Health and Social Care Committee
Oral evidence: Cancer services update, HC 901
Wednesday 23 November 2022
Ordered by the House of Commons to be published on 23 November 2022.
Members present: Steve Brine (Chair); Chris Green; Dr Caroline Johnson; Rachael Maskell; James Morris; Taiwo Owatemi.
Questions 1 - 74
Witnesses
I: Dame Cally Palmer, National Cancer Director, NHS England; and Professor Peter Johnson, National Clinical Director for Cancer, NHS England.
Witnesses: Dame Cally Palmer and Professor Johnson.
Q1 Chair: Good afternoon. This is the Health and Social Care Select Committee. Today is a special topical session focused on a subject that touches every single one of us: cancer. We will look at the current performance of NHS cancer services in England and the recovery of the cancer backlog.
We will be asking about the state of the new, much-promised 10-year plan for cancer and the workforce plans attached to it. Hopefully, throughout that, and if I still have a voice left, we will do a stocktake on some of the recommendations made in this Committee’s 12th report of a session at the end of March, earlier this year, on cancer services. The most recent set of NHS cancer waiting times was published on 10 November this year and measures September. We are going to start with that. Before we do, we will introduce our guests.
Dame Cally Palmer is national cancer director at NHS England and Professor Peter Johnson is the national clinical director for cancer at NHS England. You are both very welcome. Thank you for organising and rearranging diaries at relatively short notice to join us today. It is much appreciated by the members of the Committee and the whole House.
You will know that there has been a lot of press interest in the cancer figures. I talked about the most recent figures published on 10 November, looking at how we were doing in September. On the key 62-day wait for first treatment, 60.5% of people began their first definitive treatment within 62 days of being urgently referred for suspected cancer, against a target of 85%.
Cally, will you be able to achieve the self-imposed target of 85% of people receiving their first cancer treatment within 62 days by March 2023, which of course is NHS England’s own target?
Dame Cally Palmer: Thank you, Chair. The planning guidance target is actually to reduce the over-62-day backlog to pre-pandemic levels by March 2023. The 85% standard has not been met for some time, although cancer volumes have increased very significantly.
On the reduction of the 62-day cancer backlog, we are absolutely going in the right direction. That backlog has reduced from a high of around 36,000 down to just under 31,000. Pre-pandemic it was just over 14,000, so we have a job to do, but we have a foot on the gas. We have a new system called a tiering system, with providers who are finding it particularly difficult to get back to the pre-pandemic backlog level.
That means that there is regular oversight and regular data and evidence to each of those trusts and to their ICBs. Peter and I join those calls just to make sure that there is complete visibility of cancer performance; that they have done three must-dos in the three cancer types that account for two thirds of the backlog level; and that we can intervene and provide funding and support where required.
There are just over 40 trusts in the tier 1 and tier 2 categories nationally, which has happened since the summer. In the tier 1 trusts, their 62-day backlogs are down by 9% and in tier 2 by 4%. There is reason to feel that we are making significant progress and that we are going in the right direction, but there is clearly more to do to get back to the pre-pandemic level by March.
Q2 Chair: The performance has been revised since 2021, hasn’t it? It was going to be March this year and now it is March next year. You talked about stepping on the gas and the tiering system as important in that. Could you unpack that some more for us, Cally? What specific steps are being taken to hit the target?
Dame Cally Palmer: Clearly, when the original target was set to get back to pre-pandemic levels, that was pre the second wave of Omicron and all the things that we faced, but we are still determined to try to meet that target by March 2023.
I will go into a bit more detail. Most of the patients waiting on that 62-day pathway will not have cancer. Diagnostic capacity is particularly key. We have looked at three particular pathways that are causing an issue. The first is skin, a very high-volume cancer. We are making sure, particularly with challenged trusts but also where it can help people locally, that tele-dermatology is in place. That can make a big difference to the productive, swift movement of patients through that pathway. We have a comply or explain policy on, “Have you got tele-dermatology in place?”
The second, new thing we have done is this. The lower GI colorectal pathway is particularly challenged as well. It is high volume and accounts for two thirds of the backlog. We are now ensuring FIT testing, which is home testing in primary care. The importance of that is that people are then risk-. Higher risk people come through for a fuller work-up and a fuller diagnosis, and lower risk people can be taken off that pathway. We are making sure that the FIT test is done in primary care with our primary care colleagues, and that only FIT-positive patients go back on to the 62-day pathway.
The third cancer is prostate cancer, which makes up a large part of the 62-day backlog. That is where we are ensuring that people have the best practice time pathway in place. It is a new pathway that we have rolled out with timings at each part of the process. It is a much more productive clinical model, where people get an MR scan before biopsy. This is all about targeting areas of greatest need to see if we can accelerate improvement.
The other important thing to tell the Committee, and which is very important for survival, is that we are seeing record numbers of urgent cancer referrals. While it is very important to meet the 62-day target, demand is at an all-time high. Urgent cancer referrals are at 129% of pre-pandemic levels, and they have been consistently higher than pre-pandemic levels since March 2021. This is a moving target, but we are working really hard to get there by March.
Q3 Chair: Never ask a question you don’t know the answer to, but why do we think that demand is at 129% of pre-pandemic levels?
Dame Cally Palmer: Because we have been doing an awful lot of campaigning—both the NHS and cancer charities—to encourage people to come forward. We have been running constant campaigns. Some of them are cancer specific for lung or lower GI. We also recently ran a fear campaign. That is all about trying to get people to come forward because timely presentation and early diagnosis is crucial for improved outcomes. We can often cure if we catch a cancer at stage 1 or stage 2, but once it has advanced it is much more difficult to manage. We have been putting a lot of work into timely presentation with primary care colleagues, with the charities and with a series of Help Us Help You campaigns.
Q4 Chair: True, but, as you well know when we worked together when I had the cancer job in government, we did the signs and symptoms of cancer campaign and that obviously then led to peaks of people coming into the system. There is pent-up demand in the system, is there not, because we paused our three big screening programmes—breast, bowel and cervical—and we know that about 3 million fewer people were invited for screening between March and September 2020. Presumably, there is a backlog of demand that is now presenting when symptoms present as well. Is that adding to your 129% increase?
Dame Cally Palmer: The pause in the screening programmes?
Chair: Yes.
Dame Cally Palmer: Peter will talk about the percentage of patients that come through screening and how that works, and I will defer to him in a moment, but this is not primarily about that pause in screening programmes. Cervical and bowel cancer are operating normally. With population-based breast screening, there is still a bit of work to do to get back to normal, but invitations are now at above pre-pandemic levels.
I do not think it is so much about the pause in screening programmes as that people did not come forward during the pandemic. We have really pushed very hard to campaign to get people to come forward, with a lot of support from the charities. That is why we have seen those record levels of urgent cancer referrals. The issue for us is that diagnostic and treatment capacity needs to keep up with that.
Q5 Chair: Peter, welcome. Let’s bring you in. Was it a mistake to pause the screening programmes during the pandemic?
Professor Johnson: The screening programmes took the view on the ground—this was not NHS England’s decision but the individual regional screening programmes themselves—that they needed to pause invitations, particularly for women coming for mammography during the pandemic, in order to maintain safety.
