Written evidence submitted by Cancer Research UK Submission (ICS0050)

Summary

• Integrated Care Systems (ICSs) will play a vital role in the planning, commissioning and delivery of cancer services across England in coming years and have important responsibilities to support research and innovation.
• Given the scale of the difficulties facing cancer services – with significant service challenges due to rising demand, the ongoing impact of COVID-19, and wider system pressures in areas such as workforce and infrastructure – it is vital that ICSs hit the ground running.
• England’s 21 Cancer Alliances have worked to drive integration in cancer services since 2016, and the successes and challenges they have faced offer a number of instructive lessons for Integrated Care Systems as they establish themselves. Where they are working at their best, Cancer Alliances have decisively taken forward the cancer transformation agenda by bringing key stakeholders together providing strategic direction and investment and acting as the leading voice on cancer within their geography. High performing Cancer Alliances have also helped embed collaboration in system-wide working and were critical in facilitating collaboration across the NHS to maintain cancer services through the COVID-19 pandemic.
• Looking forward, there are a number of key considerations for Integrated Care Systems and Cancer Alliances to ensure they deliver on their potential to prioritise cancer prevention, drive progress towards national targets on cancer early diagnosis, improve treatment services and embed research as a core function of the NHS.
• There are also a number of opportunities which, if successfully harnessed, ICSs could realise in terms of better population health management, service alignment and integration. ICSs should be accountable for leading on system transformation and progress towards achieving national priorities and ambitions for cancer in their area, whilst retaining the flexibility to tailor their work to the specific needs of the local population.
• For specialised services to be successfully integrated with ICSs, national policymakers and ICSs must take a range of issues into consideration. They must ensure patients continue to have equitable access to the treatments they need. Steps must also be taken centrally in NHS England to ensure service optimisation processes, such as centralisation of services, continue to happen where they deliver benefits. Finally, they must ensure ICSs can quickly and equitably adopt and spread innovation.
• A lack of accountability for research in the NHS has contributed to a culture where research is seen as a burdensome, albeit beneficial, add-on to standard of care. Welcome steps are being taken to address this, including the UK clinical research vision’s commitment to embed research in the NHS; something the 2022 Health and Care Act has given a stronger statutory footing to.
• It is important that roles, responsibilities, and funding streams are clearly defined to facilitate collaborative working across local authority, NHS and voluntary sector activity. Prevention should also be a key part of Integrated Care Partnerships’ (ICPs’) integrated care strategies, and Integrated Care Boards’ (ICBs’) first 5-year forward plans for healthcare acknowledges and builds on this focus from ICPs. The recent independent review of tobacco control for England by Javed Khan also made recommendations that ICSs and UK Government must take forward.

1)       How best can a balance be struck between allowing ICSs the flexibility and autonomy they need to achieve their statutory duties, and holding them to account for doing so?

Making progress on national ambitions for cancer

1. Central targets and performance management have played an important role in improving health service performance in the areas targeted, while also serving as an important signal of government’s priorities to the public and health system and ensuring there is accountability for making progress against these priorities.[1] This is clearly important in cancer, with Cancer Waiting Times (CWT) standards a vital tool for improving the experience of patients by setting a clear expectation for how quickly they should be seen.
2. Clinically relevant CWTs also could improve cancer outcomes by incentivising timely diagnosis and treatment,[2] with CWTs having played an important role in driving progress on cancer since their introduction.[3] Targets also allow NHS England (NHSE) to understand which areas are struggling and provide targeted support. More widely national ambitions, such as the NHS Long Term Plan ambition to diagnose 75% of cancers at the earliest stages by 2028, can incentivise the development of targeted interventions to improve outcomes at the national and system level.
3. Integrated Care Systems, along with their Cancer Alliances, have a range of responsibilities and accountability for performance management within their geographies. Relevant targets across cancer services, including:

-          Cancer Waiting Times (CWT) targets measuring the time it takes for patients with suspected cancer to see a specialist, receive a diagnosis or all clear, and receive treatment.[4]

-          Ambitions for cancer within the NHS Long Term Plan, most notably an ambition to see 75% of all cancers diagnosed at Stage I or II by 2028.[5]

-          Central targets to see improvements in key outcomes measures within the NHS Mandate, including improving cancer survival and reducing variation in survival between different areas, diagnosing more cancers at an early stage, among others.[6]

