IBH0025

Written evidence from Cancer Research UK

Cancer Research UK’s response to Health and Social Care Select Committee inquiry on Implementing the NHS long-term plan

Key points

1. Cancer Research UK (CRUK) welcomes the opportunity to respond to the Health and Social Care Select Committee’s inquiry into the implementation of the Long Term Plan (LTP) for the NHS. The LTP includes important and welcome commitments to improve cancer survival, including the commitment to diagnose 75% of cancers at stage 1 or 2 by 2028 and to offer smoking cessation services to all hospital patients on an opt-out basis by 2023/24.

2. The £20.5bn funding settlement for NHS England, announced last year, will go some way to supporting the implementation of the plan. It is welcome that some of the £20.5bn funding has been allocated specifically to cancer, including ‘fair shares’ allocations for the next five years to support Cancer Alliances transform services and implement programmes such as Rapid Diagnostic Centres and Targeted Lung Health Checks.

3. It is important that this investment is spent as effectively as possible so that it has the greatest possible impact. This requires ensuring that investment earmarked for cancer is spent on those interventions where evidence shows they will have the greatest impact on survival, such as cancer prevention and diagnosing more cancers at an earlier stage. Financial levers and incentives should be optimised to encourage efforts to drive service improvements and innovation, ensure adoption of best practice and support cooperation across the pathway.

4. However, the £20.5bn funding settlement will only apply to the services NHS England directly or indirectly commissions. Achieving the ambitions of the LTP for cancer will require wider action, and increased funding for wider Department of Health and Social Care budgets. In particular, the Government must urgently ensure that:

• There is sufficient investment in medical education and training budgets (including the Health Education England budget) to develop and implement a plan to address NHS staff shortages, now and in the future. Recent announcements to release capital funding in the NHS, and for plans to further develop AI capability, are a welcome step to solving some of the wider pressing issues faced by NHS services. But without a new settlement for medical education and training, the ambitions of the LTP will not be achievable. The NHS workforce urgently needs investment to ensure that there are enough staff to diagnose and treat cancer, now and in the future.
• There is enough public health funding to ensure that local authorities can fund a range of functions and services to continue to reduce adult smoking rates.
• The UK remains a world-leader in medical research, by investing in the UK’s Life Sciences sector. As part of Government’s commitment for 2.4% of GDP to be spent on R&D by 2027, National Institute for Health Research investment should increase in line with inflation and uplifts to UKRI funding.
• The infrastructure of the NHS – especially the equipment needed to diagnose and treat cancer – is fit for purpose, now and for the future.

Workforce investment

5. Diagnosing cancer at an early stage is critical to improving survival for people affected by cancer. But UK cancer survival continues to lag behind other comparable health systems, in large part because we tend to diagnose cancer later. While geographical variation in survival has reduced in England[i], inequalities persist – not just geographically, but also by cancer type, age and socio-economic status[ii], [iii]. We can and must do better on early diagnosis for all people affected by cancer.

6. The UK Government and the NHS recognises this position and has committed to improving early diagnosis. The LTP targets diagnosing 3 in 4 patients at an early stage (1 & 2) by 2028, up from just over half of patients currently, backed by several initiatives to support this improvement. If this ambition is met it could save thousands of lives and help the UK close the survival gap with comparable countries.

7. A major enabler to achieving the LTP ambitions is having the right workforce capacity[1] to implement the necessary changes in the NHS. But right now staff shortages are affecting every part of the cancer pathway. Currently 1 in 10 posts across the NHS are vacant, and it is estimated that without action this rate will increase to more than 1 in 7 by 2023/24[iv]. Vacancy rates are likely to underestimate the scale of the problem, as employers advertise for posts they can afford to recruit to, which may be less than is needed to meet patient demand.

8. Because of this the NHS has been struggling to keep pace with growing demand for cancer diagnosis and treatment. In 2018 there were over 1.9 million urgent GP referrals for suspected cancer – 40% higher than the equivalent period four years previously[v]. This is welcome as earlier GP referrals give patients the best chance of receiving an early diagnosis of cancer. Yet as referrals have grown, performance against the 62-day wait standard, which measures the time from a patient’s referral to their first treatment for cancer, has steadily declined. This is largely because of a lack of staff to carry out vital tests.

9. Staff shortages are already impacting on the implementation of the LTP. One of its key commitments is the roll out of the faecal immunochemical test (FIT) in the bowel screening programme, and to lower the age range for bowel screening to 50. Yet due to staff shortages in endoscopy services, FIT is being introduced at a less sensitive level which means that more than 1,000 cancers and nearly 7,000 pre-cancerous changes could be missed per year compared to if England used the same sensitivity level as Scotland[vi]. Health Education England (HEE) has acted to increase the number of clinical endoscopists working in the NHS in the short term, but a long-term solution needs to be found.