Going back to the question of the numbers of people coming through the urgent cancer referral pathways, historically for the last decade we have been driving hard to get people referred into the system on the urgent cancer pathway. We have been very successful in progressively increasing the proportion of cancers that are diagnosed through that route. It is now up to just under half of cancers that come through the two-week wait pathway. As we have done that, the number of emergency presentations has fallen concomitantly because we have started to pull people in before they present as emergencies. We have also brought them in off routine referral pathways, where GPs might have referred them for problems to hospital but not on a cancer pathway.
We have brought a lot more people into the two-week wait system, which has driven up the volumes there, but of course has put pressure on the diagnostic system as we have done so. The numbers of two-week wait referrals have risen about 10% year on year, whereas the actual numbers of people with cancer only go up about 3% per year as a result of our ageing population.
Q6 Chair: Cally mentioned fear. Was there a Project Fear, to borrow a phrase, during the pandemic that frightened people out of the NHS? Has that led to a serious situation now? Anecdotally, certainly as a constituency MP, I hear that. I don’t think we can deny that, can we?
Professor Johnson: From the point of view of the cancer service, we started very early on. I could probably go back to April 2020 when we first started putting out the message in the media, through social media and through all sorts of channels, that we wanted people to continue coming to see us and that the NHS was there for them if they had symptoms that were worrying. From very early on during the pandemic, even while the country was coping with all the disruption caused by the wave of infections, we had already started to say that we wanted to do that. We ran a series of campaigns throughout the pandemic, specifically to try to counteract the effect of people not wanting to bother their GP or trouble the NHS at that time.
Q7 Chair: Cally, you were talking about the winter resilience plans that were set out last month. Do you feel that the three pathways you were mostly concerned about are sufficient? Are you happy that they are in a good place?
Dame Cally Palmer: There has certainly been incredible progress if you look at some of the hospitals across the country that were really struggling with their volumes because of the increased level of urgent cancer referrals that we have seen at a sustained level. I repeat that the trusts that were the most challenged—the tier 1 trusts—have reduced their 62-day backlog overall since August by 9%, and those in the tier 2 category by 4%. Sometimes you just need prioritisation and visibility, and to go through some basic steps about how patients are being tracked, whether individual boards are seeing the data about how many patients are being seen within a certain timeframe, and then the comply and explain, as I mentioned, in the three tumour types that make up a large part of the backlog. The big focus as well is that only 6% of the people on that 62-day pathway will have cancer. Most of them are still waiting for a decision to treat or for an exclusion of cancer.
Q8 Chair: That is one of the reasons why I wanted to do this session. There are some very sensationalist, dare we say it, headlines out there which will frighten people. I want to drill into the facts. That 6% is a key figure.
I have a final question and then I will bring in colleagues. You will know the “Cancer Services” report that we produced earlier this year. The Government responded to it. We talked about ICSs—integrated care systems—where there seems to be huge cross-governmental interest these days, which is great. As one of our recommendations, we asked that they should appoint cancer leads. Has that happened, or is it in the process of happening?
Dame Cally Palmer: It has, because we have a series of 21 cancer alliances across the country and the guidance to the ICSs is that the cancer alliances—collaboratives of primary care colleagues and acute colleagues, all focused solely on cancer—will be the cancer arm of the ICB. They will do a cancer plan. They will do all the transformational work. The work we are doing to encourage particularly people with symptoms suspicious of lung cancer to come forward early—some of our transformational initiatives—is driven by the cancer alliances. The ICBs look to the alliances to advise on the strategy for cancer and to show delivery in cancer. There is very clear guidance now to ICBs about the role and function of cancer alliances in the new structure.
Chair: This is a perfect moment to bring in James Morris.
Q9 James Morris: Notwithstanding the short-term pressures that we have been talking about, are we going to get a 10-year plan for cancer services?
Dame Cally Palmer: I think that is really a matter for the Government. What we do have—
Q10 James Morris: Do you think we need one?
Dame Cally Palmer: We have an NHS long-term plan already. We are partway through that. The big focus, which the NHS has not had before, is on the front-end presentation, the diagnostic pathway. We know that early diagnosis is a big determinant of survival and outcome. The long-term plan is the thing we are working to anyway.
Q11 James Morris: Can I press you? Do you think there needs to be a 10-year plan for cancer?
Dame Cally Palmer: I think there needs to be sustained investment and prioritisation of cancer, yes. As the national cancer director I would say that, because there has been huge development in our knowledge and understanding of the causes of cancer and better precision treatment for cancer. It is very important that we have sustained prioritisation of cancer to accelerate some of those advances in the NHS. They are the best thing for patients for their cure or extension of life. Actually, they can be much more productive for the NHS because it is about precision—precision diagnostics using genomic capability and precision treatments.
Q12 James Morris: Do you think there is resistance in the Government to have a 10-year cancer plan? It was mooted several months ago. Understandably, there have been several Secretaries of State. Are you getting direction from Ministers that we are going to be working on a 10-year cancer plan, and that it is going to be delivered?
Dame Cally Palmer: At this point I cannot answer that. There has obviously been a recent change of Secretary of State. What I do know is that there is continued interest, for which I am very grateful, in the transformation of cancer services, with investment behind it, which is what we are doing with the long-term plan.
Q13 James Morris: Professor Johnson, do you think there needs to be a 10-year cancer plan urgently?
Professor Johnson: I think it is really important that we stick to the ambition to drive up rates of early diagnosis and that we continue to innovate and pursue many of the initiatives that we already have under way, such as piloting new blood tests to find cancer at an earlier stage and accelerating diagnostic pathways. We have a huge amount in hand already. The most important thing is that we have consistency—
Q14 James Morris: Do I read that as saying that no, you do not think we need to have a 10-year cancer plan because it is all there already, so it does not need to be articulated as a 10-year plan? Is that what I am reading from what you say?
Professor Johnson: I think it is important to have a cancer plan, and we have a cancer plan. Whether it needs refreshing at this point is a matter for the Government rather than us.
Q15 James Morris: If we were to have a 10-year cancer plan, or if for future priorities there was a recommendation in the Committee’s report on cancer services that was for an action plan for improving survival for less survivable and less common cancers, can I ask whether that is happening?
Professor Johnson: There is a lot of work going on across the piece on trying to, for example, diagnose at an earlier stage the more difficult to survive cancers such as pancreatic cancer and some of the leukaemia and childhood cancers. Again, a lot of our work and focus is on how we identify people with difficult to pin down symptoms. We have our rapid diagnostic centres in 90 different locations around the country, specifically focused on helping people with symptoms that do not fit any of the usual suspects, to help them into the system more rapidly. There is an enormous amount going on in that area already.
Our ambition to diagnose more cancers at an early stage will not be met if we only focus on bowel cancer, prostate cancer, breast cancer and lung cancer. We need to make sure that we bring people with all types of cancer into the system more efficiently and diagnose them more rapidly.
Q16 James Morris: Cally Palmer, do you agree with Professor Johnson that we do not need a refresh of the strategy for cancer?
Dame Cally Palmer: It is really important that we deliver what we say we are going to deliver against the long-term plan. We need sustained investment in the cancer workforce and diagnostic capacity. Those are the things that I think need to be maintained to allow us to work with local systems and to improve survival.
Q17 Chair: I am a bit confused now. In February, Sajid Javid, as Secretary of State, announced a new 10-year cancer plan. A call for evidence was put out on 31 March with a focus on early diagnosis, health disparities in cancer prevention, workforce, technology and improving cancer pathways.
