, process targets do not represent the best means of helping the rarer and less survivable cancers, which for too long have been the ‘poor cousins’ of the ‘Big Four’ cancer types. These cancers often fall between the cracks of process targets – data on these cancers is not used routinely in much of the NHS, which encourages it to go for the ‘low hanging fruit’ of the latter. However, given rarer cancers account for more than half of all cancer cases, serious improvements in survival rates will not be possible unless they are included.

The APPGC’s report launched at ‘Britain Against Cancer’ last December identified one such example of when process targets can act against the interests of patients. In 2016, NHS England announced £200 million of Transformation Funding to help Cancer Alliances achieve the standards set out in the Cancer Strategy (2015-2020). However, after bidding closed, a requirement for good performance against the 62-day target was retrospectively introduced.

The result is that multiple Cancer Alliances, their performance deemed not good enough, have not received their expected funding allocations. This leads to the iniquitous situation whereby high-performing Alliances receive even more money, whereas those which are struggling – and therefore in most need for this extra support – do not.

Submissions in evidence to our report suggested this issue was causing real problems and constituted, in the view of APPGC Officers, a ‘cry for help’ from those at the front-line of our cancer services. Accordingly, one of our report’s major conclusions was that the link between funding and the 62-day performance should be broken.

Since we launched our report in December, I have had a meeting with the Prime Minister and No 10 officials during which the Prime Minister agreed all Transformation Funding should be released immediately provided the relevant Alliances promised to produce a plan to improve their performance against 62-days. Further discussions have continued, and have broadened out to include officials from the Department of Health and NHS England.

Whilst proposals have been put forward by NHS England which seem promising and would potentially allow at least partial funding realise, it appears we are still a way off resolving this issue completely – and, importantly, meeting what the PM agreed at our meeting in March.

At a presentation by NHS England in Parliament just this week, in answer to my and Nic Dakin MP’s questions, we were reminded that those Cancer Alliances struggling to meet their 62 day target will only be able to access 50% of their entitlement to the Transformation funding – but may be able to apply to a support fund to at least in part make up the difference. Such bureaucracy is time consuming, costly and deeply frustrating to those at the front line wanting to deliver the Cancer Strategy. Let’s get the funding, currently languishing in NHS England’s coffers, out to those who need it.

Following my further PMQ on 25^th April, I look forward to my next meeting with the Prime Minister in June – a recent meeting of the Cancer Campaigning Group, a coalition representing over 50 cancer charities, suggests many in the cancer community will be eagerly awaiting the outcome of our discussions.