10. Staff shortages in the cancer treatments workforce are also affecting the NHS’s ability to deliver high quality care. There have been several high-profile instances where staff shortages have impacted chemotherapy units, such as in Oxford[vii] and Ilford[viii]. CRUK research has also shown that staff in non-surgical oncology believe shortages are a barrier to providing the best possible cancer care[ix].

11. And demand on cancer services is only going to grow. An ageing and growing population will mean over 500,000 people will be diagnosed with cancer each year in the UK by 2035 (150,000 more than in 2015)[x]; of these 46% will be over 75 (up from 36% in 2015)[xi], meaning that thousands more patients with cancer will be presenting with complex needs and require greater staff attention[xii]. Moreover, as more cancers are diagnosed at an early stage, the treatments workforce must be staffed to be able to deliver more curative treatment – for example, 70% of patients diagnosed with stage 1 cancer receive surgery, compared to 13% at stage 4[xiii]. And new forms of treatment like advanced radiotherapy techniques and the growth of genomic medicine will have an impact on the workforce which needs to be understood. If the early diagnosis ambition is met then we will also need to have a cancer ‘treatment’ workforce that is sufficiently equipped to meet demand.

12. The NHS has started to address staff shortages related to cancer in the short term. HEE’s ‘phase 1’ cancer workforce plan, published in December 2017, contained welcome actions to grow the number of key cancer staff by an additional 4126 by 2021. We understand that this is having some positive impact. In addition, the recent Interim People Plan sets out some short-term actions to change the working culture in the NHS and make workforce planning fundamental to local NHS plans. It also brings together national NHS bodies with workforce responsibilities for the first time.

13. But we are yet to see a truly demand-led approach to planning the future workforce numbers needed for cancer services, or any spending commitment for education and training to complement the uplift in NHS funding. Our own estimates suggest that we will need to double the NHS cancer workforce by 2027 just to meet rising demand[xiv]. We now need:

• The final NHS People Plan to contain a demand-led projection of staff numbers for cancer. HEE developed a ‘phase 2’ cancer workforce plan, which focussed on future needs and was a positive start. It is vital that this good work is not lost and is fed into the development of the People Plan.

• The Government to be bold and invest so that there is sufficient funding for HEE to train the workforce we need for the future. HEE has suffered a real terms budget cut of over £800m since 2015/16, including a nearly 10% budget cut in cash terms between 2017/18 and 2018/19[xv]. These cuts have meant significant reductions in workforce development and CPD budgets, which has particularly undermined HEE’s ability to increase retention in the short term, worsening the workforce crisis. And while HEE’s future workforce budget (which partly pays for the pipeline of training) has been protected in cash terms, ongoing real-terms cuts to this budget means that HEE will not be able to fund necessary future increases in workforce numbers within its current budget envelope. Just to reverse these budget cuts and restore 2015 real-terms funding levels would require HEE to receive an additional £1bn by 2023/24[2]. But at the very least we believe training and education budgets should see the same growth as the investment in NHS services to be fit for the future.

14. Cancer Research UK is commissioning research to estimate how much investment would be required to deliver different growth scenarios for the cancer workforce (using the key professions defined in HEE’s phase one cancer workforce plan) and we will be happy to share this evidence with the committee when it is available later in the autumn.

15. This is not solely about increasing the number of staff – retention, new ways of working (including better use of skills mix), better use of technology and AI all have the potential to have a positive impact in time. However, ultimately more staff are needed, to not only meet increasing demand but transform the NHS into a world leading system for cancer survival. 

16. This is a widely understood and accepted challenge for the NHS. There have been calls for a longer term, demand-led, approach to NHS workforce planning for several years. In cancer, the Cancer Strategy that was published four years ago made clear that the scale of the challenge in cancer was significant, and that action was needed. Unfortunately, not enough has changed over the last four years to adequately address this.  

Capital spending

17. As well as growth in the workforce, diagnosing more patients at an early stage will require investment in diagnostic equipment. OECD figures show that the UK has fewer MRI and CT scanners per head than many comparable countries around the world including Australia, Denmark and Canada[xvi]. And many of the machines in the UK are likely to need updating to deliver modern techniques such as multi-parametric MRI scans for diagnosing prostate cancer.

18. Problems with diagnostic equipment have already had an impact on the NHS’s ability to deliver care. For example, a serious incident was declared at King’s College Hospital Foundation Trust recently due to a backlog in cancer diagnostics – one of the reported issues was faulty endoscopy machines[xvii]. Recent reports have highlighted that the NHS already has a £6bn backlog of required capital investment[xviii] – and transforming services will require further investment.