That did not happen. It has not emerged. At Prime Minister’s questions on 7 September, the then two-day-old Prime Minister—it did not last much longer—confirmed that she intended to proceed with a 10-year cancer strategy, but there has been no equivalent confirmation by the current Government. I wrote to the new Secretary of State on 8 November asking about this. If I am honest, I thought there was a changeover of personnel, a changeover of Ministers, a changeover of special advisers and that it was coming. I get that you are not the Ministers, and you are saying that we need to ask Ministers. Trust me, we will. When the Secretary of State comes before us, we will enjoy asking him about this. We look forward to a date.
You are the cancer team. I am not sure now whether there is a 10-year cancer plan in the offing. Are you saying to Ministers, “No, we need a refresh of the 10-year cancer plan, guys. We need to get this out there. It needs to have a credible workforce plan attached to it.” I am getting the sense here that you are giving me politicians’ answers that you worked out before coming to see us about the need for a new 10-year cancer plan, which was committed to by the Secretary of State. Yes, the personnel have changed but the role is still the same. It is still the same Government.
Dame Cally Palmer: My job is to deliver the current cancer plan. I am doing that with Peter’s help and with the cancer alliances across the country and the support of the cancer charities. All the ingredients that are in that plan—early diagnosis, harnessing innovation, trialling blood tests to detect cancer in asymptomatic populations—all those things—
Chair: All there.
Dame Cally Palmer: They are all there. We have a series of interventions between now and 2028 already that we are working through so that we can save 55,000 more lives a year. As I say, cancer is a fantastic subject for transformation because we have so much technological advance and capability, and we have a unified NHS to roll it out.
We have a plan. I think there needs to be sustained investment in the cancer workforce and in diagnostic capacity, particularly as only 6% of the people on that big backlog pathway will have cancer, as I said to you. It is about how we manage the front end of the pathway with very early and fast diagnosis efficiently and well. We are midway through that big plan.
Q18 Chair: Would it be mischievous of me to say that, when the Secretary of State announced that in February, it was not necessary?
Dame Cally Palmer: I am always happy to have a focus on cancer. I think it is really important, but all the actions that we are taking would have been relevant to that. They are relevant now and they are relevant through to 2028. There will need to be sustained investment beyond then, but I think it is a matter for the Government. We are sticking to the plan that we have.
Q19 Chair: The long-term plan’s commitment on diagnosis is 75% of cancers at stage 1 or 2 by 2028. Let’s put it on the record here, live on the television. It is something that you and I agreed together when I was the cancer Minister. I stand by it 100%. I am asking you whether you think you have the tools and the funding to achieve it.
Dame Cally Palmer: This is a funding line we have through to 2028. I think Peter’s phrase last time was “cautiously optimistic”, and I am behind that phrase. It is very important for patients that we achieve it. With one of the activities that we are undertaking throughout the country—the targeted lung health check, with low-dose CT scanners in supermarket car parks and football stadia in areas of high social deprivation and high lung cancer mortality—we were seeing only 14% of people at stage 1 or stage 2, when you can cure many of those lung cancers completely. We are now seeing 76% early. It is that scale of difference, if you get the model right to encourage people to come forward in community settings that are appropriate for the public.
Chair: I think of our late colleague James Brokenshire when you mention that. He was instrumental in pushing that agenda here in the House and pushing it with us as Ministers. He would be pleased—God bless him—to hear that.
Q20 Rachael Maskell: Thank you, Dame Cally and Professor Johnson, for coming along this afternoon. I want to continue on the theme of diagnostics. Clearly, data leads you to understand the deficit that exists, but not necessarily to knowing the people, because people have not come forward—the missing million for breast cancer screening, for instance, and many more. How are you prioritising, not just to have business as normal but to pivot the diagnostic services to be able to catch up with cancer diagnoses?
Dame Cally Palmer: There is a huge investment, as you probably know, in community diagnostic hubs. This is about creating many more scanners per head of population and a £2.3 billion commitment by the Government to do that. There are 91 of those rolled out already. The work that Peter and I are doing with the cancer alliances and those community hubs is to try to get direct GP access to tests, so that you can wrap the tests around a patient and a GP can make a direct referral. We are trying to truncate the front end of the pathway to make it easy for patients to come through to the diagnostic capacity and to get an exclusion of cancer or a diagnosis of cancer and then onwards into treatment. There is a big investment in community diagnostic hubs and extra scanning.
We are also working with GPs on timely presentation. We are looking at things like routeing patients through community pharmacy as well as through primary care, and at how we can pilot different ways to get people into the system. There is a lot of work going on in timely presentation, getting people to come forward and then have swift access to tests that are wrapped around a person. What you do not want is someone who bounces around in the system, which patients often tell us happens. Those hubs will be really important.
The other thing that Peter mentioned, and the message we get very strongly from patients, as I said at the last Health Select Committee, is that where there is a sign or symptom, a breast lump or a mole, very often you get people at a much earlier stage because there is a visible sign, but many people do not have a visible sign or symptom. It is general weight loss, bloating or pain, so we have created non-specific symptom pathways for GPs. Rather than patients going in for a test, coming back out and then going in for another test and coming back out, there is a new pathway for someone with general symptoms that the GP and the patient are worried about. There is a range of things about timely presentation and methods of enhancing the way we diagnose different types of cancer, which, hopefully, make it easier for the public to access services.
Q21 Rachael Maskell: Clearly, that backlog will be stratified and those from areas of greatest deprivation are likely to have less contact with diagnostic services. How are you particularly targeting to ensure that we do not see the inequalities that we have seen in the past?
Dame Cally Palmer: I will start, and Peter might want to come in. We are doing targeted interventions. The lung checks are the big thing and are already showing promise. We are piloting liver surveillance for people with alcohol abuse or liver issues. It is a much more specialised version of the lung check. We are also taking certain groups. Some of it is about social deprivation, which is a big determinant of outcome. Some of it is about people at higher risk. The higher risk category involves new work on BRCA mutations with the Ashkenazi Jewish population, to make sure that they can be screened effectively and well. We are trying to do the right targeting, both for people’s individual risk and for the level of social deprivation, so that we target groups rather than saying that it is one size fits all. Peter can probably give a better clinical answer than me.
Professor Johnson: You are absolutely right to highlight the fact that people at the low end of the socioeconomic scale were disproportionately affected, particularly during the pandemic, although interestingly they continued to consult their general practitioners in probably greater numbers than people in less deprived areas. The number of referrals that we saw coming through from those communities was lower and they have been slower to recover. A lot of the work we are doing in restoring services is very much targeted, and a lot of our public information campaigns are specifically aimed at that particular demographic.
The lung health checks, as we have already said, are particularly aimed at deprived communities. We are taking the diagnostics to where people are. Similarly, community diagnostic centres are preferentially being located in places of greatest deprivation. We are working, for example, on a pilot scheme with community pharmacists for people who do not traditionally go to see their GP but might go and see a pharmacist to get a repeat supply of over-the-counter medication for worrying symptoms, and whether we can direct them into the system more readily. There are lots of different angles of work going on to try to make sure that we really target the population where we think the risks are highest.