4. However, targets do not capture all patients. For example, many patients diagnosed with cancer are diagnosed following a routine GP referral or through an outpatient route – and so they would not be captured in the 28-day Faster Diagnosis Standard CWT target. This is concerning because analysis by CRUK and PHE has found that for patients referred routinely, the wait for diagnosis has previously been significantly longer than urgent referrals.[7] Targets cannot be looked at in isolation, and service improvement cannot be driven solely through national targets.
5. While national targets are important for ensuring patients get equitable access to quality cancer services, significant variation in demographics and specific challenges faced by different geographies mean the approach to achieving targets and ultimately improving outcomes will not and should not be the same everywhere.
6. There is significant regional variation on performance against key cancer targets, risking inequalities in access and outcomes if targets are met nationally but not in certain areas.[8] NHS England must provide robust accountability and sufficient support to struggling areas – while recognising that the reasons driving poorer performance will vary and so the interventions needed to improve performance cannot be one-size-fits-all. Further, for better performing areas targets should not treated as a panacea, and innovation and excellence above and beyond meeting these targets should be fostered and facilitated.
7. We have heard from clinicians and system leaders that the current directive approach from NHSE, which preconditions funding on implementing nationally mandated programmes of work, can sometimes limit the ability of systems to trial innovative approaches or tailor their approach to their population’s needs.
8. Therefore, NHS England and the Department of Health and Social Care should ensure that Integrated Care Systems and Cancer Alliances are supported and held to account on achieving national cancer targets, while allowing greater flexibility to develop and fund programmes of work tailored to their population to achieve those targets as well as local priorities.
9. Where systems are struggling to achieve national targets, it is important that targeted financial and technical support, along with robust accountability, is provided from NHS England to support service improvement, alongside facilitating shared learnings from better performing areas.

Commissioning high quality cancer services

10. For specialised services to be successfully integrated with ICSs, national policymakers and ICSs must take a range of issues into consideration. They must ensure patients continue to have equitable access to the treatments they need. Steps must also be taken centrally in NHSE to ensure service optimisation processes, such as centralisation of services, continue to happen where they deliver benefits. Finally, they must ensure ICSs can quickly and equitably adopt and spread innovation.
11. The move to population health budgets could bring practical challenges for care which is not closely linked to the local pathway. Workarounds may be needed, risking complicating the governance and commissioner structures, and driving distortion in funding and access to care.[9] Some specialised services have arguably benefitted from a ringfenced budget, commissioning decisions made centrally and nationally mandated service specifications. For example, funding for new radiotherapy linear accelerators (LINACs) in 2016 and 2021 has been hugely beneficial to radiotherapy services and cancer patients. Such benefits must not be diluted in the new commissioning structures.
12. According to NHSE, several ICBs will be commissioning with neighbouring ICBs on a multi-ICB footprint. These footprints have not yet been specified. ICSs must therefore work together to ensure they deliver optimal specialised services for patients. This could involve centralising some services and providers within certain ICB-footprints and scaling down those services in neighbouring ICB-footprints. This could be challenging, and steps must be taken centrally in NHSE to ensure these service optimisation processes continue to happen where they deliver benefits. It is also important that the transition phase does not result in service optimisation processes slowing down as this would risk negatively affecting services’ abilities to deliver optimal patient care.
13. NHSE has said that clinical commissioning policies and service specifications will still be developed nationally, meaning in theory there should be little change to how new treatments are evaluated and approved. However, evaluation and adoption pathways can be slow, and a lack of capacity and funding can act as a barrier to adoption. The Commissioning through Evaluation (CtE) programme has broadly had a positive impact. For example by enabling data collection, patient access, and subsequent routine commissioning for stereotactic ablative radiotherapy (SABR) for a range of indications.[10] However, evaluation processes can be lengthy, and the CtE programme has only reviewed two radiotherapy techniques since 2013.[11]
14. Even for treatments and new techniques that have been approved for reimbursement, implementation can be slow and unequal. This is especially true for innovative techniques such as molecular radiotherapy that require specialised staff, facilities, and training.[12] Ensuring swift and equitable access to innovation should be a priority for both NHSE and ICSs. Processes for evaluating and adopting innovative treatments must be adequately resourced, and implementation must be monitored to ensure equitable access.
15. We understand accountability for specialised services will continue to sit centrally with NHSE. However, there is a risk that if patient groups or clinicians have to communicate with a range of ICSs, this might create challenges for the speed of escalation where issues emerge. Under the new structures, NHS England and ICSs must ensure it does not become more difficult to escalate issues in cases where services are not operating according to their service specifications.