19. The LTP rightly identifies a need to invest in new equipment, including CT and MRI scanners. A new settlement for capital funding will be required to deliver this. The recent Government announcement to release £1.8bn capital funding is a welcome start to addressing the gap, but further action will be needed to provide the investment the NHS will need to achieve transformative change.

Prevention and public health

20. After decades of continued and successful action on tobacco control, less than 1 in 7 (14.4%) adults in England were smokers in 2018[xix]. Yet smoking continues to harm our economy; costing society around £12.6 billion per year, £2.5 billion of which falls on our NHS, £1.4 billion on social care and £8.6 billion as a result of lost productivity[xx].

21. The Government announced the ambition for England to become smoke-free by 2030, which will be achieved when smoking prevalence is at 5% or below[xxi]. CRUK welcomes this ambition, but as the Government itself recognises, it is ‘extremely challenging’. Unpublished data from a modelling study commissioned by CRUK has found that, based on current trends, the UK is not on track to meet the Government’s 5% smoking prevalence target by 2030[xxii].

22. Achieving this ambition will require comprehensive action from national and local government and the NHS to prevent people from starting smoking and supporting existing smokers to stop. The role of the NHS is acknowledged by the LTP – but this must be supported by local authority services. Increased funding for public health is essential for this.

Local public health is essential to delivering the NHS Long Term Plan

23. The NHS LTP committed to treat all smokers admitted to secondary care in England by 2023/24. However, these smokers must be able to access evidence-based smoking cessation support through primary care support and local stop smoking services once they are discharged from hospital. Furthermore, smokers must be able to access support to quit even if they do not pass through secondary care at all.

24. Local stop smoking services, which provide smokers with a combination of specialist behavioural support and prescription medication, offer the best chance of successfully quitting[xxiii]. These services are an integral part of a smokers’ clinical pathway as they leave the hospital-based treatment model. Without them, patients treated for tobacco dependency in hospital will not be able to access ongoing specialist support, which will severely impact on their chances of staying quit.

25. But local stop smoking services are being increasingly threatened because of continued and significant cuts to local authority public health funding. In 2018, only 56% of local authorities were able to commission a universal specialist service open to all local smokers[xxiv]. 

26. CRUK wants to see evidence-based, specialist stop smoking services available to all smokers in England. UK Government’s failure to fund these services will threaten the success and sustainability of the NHS LTP commitment to universally treat smokers in secondary care.

The Government must deliver increased and sustainable public health funding

27. In the 2015 Budget, the Chancellor announced a £200 million in-year cut to the local authority public health grant, followed by a further real-terms cut averaging 3.9% each year (until April 2020) in the 2015 Spending Review[xxv].  Overall, the grant will have seen a £700 million real terms reduction between 2014/15 and 2019/20—a fall of almost a quarter (23.5%) in spending per person[xxvi]. 

28. These funding cuts have impacted a range of local public health functions and services. Tobacco control and smoking cessation services have been among the worst hit of all the areas of local public health spending, with a 30% reduction in funding between 2014/15 and 2017/18[xxvii].

29. CRUK wants the UK Government to increase its investment in public health so that local authorities can fund a range of functions and services, including stop smoking services. In the first instance, this means urgently restoring £1 billion per year of real-terms per head cuts to the public health grant, a call which is supported by both the King’s Fund and Health Foundation.[xxviii].

30. As outlined in the recently published green paper ‘Advancing our health: prevention in the 2020s’[xxix], the Government is exploring options for raising funds from the tobacco industry via a ‘polluter pays’ principle. The tobacco manufacturers are highly profitable and could afford to pay at least £150 million per annum, and up to as much as £500 million per annum. These funds could help pay for evidence-based measures to encourage and help people quit smoking. Any funds raised should be in addition to increased public health funding for local authorities.

Research and innovation

31. A thriving research environment provides patient benefit and boosts economic growth. Supporting research and innovation in the health service is key to ensuring that patients can access the most modern, high-quality interventions and achieve the best possible outcomes.

32. The LTP recognises the critical importance of research and innovation in the NHS, which is welcome, but its ambitions to advance medical progress, make research easier to conduct and provide better access for patients will only be achieved with adequate investment. The additional spending commitment provides NHS England with the opportunity to support these efforts. NHS England, should consider how to deliver investment to ensure that our research capabilities are fit for the long-term, for example by ensuring that we have sufficient time for research in the NHS workforce and that our infrastructure supports new forms of trials such as adaptive trials and trials for stratified medicine.

33. As well as this it will be vital to increase investment in health research through the National Institute of Health Research (NIHR), as recommended in the Life Sciences Industrial Strategy. The Government has an ambition for research and development (R&D) spending to reach 2.4% of GDP by 2027. NIHR’s budget has been flat for the last three years whilst there have been increases to Government R&D funding through UK Research and Innovation (UKRI). Investing in the whole medical research pipeline, from basic to applied clinical research, is vital to reach the Government ambition to boost R&D to 2.4% of GDP by 2027.