Q22 Rachael Maskell: Another challenge that has not been mentioned is the workforce deficit. That is going to challenge the targeting and your ambition. How are you particularly looking at professions to bring them forward—for instance, diagnostic radiographers? We know there has been a constant issue for over a decade, and a massive challenge in other areas. How are you particularly focusing on the workforce? Within a 10-year plan, should that emerge, how prominently should workforce planning feature? The Chancellor mentioned that the workforce plan is going to happen. We do not know the shape of that, but how would you bring it forward to ensure that you had the tools to do the job that you need to do?
Professor Johnson: It is a really important emphasis for us. The workforce will be critical to delivering everything that we have set out to do. We have made progress in the last five years in increasing the counts of workforce. I think we increased it by around 4,300 full-time equivalent staff. That is an increase of about 20% in diagnostic radiographers, therapy radiographers, oncologists and so forth. There is work going on, and we have had settlements in the last two years that have allowed us to continue increasing the numbers of people in training. Of course, it takes some time for people in training to come through.
Q23 Rachael Maskell: Is that the factor that is holding you back?
Professor Johnson: At the moment, no. We have resources. What is important is that we have a settlement going forward for the next few years that allows us to continue that process. There is a long-term workforce plan in development which we are hoping to share with the Department of Health by the end of the year. It will be critical to our success that we have that support to allow us to continue recruiting the sorts of numbers of people that we need.
Q24 Chair: Following up something that Rachael was talking about with you, radiotherapy is needed in about 40% of all cancer cures. If radiotherapy falls over, the entire cancer pathway falls over. Radiotherapy are raising red flags with me about the workforce. No matter how many machines we have, it is the radiotherapy workforce. Peter, should we be concerned about the radiotherapy workforce? They are concerned about it.
Professor Johnson: As I say, we have increased the number of therapy radiographers, who are the people who drive the radiotherapy machines, by about 20% over the last five years. We have continued investment going into that workforce. I agree that it is very important. We have put capital into new machinery. We need to continue to bring people on to that workforce. It tends to be quite a young, mobile workforce with a high turnover level, so you cannot afford to stop bringing people into training.
Q25 Chair: We spoke in our report about diagnostic capacity. We talked about GPs facing pressures not to refer because of the strain on the diagnostic services that they would be sending into. Do you think that is fair criticism?
Professor Johnson: We have seen record numbers of referrals from colleagues in primary care to the cancer pathways. We have seen about a quarter of a million people a month being referred in. That is about a quarter of all GP referrals on urgent cancer pathways.
Our colleagues in primary care are doing a fantastic job of finding people and referring them into the system. The important corollary of that is that the proportion of those people found to have cancer ultimately has not really dropped as we have seen the numbers going up. It is still low. It is 6%, but the fact of the matter is that it has stayed stable. Our colleagues in primary care are doing a great job of trying to get people referred and diagnosed.
Q26 Chair: Dr Richard Roope from the RCGP gave evidence to our cancer services inquiry. He said that no GP comes into work to miss cancer. Of course. When you come to the less survivable cancers that James Morris was talking about—we had a big event in the House targeting ovarian cancer last week—we hear so often women saying that they knew something was wrong, and they are very critical of our colleagues in primary care about missing ovarian until it is very late. From a clinical perspective, could you expand on what Cally Palmer was talking about with the non-symptomatic presentation that you are helping GPs recognise?
Professor Johnson: As well as having GPs refer into the urgent cancer pathway, we have sought to empower them to do their own tests if they feel they need them. Historically, provision of that has been quite patchy. Some GPs have had access to CT scanning, MRI scanning and ultrasound, and others have had difficulties with that.
What was announced, I think last week, is that direct access for GPs for CT scans to pick up things like ovarian cancer, where often the symptoms that present are quite low level, is something we have set out to make available universally across England. I hope that will help colleagues in primary care to investigate people more when they have suspicious symptoms. Similarly, as we have already talked about, the rapid diagnostic centre pathways allow people to come in when it is not very clear in which part of the hospital they might need to be seen to investigate their symptoms.
Q27 Chair: Do we need to be more understanding of GPs? They have the devil’s own job, don’t they, especially when it comes to ovarian, for instance? There can be very vague symptoms that can quite easily be confused with other completely non-threatening symptoms.
Professor Johnson: I have huge respect and sympathy for colleagues in primary care who, every day, see hundreds of people with all sorts of symptoms, some of which could be cancer. Working out which of those truly are and which are something not to worry about is incredibly difficult. Our ambition is to give them the tools to lower the barriers to onward referral and make sure that they have support. We are working on rolling out clinical support tools, for example, to go on GP desktops to help them to sift through the symptoms and the ways in which people present them. Yes, absolutely; they deserve full support and everything that we can do to make their jobs easier.
Chair: We mentioned pharmacists earlier, so I am going to bring in my colleague Taiwo Owatemi, who may well have some questions in that regard and some other things she wants to talk about.
Q28 Taiwo Owatemi: Thank you, Dame Cally Palmer and Professor Johnson. Earlier this year, in our report we made a recommendation that both MHRA and NICE should work better together to improve access to cancer medications. As a cancer pharmacist, that is something that I personally would like to see. I wanted to know if any progress is being made to help achieve that.
Dame Cally Palmer: In terms of working more closely together to accelerate the introduction of new medicines, do you mean?
Taiwo Owatemi: Yes.
Dame Cally Palmer: Peter can probably reference the nature of some of the drugs, but working together is very important. Cancer is obviously a drug-heavy subject area. We have introduced a very significant number of new medicines in the last 12 months or so. There has been an acceleration of the introduction of new types of medicines and new combinations of medicines for cancer. That has been working well. I think there is probably still some work to do on alignment, Peter.
Professor Johnson: Yes. In general terms, I think the system for appraising and bringing new drugs into routine use, if they are shown to be good value for money to the NHS, is working rather well. Certainly, if we look at the UK adoption of new medicines, I think we are competitive on an international level. A review of over 200 new medicines recently showed that the UK was third globally in the numbers that we have commercialised within a year of first approval. I think the system works well. In some respects, the numbers of new drugs coming through, particularly for indications such as breast cancer, are putting pressure on the system to make sure that we have enough people to deliver them— enough specialist nurses, enough oncology pharmacists and enough oncologists themselves.
Q29 Taiwo Owatemi: Are you saying that there is no need to better align both NICE and MHRA processes?
Professor Johnson: NICE works very closely looking at what is coming through for licensing at MHRA and is increasingly proactive at making its assessments of value for money in the NHS. I think the pipeline for that is very effective at bringing in new medicines.
Q30 Taiwo Owatemi: On the subject of research, earlier this year I met the Rare Cancer Alliance, and they expressed their concerns about research into rare cancers. The Health and Social Care Committee recommended that we should have a ring-fenced budget to promote cancer research in these particular areas. Is any progress being made to help achieve that?
Professor Johnson: In terms of research into cancer?
Taiwo Owatemi: Particularly rare cancers.
Professor Johnson: That is less NHS England’s business than that of the National Institute for Health Research. Our job in NHS England is to provide the most facilitating environment that we possibly can for the conduct of research. In order to do that, for example, we are working on a thing called the national contract value review, which is aimed at making it easier and faster to set up things like commercial trials so that we can gain the evidence as rapidly as possible. We are working with colleagues in the National Institute for Health Research on how we can streamline the set-up of clinical trials, how we can bring these things into the system faster and how we can lower some of the barriers to innovation in the NHS. We have started to do some research of our own, such as the very large blood test screening study with the GRAIL company. We have a partnership to do a large, randomised trial, and we recruited 140,000 people last year to take part in that. That is the NHS itself starting to move into research.