Embedding research in Integrated Care Systems

16. Clinical research is pivotal to improving health outcomes for cancer patients. However, there is not currently the right balance between autonomy and accountability for research in the NHS, with responsibility not strong or clear enough[13].
17. This lack of responsibility has contributed to a culture where clinical research is seen as a burdensome, albeit beneficial, add-on to standard care[14]. Consequently, when the NHS is under immense pressure – as it is now – research is often the first to suffer, illustrating how research is not yet embedded within the NHS.
18. We believe this represents a false economy mindset, with clinical research and high-quality care far from mutually exclusive. For instance, evidence clearly shows that research-active hospitals provide higher-quality care, have lower levels of patient mortality[15][16][17], have increased rates of staff retention and find it easier to recruit healthcare professions[18][19][20].
19. The 2022 Health and Care Act took a welcome first step on the journey to a stronger research culture, enhancing the duties of ICBs, NHSE and Secretary of State for Health and Social Care to report on how they are promoting and facilitating research. For instance, the amendments mean it is now a legal requirement for ICBs to publish how they will deliver clinical research in their annual reports and joint forward plans. The Government’s Clinical Research Vision must now build on this momentum; something we are pleased it has already started doing. This includes a commitment for NHSE to develop a new research framework to help ICBs better understand and fulfil the expectations set in the Health and Care Act.
20. We also welcome the vision’s recent commitment to work across the UK administrations to develop a set of metrics for research. The current dearth of research metrics makes it difficult for NHS leaders to see and understand the benefits of research. In comparison, NHS decision-makers have long had access to metrics for cancer services. As mentioned, this means that when resources are scarce, the incentive to prioritise services is disproportionately strong.
21. To help ensure research has the right metrics, we encourage the Government to develop them in partnership with the clinical research community, including medical research charities. CRUK would support an approach akin to the “UK-wide clinical research dashboard” proposed by ABPI.[21]

2)       What scope is there for variation between ICSs, to enable them to improve the overall health of the populations they serve and tackle inequalities?

22. There has always been variation across health and care systems due to their scale, complexity and the determents of population health.
23. Given all ICSs will be starting from a different position, there is an opportunity to consider what they will individually achieve based on the health of their population.  How performance is assessed and reported therefore will be important when considering what they are tasked to achieve. The possible use of Quality Standards in Cancer would ensure a consistent mechanism to identify local priorities and allow for variation and innovation. 
24. ICSs will be in a unique position working with their Cancer Alliances to build and further strengthen progress in improving cancer outcomes for their populations by driving innovation. The ability of ICSs to bring all partners and local communities together will help shape and support service delivery, alongside tackling and reducing localised health inequalities. We would like to see ICSs working with their Cancer Alliances on individual cancer strategies for their systems. Allowing varied approaches in this way this would ensure that these strategies are shaped to maximise opportunities to tackle inequalities and improve the health of their populations. 

3)       What can be learned from examples of existing good practice in established ICSs?