34. The NIHR underpins the UK as an attractive destination for clinical research. It funds high quality research, provides world-class research infrastructure and supports health researchers through training. The NIHR CRN supported 6,106 studies last year, recruiting 870,250 patients[xxx].

35. With a key aim of encouraging applied health research activity to follow patient need, NIHR attracts the nation’s leading researchers and actively includes patients to help design and shape research, as well as participate. This in turn benefits patients, as it’s been shown extensively that research-active NHS Trusts have better patient outcomes. For example, NHS Trusts with greater levels of NIHR clinical trial activity had reduced levels of mortality and better overall CQC outcomes.[xxxi] Research also provides benefits beyond those taking part, as the findings can improve the future standard of care for all patients.

36. Sufficient support for health research is needed to keep the NHS at the cutting edge of medical treatment and to support the implementation of LTP ambitions for research and innovation. Recent MHRA data for clinical trial applications suggest that clinical trial activity in the UK is declining[xxxii]: NIHR investment is particularly important to provide stability and attract further investment as the UK leaves the EU.

37. As well as benefitting patients, there are commercial gains for the health and care system to be made from investing in clinical research. Each pound invested in medical research by the taxpayer and charities returns around 25 pence to the UK year on year[xxxiii] [xxxiv]. By enabling the NHS to support research, additional investment and growth is gained from health research.

38. In 2014/15, the NIHR Clinical Research Network (UK CRN) supported clinical research activity generated £2.4 billion in added value and almost 39,500 jobs in the UK. Spill-over benefits are also seen since the NIHR research infrastructure actively supports collaboration with the Life Sciences sector and the commercialisation of new research and related technologies to help grow new companies. For every £1 of NIHR spend in the last 2 years (2016/17-2017/18) the infrastructure leveraged £1.05 from industry.

Working towards the cancer ambitions of the LTP

39. Clearly, delivering the ambitions of the NHS LTP in full will require increases in funding for medical education and training budgets, public health, capital budgets for NHS infrastructure, and investment in research and innovation. However, there also is much that can be done to ensure that the extra £20.5bn funding settlement for NHS England is spent as wisely as possible, and has the greatest impact in improving outcomes for patients.

40. The NHS is currently facing serious pressures. The provider sector is struggling to address a £4.3bn deficit,[xxxv] whilst the 62-day urgent referral to treatment cancer waiting time metric has not been met since December 2015.[xxxvi] These pressures clearly must be urgently addressed to ensure that patients receive timely diagnosis and treatment.

41. Nevertheless, without appropriate safeguards there is a risk that funding may simply be diverted to help services manage these existing pressures, rather than being used to support evidence-led improvements in quality and service transformation, manage demand in the long term or incentivise innovation.

42. Financial mechanisms should be used to embed high quality care by encouraging best practice throughout the health system. For example, best practice tariffs could be used to streamline cancer pathways between referral, diagnosis and initial treatment. A ‘capacity premium’ could enable investment in approaches that maximise diagnostic capacity through technology. Recent changes to Accident and Emergency funding, which uses a ‘blended payment’ model, should also be considered to sustainably resource diagnostic capacity that is scalable reflective of demand.[xxxvii]

43. Research by CRUK has also found that features of NHS funding mechanisms have historically created perverse incentives which hinder uptake of best practice or investment in innovation. NHS England and Improvement should consider reforms to the National Tariff to support service optimisation and mitigate any potential perverse incentives. This should include the delivery of outpatient services, such as supporting implementation of stratified follow up based on risk and greater use of remote outpatient appointments.[xxxviii]

44. Cancer Alliances are responsible for delivery of many of ambitions on cancer in the LTP, such as developing Rapid Diagnostic Centres and leading Targeted Lung Health Check pilots. Though it is welcome that Alliances now have more clarity about available funding for the next five years, significant amounts of this funding are tied to key programmes like Targeted Lung Health Checks and Rapid Diagnostic Centres. It is not clear whether funding outside of these programmes will be sufficient to improve outcomes across the board.

45. Despite having visibility of proposed budgets, Cancer Alliances are still reliant on the annual budgeting cycle, which hinders transformational long-term projects which may require funding certainty over a longer period to deliver meaningful impact. NHS England and Improvement should empower Cancer Alliances to be as effective as possible through the implementation of a multi-year funding model.[xxxix]

About us

46. Cancer Research UK is the world’s largest independent cancer charity dedicated to saving lives through research. We support research into all aspects of cancer and this is achieved through the work of over 4,000 scientists, doctors and nurses. In 2018/19, we committed £546 million of funding for research in institutes, hospitals and universities across the UK.

August 2019