Q31 Taiwo Owatemi: Lastly, on the subject of lowering barriers so that all patients can get involved in research, what work is being done to improve access for ethnic minorities to cancer research?
Professor Johnson: In cancer research, the research funders in many cases have prioritised visibility of people from ethnic minority groups in the research process in order to make it more accessible. The Black in Cancer initiative, which was started by Cancer Research UK, has been very successful in doing that.
On the NHS side, our job is to make sure that we are targeting the information that we put out through things like community groups. Black and Afro-Caribbean groups have been incredibly helpful to us in, for example, getting out the message about prostate cancer and early diagnosis. We know that prostate cancer is much more prevalent in those communities. We work proactively with community groups through our cancer alliances and through our patient and public voices forum to try to make sure that we are reaching those communities and, at the same time of course, emphasising to them the opportunities to take part in research.
Chair: Dr Caroline Johnson has just joined the Committee today. Over to you, Caroline.
Q32 Dr Johnson: Thank you, Chair, and thank you, Dame Cally Palmer and Professor Johnson. I have a few questions following up on some of the things raised earlier. One was about trials. I am a consultant paediatrician. The vast majority of children who have cancer are treated within a clinical trial. That has driven quite substantial changes in cancer outcomes for children over recent years. What proportion of adults are in a trial, and what can be done to improve that?
Professor Johnson: The proportion of new incident cancer cases taking part in clinical trials is somewhere between 15% and 20% at the moment. That is my understanding of the figures from the National Institute for Health Research.
Q33 Dr Johnson: Compared with over 90% in children.
Professor Johnson: It depends a little bit on what you call research. A lot of children’s cancer is done according to a very specific protocol which is not in the nature of a trial. It is prospective registration of information about the outcomes of treatment rather than a trial comparing this treatment versus that treatment. It increases the numbers, but, yes, as a proportion, generally speaking, children’s cancers are more often the subject of research.
Q34 Dr Johnson: What can you offer that would improve the number of adults, enabling them to take part in research and improve their outcomes?
Professor Johnson: Again, in general terms, this is much more a subject for the National Institute for Health Research and the funders of research rather than NHS England. What we are trying to do in NHS England is to make sure that the processes for approvals of research, through research and development departments for example in NHS trusts, are as streamlined as they possibly can be. There are a number of different agencies: the medicines regulatory agency, the Health Research Authority; NIHR; and R&D departments in trusts. As I said, by trying to streamline this through the national contract value review, we are trying to accelerate the recovery of research that was suppressed during covid when a lot of attention in NIHR went into covid research. Resetting that and bringing the trials back up again has been a big piece of work for NIHR.
Q35 Dr Johnson: I am glad to hear that you are streamlining things, because my experience has been seeing people who say, “Well, if I can count it as an audit I will do it, but if it is research it is too complicated to register.” That is good to hear.
You referred to the Galleri trial and what is being done there to look at blood tests to identify people who might have cancer but do not have any symptoms at all. When will you start to get early results from that?
Professor Johnson: The plan for that study is for people who are taking part to have three annual rounds of blood tests. The final results of the trial would be about a year after the three years of sampling.
There is an intermediate milestone, when we look at the results of the first round of screening. Those will come through when we have a year’s follow-up on everybody who has been included. It will be the end of next year and the beginning of 2024 when we start to see some initial results. What we are going to be looking at there is whether we see an increase in the absolute numbers of cancers that we pick up; whether we see a reduction in the numbers of late-stage cancers that we pick up; and what the positive predictive value of the test is.
Q36 Dr Johnson: Thank you very much. My other question is about numbers. Our report from earlier in the year—I was not part of the Committee then—said that 45,000 fewer patients started on cancer treatment during the pandemic than in previous years. Have we seen those patients come through with late-stage cancer, or was there a genuine reduction of any kind in incidents in that period?
Dame Cally Palmer: I will come on to the cancer treatments in a minute. On the early diagnosis rates, we have completely recovered the number of patients, the proportion of patients, being diagnosed at stages 1 and 2. That is quite recent information. We were obviously worried that people were not coming forward and that there had been more late-stage disease. Generally speaking, the proportion of people being diagnosed at stages 1 and 2 has slightly increased beyond the pre-pandemic level.
Q37 Dr Johnson: If you are saying that there are 45,000 fewer patients in that period, one would presume there would potentially be 45,000 patients with cancer who did not know it, who would otherwise have been starting their treatment and would have to present at some point.
Dame Cally Palmer: A number of patients did not come forward. What we were doing was comparing the number of first treatments you would ordinarily expect to see with what we saw during the pandemic. That number has halved now. It is down to about 22,000 and they are known to the system. What we were worried about is that if you looked at the maths of people who would ordinarily have had a first treatment, compared with what we saw during the pandemic, there was a gap. We have caught up with that. It is much reduced and those people are now in the system, so they are not lost to the NHS, if I can put it that way.
Q38 Dr Johnson: You have had a comparable increase in the number of first starts this year.
Dame Cally Palmer: Yes. Treatment levels are above pre-pandemic. Not only are urgent referrals well above pre-pandemic levels, but treatment levels are also above pre-pandemic levels.
Q39 Dr Johnson: Early diagnosis only leads to better outcomes if you start the treatment earlier as well. It is actually the early starting of treatment that saves you rather than knowing about it. You said that only 6% of people on an early 60-day cancer pathway will actually have cancer. As a medic, I know that there are patients that you refer on this pathway largely as an exercise because they have met a threshold and therefore you send them in. There are other people where you think, “No, they have got cancer.” As a medic, you can appreciate that there is a difference between the people you are doing it for because you have to and those you are doing it for because you think they actually do have cancer. Given that we want to reduce mortality overall, is there anything you can do with the pathways so that when we think patients actually do have cancer, as opposed to might have cancer, they get pushed further to the front of the queue?
Dame Cally Palmer: One of the key new measures we have introduced is the faster diagnosis standard, so that you can either diagnose or exclude cancer within one to 28 days. Interestingly, when we were developing the standard, what we had to find a data point for was the point at which cancer is excluded. You have a lot of people who wait on that pathway for a decision to treat. The faster diagnosis standard was about getting a definitive decision to move someone on to a treatment pathway and have a treatment plan, or to exclude cancer, rather than leaving them in a line of further diagnostic testing to try to get to a resolution of what type of cancer, or whether they had cancer. The FDS has been quite an important milestone in trying to focus on that first part, and then speed people through to treatment.
Q40 Dr Johnson: There is no way that a doctor can say, “Actually, I am certain or as certain as can be that this patient does have cancer, so can they jump that possible cancer queue?”
Professor Johnson: It is really difficult to do. Obviously, if it were straightforward to do it, it is something we would be keen to do. Faecal immunochemical testing is a good case in point. By asking GPs to do a faecal immunochemical test—a blood in poo test—at the point of referral, we then get a numerical value for the amount of blood in the poo. The people with very high levels are the ones who need to be fast-tracked to have a colonoscopy test to examine the bowel, to see if they have a cancer. The people with a low, but not negative, value can probably go down a different diagnostic pathway such as the colon capsule—the camera in a pill that we have been piloting—or CT colonography. People who have a very low level, and consequently have a very low risk of cancer, can probably be managed in other ways, perhaps with a repeat test at some time. Being able to triage and select the people at the highest risk of cancer is something we would like to do for lots of other pathways, but at the moment we do not have the tools to allow us to do that very readily.