25. England’s 21 Cancer Alliances were established in 2016 to deliver many of the recommendations in the Cancer Strategy for England. This included ambitions around improving early diagnosis, cancer prevention, workforce planning, reducing unwarranted variation and serving as a clinical network within their geographies. More recently, Cancer Alliances have been given a central role in delivering the Long Term Plan (LTP) and have been responsible for transformation projects and improving performance.
26. While there has been and remains variation across Cancer Alliances in their effectiveness, where they are working at their best, they offer a number of instructive lessons on principles behind good practice for ICSs as they look to formally establish themselves.
27. Building a culture of system working and patient-centrism has been critical for enabling a collaborative approach. Creating a culture of openness, which recognises that trusts are facing major challenges, has empowered leaders across regions to be candid in sharing their experiences and areas they are struggling with. The role and resources of the Cancer Alliance has been fundamental in facilitating the move away from a sense of competition to consistently putting patients first.
28. This has been clear in the Wessex Cancer Alliance, where they have improved performance and personalised care[22] through facilitating collaboration between providers and across the cancer workforce. Improving Faster Diagnosis Standard performance has also been based on collaboration, as one trust translated their success for Lower GI into actionable learnings which were shared with another trust and led to a significant improvement in their performance.
29. Clinical leadership within Cancer Alliances has also been vital. For example, the Lung Cancer Pathway Board, a clinician-led group within Greater Manchester Cancer Alliance has representation from a range of professions, which has facilitated close collaboration to tackle lung cancer in Manchester though the CURE programme[23] which has been highly effective in supporting people to stop smoking, funding specialist nurses to support hospital patients to quit.
30. Key to the success of West Yorkshire & Harrogate Cancer Alliance has been their work to become firmly embedded in the region’s health system. Working closely with the area’s ICS since their inception, the Alliance remains well-placed to support the development of effective system working, taking their own learnings from Cancer Networks and demonstrating how joined-up care delivers for patients[24].
31. In order to build strong relationships across the system, WY&H Cancer Alliance have worked with a range of partners to both contribute to and benefit from ongoing activity. For example, the Alliance worked closely with West Yorkshire Association of Acute Trusts through providing crucial resource and funding to help advance networked approaches to both imaging and pathology. This accelerated cancer ambitions, reducing turnaround times of patient reports and allowing clinicians to share expertise and balance workload, as well as bolstering diagnostic services as a whole in the region.[25]
32. More broadly, it is important that as ICSs establish themselves, there are appropriate forums and mechanisms, supported by NHS England, to facilitate shared learnings between systems.

4)       How can a focus on prevention within ICSs be ensured and maintained alongside wider pressures, such as workforce challenges and the electives backlog?

33. Around 4 in 10 cancers are preventable.[26] This is also an issue of inequality: smoking is the single biggest driver in inequality in life expectancy in the UK, [27] and remains the biggest cause of cancer and premature death in the UK.[28],[29] Overweight and obesity is the second biggest cause of cancer, [30] and CRUK modelling suggests that, if current trends continue, around 7 in 10 adults in England will be overweight or obese by 2040 – and the deprivation gap for obesity between the least and most deprived groups will increase by over 50%.[31]
34. That’s why we welcome the Health and Social Care Select Committee’s emphasis on the need for prevention to be an integral part of ICSs work. ICSs are uniquely positioned ensure that prevention is a focus across local authority, NHS, and voluntary sector activity, but it is important that roles, responsibilities and funding streams are clearly defined to facilitate collaborative working.
35. It will be also be important that prevention is a key part of integrated care partnerships’ (ICPs) integrated care strategies, and integrated care boards’ (ICBs) first 5-year forward plans for healthcare acknowledges and builds on this focus from ICPs. Harnessing the wealth of expertise within ICSs and prioritising prevention within strategies and plans could help ensure it is a key focus of ICS work.  
36. It is also important to learn from experts in the sector. The APPG on Obesity recently released a report on the role of ICSs in supporting people living with obesity that we would encourage the Committee to review. Javed Khan also recently released an independent review of tobacco control for England, which CRUK supports. As part of this, Javed Khan set out recommendation 14 for ICSs.[32] This stated:

“Invest £8 million to ensure regional and local prioritisation of stop smoking interventions through ICS leadership. ICSs and directors of public health must set, and annually report against, clear targets to reduce smoking prevalence in their areas and commission services to allow that reduction to be achieved. The government should set up a support fund to which ICSs can bid for funding to support regional collaboration and partnership.”

37. Broken down, this puts forward the following measures:

-          Making planning across ICSs more integrated: this includes each ICS chief executive having a mandatory stop smoking impact objective, prioritising smoking cessation and NHS long term plan commitments, prioritising targeted interventions and annual reporting.

-          Investing £8 million for a new fund to support regional partnership working: this would support regional collaboration and partnerships. This funding would come from the £125 million that Javed Khan says is needed for tobacco control, with his preferred method of raising this through the polluter pays model. This would use industry funds, without their interference, to pay for the much-needed tobacco control measures across England. More information on the polluter pays model can be found here.

-          Enhance working in ‘place based partnerships’: to ensure they are providing evidence-based tobacco control interventions and stop smoking support

The UK Government must turn Javed Khan’s recommendations into concrete action to support ICSs and wider tobacco control across England.

About Cancer Research UK

Cancer Research UK exists to beat cancer. To achieve this, we fund world-class researchers who are pioneering new ways to prevent, diagnose and treat cancer, and we empower patients, policymakers and the public to make sure advances in research improve outcomes for everyone affected by cancer.

References