Q41 Dr Johnson: Looking at the chief medical officer’s previous report, from 2020, on the different incidences of different cancers, he reported at that point that the greatest increase in cancer mortality and the largest increasing incidence was in liver cancer. Do you have any information on what is causing or driving that, and what you believe can be done to reverse it?
Dame Cally Palmer: Can you talk about the liver pilots, Peter?
Professor Johnson: Yes, sure. What is driving the increase in liver cancer mortality is probably an increase in fibrotic liver disease, where there is cirrhosis. The causes of that are chronic hepatitis C infection, excess alcohol, or fatty liver disease as a consequence of obesity and being overweight, the metabolic syndrome. All of those can potentially give rise to an increased risk of liver cancer, which is why we have started piloting an approach with hepatologists to make sure that people at the highest risk of moving from fibrotic liver disease to hepatocellular carcinoma are referred for ultrasound surveillance of the liver to see if we can pick up liver cancers at an earlier stage. Again, this is another cancer where, if you can pick it up early, you can potentially carry out curative surgery.
Q42 Dr Johnson: I was briefly a Minister in the Department of Health—quite briefly—and was privy to seeing the results, and presenting the results, of the opt-out testing that has been going on in some of our hospitals to test for the blood-borne viruses, hepatitis B and C and HIV. In 100 days, it found that 328 cases had hepatitis B and 137 had hepatitis C, but it is only working in a small number of hospitals. Given what you said about liver disease, liver cancers and hepatitis C, and the treatability of hepatitis C now compared with when I was at medical school, should we not be rolling out that opt-out testing to more hospitals across the country?
Professor Johnson: To be honest, you are well outside my area of expertise in hepatitis C screening.
Q43 Chris Green: Dame Cally, breast cancer survival at stage 1, if it is caught then, is 98%. If it goes to stage 4, it crashes down to 24%. Shouldn’t people around the country be deeply concerned that the cancer diagnosis target for catching up has been shifted back from March 2022 to March 2023?
Dame Cally Palmer: Sorry. Which target do you mean?
Q44 Chris Green: The target to clear the backlog. The Chair was referring earlier to the target that was March 2022 this year.
Dame Cally Palmer: The reduction in the 62-day backlog.
Chris Green: Yes.
Dame Cally Palmer: For the 62-day backlog, we need to return to pre-pandemic levels by March. That is the target, as I said earlier. Two thirds of the patients waiting are not breast cancer; they are lower GI—
Q45 Chris Green: I didn’t mean to say that all of those were breast cancer. I was just highlighting the point that a delay in diagnosis, and therefore, treatment, may take people up from stage 1 to stages 2, 3 and 4.
Dame Cally Palmer: The really important thing is that 6% of people in that backlog will have cancer. The majority will not have cancer. That is not to be overly defensive, but I want to put it into context.
Q46 Chris Green: I appreciate the clarification. Will the pushing back in meeting the target be of deep concern to people?
Dame Cally Palmer: If you are a patient, any wait will make you anxious, quite understandably. Our job is to make sure that we streamline patients through as fast and as efficiently as possible, whether they have cancer or not. Generally, breast cancer has a sign and a symptom and is diagnosed early and fast. Our survival rates are high in this country compared with international rates.
Q47 Chris Green: How confident are you that the March 2023 target will be met?
Dame Cally Palmer: We are working really hard to get there.
Q48 Chris Green: How confident are you of meeting that target?
Dame Cally Palmer: I have said that we are working really hard to get there. I have explained that there has been a reduction in all the challenge providers. There has been a very significant reduction in the backlog since August for those waiting between 29 and 62 days and those waiting over 62 days. We have very specific plans in place. It is all going in the right direction, but, having said that, that target was set before the second wave of covid. We have to work really hard to get there. We are trying hard.
Q49 Chris Green: I appreciate the difficulties. One of the concerns I have as a Member of Parliament representing my constituents is how well informed the public debate was of the impact of lockdowns in terms of the impact assessment. If we, on the one hand, focus more on covid and have those restrictions, what impact does that have on cancer, on heart disease and a whole series of other challenges? We are now seeing delays because of the second and third lockdowns.
Dame Cally Palmer: I will say a couple of things because I see you pausing. Cancer treatment overall was maintained at 93% of pre-pandemic levels, so it did not drop. We saw a drop-off in referrals, but the treatment levels were maintained at quite a high level. During the pandemic, cancer and covid were the two big priorities. It was maintained very well, and we worked very closely with all the cancer charities, who have very powerful patient information lines, to get people to come forward.
Q50 Chris Green: To clarify, if there was a significant drop-off in GP referrals, because people did not go to the GP any more, that would then have a knock-on impact, wouldn’t it?
Dame Cally Palmer: Except that we are back up to 129% of pre-pandemic levels and the early diagnosis rates overall are above where they were pre-pandemic.
Q51 Chris Green: It is more about that pandemic period, when Members of Parliament were trying to make decisions on whether to support the second or third lockdown, in terms of our information and understanding at that stage.
Professor Johnson: There are a couple of observations that might be relevant. First, we have not seen an absolute increase in the numbers of people diagnosed with late-stage cancer. We saw a decrease in the proportion diagnosed with early-stage cancer because people with very small breast lumps that they were not aware of, or early prostate cancers that would not have been picked up because people were not seeing their GPs and getting their PSAs measured, were not coming forward. That recovered very quickly. As Cally said, we are actually seeing more people with early-stage cancer than ever previously.
The second thing is that we have not seen any increase, and we have been looking very carefully, in the numbers of people dying of cancers in the last three years. That is obviously very important. It is still early days, and we are still very vigilant. Nobody is complacent about this, but we have not seen any increases in people dying of cancer.
We have seen, intermittently, increases in the rate of death among people with cancer—some excess death rates—and those coincide with periods of peak incidence of covid. Mostly, that was people dying of other things who happened to have cancer during the times when covid was very prevalent. In between times, we have often seen lower rates of death among people with cancer. The most important thing, clearly, is to contain the infection and to stop people getting covid, and to stop covid putting pressure on hospital systems.
Q52 Chris Green: As a follow-on from that, there was presumably quite a significant impact on medical research, whether the charitable sector, pharmaceutical companies or others, during the covid period when the system more broadly was focusing on covid and perhaps lung specialists were moved over to focus on covid. There would have been a very significant impact on that research effort, as well as on the people attending and populating the clinical trials. Could you give me a very broad assessment of how great an impact it had on that medical research effort?
Professor Johnson: I think we all recognise that research in the broader field of medicine was affected by the need to switch our resources very heavily into covid research for the period when prevalence was very high and before we had the vaccines. That is now being recouped. We lost a certain amount of time, and there are some trusts—
Q53 Chris Green: Can you give me a sense of what the impact has been? Obviously, there are going to be problems, challenges and delays, but can you give me any sense at the moment, whether in the field of cancer research or more broadly, of what the level of impact has been? Over this period, has the research effort broadly been delayed by a year, six months or three months? I know it is quite a crude way to look at it.
Professor Johnson: It is genuinely difficult to say. My colleagues at the National Institute for Health Research may have a better sense of that. I think that probably about a year is a reasonable estimate of the level of delay, but it is a very rough estimate.
Q54 Chris Green: Thank you. I appreciate the difficulty of pinning it down in a clear and robust sense. Turning to clinical trials, how great is the concentration of people participating in clinical trials, perhaps in the south-east or particularly in London, in comparison to some other parts of the country?
Professor Johnson: That is not a phenomenon as far as I am aware. The advantage of having a nationwide network of cancer research is that recruitment goes on pretty much across the piece. Very early stage trials and very experimental medicines tend to be concentrated in large teaching hospitals, but again those are across the country. I have colleagues in Newcastle, Manchester and Birmingham conducting early phase research, as in London. The large-scale trials that recruit hundreds of people from across the country, where we may have 90 or 100 centres entering patients and offering people the chance to take part in that research, allows us to recruit from a very wide range.
Q55 Chris Green: There might be exceptions and particular cancers or treatments that are given where it might be different, depending on the centre, but broadly speaking if a new and perhaps effective treatment or medicine comes along, your geographical location in England or in the UK does not have such an impact on access to those early-stage treatments as they are going through clinical trials. Participating in a clinical trial can often be a very positive way to access treatments early on.
Professor Johnson: Proximity to a large teaching hospital undoubtedly makes it easier to take part in the very early-stage research, but the national cancer network allows people to take part in much larger trials much more readily, wherever they are. It varies a bit according exactly to what sort of treatment and what sort of research you are talking about.
Q56 Chris Green: You are not overly concerned that because harder-to-reach communities are in different parts of the country their access is reduced. I do not get a sense that you are overly concerned. Obviously, it is not going to be perfect.
Professor Johnson: Not specifically. Paradoxically, many of our large urban centres, where we have greater concentration of deprivation, are the places where a lot of research is most concentrated.
Q57 Chris Green: Just a final point. In the annual funding of the national health service, when you are looking at radiotherapy treatments and radioligand therapy where you might need specific infrastructure and expensive equipment or specialised training, is there a bit of a challenge in the up-front costs for those sorts of treatments, with the approach we have at the moment to funding?
Dame Cally Palmer: There are a couple of things. The first thing is that we have national specifications. When we are rolling out SABR or new radiotherapy techniques, it is done in a unified way across the country, which is important. When a decision is made to change the way that something is being done—hyperfractionation, SABR or different types of radiotherapy techniques, for example, or different drug regimens or combinations—that is a national decision point.
Cancer is high tech. As I was saying to one of your colleagues earlier, it is heavy on drug use and so on. It is an expensive specialty, but I think we have high-quality cancer provision across the country. We have some variation that needs ironing out. The big issue for people is speed of access to the system, and then precision treatment in the system. The issue on your resource point is that much of what we are trying to do is to risk-stratify pathways and make treatment and the diagnostic part of the process much more precise. Cancer is a great candidate for precision, and that means a much more productive use of a specialist workforce, of drugs and of radiotherapy techniques. Decades ago, it was a one size fits all for cancer. That is not where we are now. It is all about precision and making sure that it is rolled out evenly across the country.
Q58 Chris Green: In terms of the funding—this is a very crude thing to say—if there are two treatments of equal value but you have more up-front costs with one particular treatment, that would not necessarily hold that treatment back.
Dame Cally Palmer: No, that is negotiated for us. Luckily, Peter and I do not do the negotiation on cancer drugs. That is negotiated for us. Our job is to make sure that we eradicate variation across the country so that people have access to the highest-quality care based on the latest research evidence. It is all about scaling up and making sure that there is a uniformly high quality of care for people throughout the country.
Chair: Inevitably, colleagues have a few follow-up questions as they have listened to the session. We will go to Rachael, Caroline and then Taiwo. Then there is a bit on prevention, which I would like, inevitably, to ask you about.
Q59 Rachael Maskell: I think that is where I want to go as well. The alarming thing I have heard from your presentations this afternoon is the rise in cancer of the liver. We know that people increased their alcohol use during covid, being at home. Clearly, this is very preventable. It seems that the piece that is needed is still the public health piece, sitting alongside the excellent work that you are doing. Obviously, there are early warnings. We have been through it with lung cancer. We are now looking at huge spikes in alcohol use, particularly in younger patients as well. That is of real concern. I am interested to know how you are getting on top of areas where a rise in lifestyle uses of alcohol—I won’t say choices—is then building into a rise in disease, as opposed to a reduction in disease.
Dame Cally Palmer: The NHS more widely is working on and investing in alcohol care teams. Across obesity, alcohol and smoking there is a range of public health prevention measures, which we in the national cancer team contribute to when asked, but that is not our main brief. There are some NHS activities across all three of those, and investment going in.
Where we try to get very actively involved is on things like the liver surveillance pilot. It is recognising where, because of deprivation or covid experience or whatever it is, there is an increased risk that we target differently. It is making sure that people find it easy to come forward. Again, it is about risk-stratifying. It is identifying areas like lung, which was our first successful example and is now going properly national. We are about a year into the liver surveillance pilot in areas where we think there is high alcohol use, to try to make it easy to bring people forward, check them and risk-stratify them to put them on a different pathway to specialist support, if they need it.
Q60 Dr Johnson: Following on from what Chris said about networks, how do you ensure, when you are creating networks across the country and are creating regions and areas for people to neatly package into, that patient choice, convenience and experience is taken into account, and that nobody falls through cracks on the edges of areas? When you have area-based commissioning, you have your primary care team and your regional oncology team. How do you make sure that no one falls through the gaps?
Dame Cally Palmer: There are a couple of things. The first thing is that the cancer alliances are our local systems that focus on clinical quality and pathway management, working across and supporting the ICBs. They are the cancer arms of the ICBs, as I said earlier. Those 21 cancer alliances have a complete mission in cancer to make sure that they are looking at quality and timeliness of care, as well as transformation of care. We fund them to roll out things like the liver checks.
Those alliances have a patient and public voice forum. They have input from local communities so that they can pick up on local issues. There is a mandated system of national cancer alliances with clinical leadership, clinical networks, and support in the management of those cancer pathways. They also have patient and public voice fora, where people can contribute to things that are an issue for people locally in quality of care or access to services.
Q61 Dr Johnson: To give you an example, if you have a child with cancer in Oundle, in North Northamptonshire, their nearest hospital by quite some margin is Peterborough, where I should declare that I work as a paediatrician. They are not commissioned to receive the services of paediatric community nurses unless they have a Peterborough GP, which they do not if they live in Oundle, but they are also living in Northamptonshire so they should theoretically get services from Northamptonshire hospital, but they do not because they are only commissioned to deliver to NN postcodes, and Oundle is a PE postcode. There is a child who has fallen through the gap at the edges, where they are not entitled to a service from either department. They have had to move general practice to a Peterborough GP who has agreed to take them on so that they can receive a community service at all for their cancer treatment.
Clearly, it is a non-ideal situation for a patient to have to change family practice at a time when they are going through such a traumatic level of treatment. What can you do, leading from the top, to make sure that we do not see children falling through a gap where there is no service commissioned for them, because no one has thought about the edges, both on patient choice and on complete coverage of services?
Dame Cally Palmer: We work closely with our specialist commissioning colleagues. We have recently issued the new paediatric specification. What is really important, as you will know, is that there is a principal treatment centre with a network of shared care centres, and then a very clear geography so that people do not fall through the system.
PTC and POSCU colleagues should be working with their cancer alliance to deal with any overlap or deficit problems around the edges of their catchments. What you are describing should not happen. I appreciate that it has, but it should not happen with the system of networked care for ill children. That should not happen, and it should be picked up. Frankly, it is an issue for the local ICB, I would say. We need to make sure that the spec is right, the network is right, and the alliances are functioning and funded. If people are falling through a system locally, that needs to be picked up locally and dealt with. It is not acceptable.
Q62 Dr Johnson: It is a question of responsibility. Whose responsibility is it to make sure that that area is covered?
Dame Cally Palmer: It is the ICB. That is the commissioning body.
Q63 Dr Johnson: If the patient chooses to go over the border into the next area because it is much easier, more convenient and more fitting with that patient’s lifestyle, who enables that patient choice to take place?
Dame Cally Palmer: The commissioners now operate through the ICB. It is the ICB, working across health and social care boundaries, that should be making sure that care is delivered uniformly and well for people.
Q64 Dr Johnson: If the ICB does not do that, who are they responsible to?
Dame Cally Palmer: They work through a region to NHSE at the centre. There is a chain of command.
Q65 Dr Johnson: Above the chair of the ICB, in this case who would be next in the chain of command?
Dame Cally Palmer: The chain of command that we work with is the other way on; we work through regions to ICBs, to cancer alliances in terms of provision of care. That is the way the hierarchy works.
Q66 Dr Johnson: Would you be fairly confident that there are no other such holes in provision, or do you suspect that there are?
Dame Cally Palmer: It is difficult to answer that question. We have cancer alliances throughout the country. We provide the evidence and data for them, and they provide assurance back to us as the national cancer team. Having cancer alliances, whose sole job it is to ensure uniformity and quality of cancer care locally, is the best way to make sure that happens. You have a whole team. We fund them to do additional quality initiatives. We fund those alliances precisely to take care of any deficit or issue in the local delivery of cancer services.
Professor Johnson: The chain is clear, from regional commissioners to integrated care boards and between them. If an integrated care board is not responding to the challenge, it will be the regional commissioner who is the next up the chain.
Q67 Dr Johnson: I suspect that the difference between Oundle and Peterborough, although it is only 20 or 30 minutes’ drive, is a regional boundary between East Midlands and East Anglia. Who looks at that edge?
Professor Johnson: It is where somebody lives that the responsibility resides for their care.
Q68 Taiwo Owatemi: I want to focus on the medicine supply chain, which was a massive issue even before the pandemic. What steps are being taken to address that? During the pandemic we saw a lot of shortages in cancer medicine. Even now, I get emails saying that a drug is not available. What are we actively doing to prevent this from happening in the future?
Dame Cally Palmer: Again, Peter might want to add to this. Oncology pharmacists are working with the UK Chemotherapy Board to look at where we can streamline processes and improve the productivity of the chain of supply. There is a lot of work going on with the oncology pharmacy community across the country to try to manage the aseptic issue, but you are right that it is a present thing that needs to be actively managed. A lot of work is going in from the specialist pharmacy teams, as I say, with the UK Chemotherapy Board.
Professor Johnson: At national level, NHS England has continuous monitoring of supply chain difficulties. This is not a problem particular to cancer drugs, although it has affected some of them because of the small volumes and some of the production problems. Happily, during the pandemic, I do not think we ever had to delay or defer treatment as a consequence, but we have had to do some quick work moving supplies from one place to another to make sure that we had them all available.
Q69 Chair: Thank you. We will end on prevention. CRUK says that about 38% of cancers are preventable; 15% of them are caused by smoking and 6% are caused by obesity. Looking at demand and supply, surely the sustainability of the NHS long term, and therefore cancer services, is dependent on us preventing ill-health as much as treating it. Never is that more important than in cancer.
Cally, do we do enough on our smoke-free ambitions, for instance, given that smoking is the biggest killer? Do we do enough on our anti-obesity measures? At the moment, they are being weighed up by Ministers as to whether they take forward some of the things that we produced in the Theresa May Government. Do we do enough on preventing cancer?
Dame Cally Palmer: It is a journey. With cancer, as you know well, the first thing to do is to prevent, and the next is fast, early diagnosis; the next is precision treatment and then support for people post treatment. There is a very clear objective in improving outcomes for people.
You are right that prevention is very important, particularly with smoking, alcohol and obesity. The NHS is investing in digital weight management schemes for the obesity issue, as I am sure you know. Quite significant investment has gone in this year to weight management programmes, and the same on alcohol dependency teams. It is a journey. There is more to do. There are issues for the Government on how that plays out too.
Q70 Chair: As the national director, are you basically busy dealing with the second two parts—the fast diagnosis and then the treatment, as well as your job at the Marsden—or are you offering advice to Ministers and the successors to Public Health England on really drilling down on our smoke-free ambitions? It is not everywhere that smoking is of hugely high prevalence, but we know that the rate of smoking among teenage mums in Blackpool is one of the highest in the country. Are the ICSs and their cancer arms—the alliances that we have talked about several times this afternoon—doing enough? Are you able to push that from the top?
Dame Cally Palmer: A community of effort is required, because these are long-term issues, and they are very significant for public health and wellbeing. As I have described already, where we in the national cancer team principally get involved, we are very happy to advise and to work with the community on how we improve performance in public health and prevention, but where we mainly get involved is in things like recognising that we need to put lung screening in certain parts of the country where, traditionally, there is a high level of deaths from lung cancer. We have a bigger job to do on smoking cessation.
Q71 Chair: That is still part 2 and part 3.
Dame Cally Palmer: Except that our lung trucks have smoking cessation services in them too. We are trying to do our bit in following through in a local community setting, so that we can support the wider community effort on prevention.
Q72 Chair: Presumably, money is never plentiful. The Government are looking for sources of income at the moment. We have given them a source of income, in that many of us tried to pass amendments around “polluter pays” in the form of a levy on the tobacco industry to pay for smoking cessation services, to drill down and help people who are really stuck. Would you support that?
Dame Cally Palmer: Sorry, support?
Q73 Chair: Would you support a polluter pays levy on the tobacco industry?
Dame Cally Palmer: I don’t think that is in my brief, I have to say. I am going to dodge that one.
Q74 Chair: You are, as ever, diplomatic in staying out of politics. Finally, what keeps you awake at night, and what should keep us awake at night when it comes to this?
Dame Cally Palmer: We need sustained investment in the cancer workforce and in diagnostic capacity. We have made a great start with the 91 community diagnostic centres. That is fantastic. We needed more scanners per head of population and we have made a great start on that. Investment is going into the cancer workforce.
There are two things. The first thing is that I want to see that investment sustained and maintained so that we can really maximise the benefit to patients and the public. The second thing for me—again if I go back to my lung example—is that I am anxious that we completely reverse late-stage diagnosis. It is rolling out the lung and liver checks and some of the work we are doing to target high-risk groups of people, and also in areas of very high social deprivation that are linked to poor outcomes from cancer. It is how we can accelerate that. We have plans, but we need to make sure that we maintain our pace and direction.
Chair: That ends our session. Thank you so much for your time, Dame Cally Palmer and Professor Peter Johnson. Thank you for joining us this afternoon at the Health and Social Care Select Committee.