Written evidence submitted by Macmillan Cancer Support (WBR0053)
- Macmillan Cancer Support is a registered charity providing information and support for people with cancer. There are around 3 million people currently living with cancer across the UK with over 360,000 people receiving a cancer diagnoses every year.[1] Macmillan plays a key role in supporting the NHS workforce. Over the past ten years Macmillan has invested £386 million in the NHS. Macmillan funds nearly 12,000 Macmillan nurses, doctors and other health professionals.[2]
- Summary of recommendations
2.1. The Government and NHS England must supply a sustained and significant increase in the numbers of health and care professionals working to support people with cancer, delivered through a comprehensive People Plan which is fully funded through the upcoming Comprehensive Spending Review.
2.2. Recovery plans for cancer services and health systems must be integrated with workforce planning to ensure that adequate surge capacity created by increasing staff numbers and altering ways of working, to try to mitigate against the impact of the backlog on the resilience of staff.
2.3. The national People Plan, aligning with local People Plan’s developed by systems (STPs and ICSs working in partnerships with Cancer Alliances) must work towards strengthening the resilience of their workforce by:
- Ensuring manageable workloads
- Utilising new ways of working
- Using a skills-mix approach to workforce design, ensuring all staff are using their full range of skills and experience
- Providing regular and high-quality training and development opportunities across the workforce, including clear pathways and provision of clinical supervision and peer support
- Making use of flexible working and return to practice initiatives as standard
2.4. The national People Plan must include plans to reverse the current and increasing gap in the specialist cancer nurse workforce. This could be through extending and expanding the grants available for CNS and chemotherapy nursing available in 2020/21.
- Key messages
3.1. Throughout their care and treatment, from diagnosis through to recovery or at end of life, people with cancer are supported by a huge range of health and care professionals in a range of settings including primary and community care, secondary care and social care.
3.2. As part of our response to this inquiry, Macmillan Cancer Support has conducted bespoke interviews with health care professionals working with people with cancer.
3.3. The publication of the People Plan in the Autumn and the Comprehensive Spending Review will be a pivotal moment in gauging whether the NHS will truly have a resilient workforce capable of delivering the NHS Long Term Plan. Significant and long-term financial commitments from the Government through the Comprehensive Spending Review (CSR) alongside an actionable and a demand-based plan is needed to make this happen. Macmillan is clear that without this fully funded plan the NHS and social care workforce will not be able to deliver the ambitions in the NHS Long Term Plan to deliver high-quality personalised care for people with cancer.
3.4. New modelling from Macmillan Cancer Support shows that the specialist cancer nursing workforce alone needs to grow by 84% (2,500 nurses) and by 3,700 (123%) by 2030 to meet the increasing need of the growing population of people living with cancer in England. The commitment to provide 250 grants for specialist cancer nurse training and 100 grants for chemotherapy nurse training in 2020/21 was a particularly welcome step in the most recent NHS People Plan 2020/21, but this commitment must be the start of steady and consistent increases on this pledge across multiple years to make the necessary change.
3.5. The workforce supporting people living with cancer in England was stretched before the start of the Covid-19 pandemic, with high vacancy rates and increasing pressures caused by rising patient need. The pandemic has thrown into even sharper focus the fragility of our NHS workforce and the need for fast-paced and substantial action.
How resilient was the NHS and social care workforce under pre-COVID-19 operating conditions, and how might that resilience be strengthened in the future?
4.1. The workforce supporting people with cancer was overstretched before the pandemic. The number of people living with cancer is growing every year, and the workforce across many roles essential to cancer care has not grown to meet current or future demand.
4.2. The Cancer Workforce Strategy developed in 2017 aimed to develop the specialist cancer workforce and recognised that ‘some key parts of the workforce are under pressure now and unless we [HEE and NHS England] take action then we may not have enough staff with the right skills’.[3]
4.3. Three years on from this strategy, and with the additional the commitments made in the NHS Long Term Plan on cancer diagnosis and treatment requiring further significant increases in the workforce, there has not been enough progress to meet the ambitions in care and treatment.
4.4. Pre-Covid-19, cancer waiting times were the worst they had ever been. In January 2020, before the coronavirus pandemic had even begun to hit, six out of eight cancer waiting times targets had been breached and seven out of nine were the lowest on record, with only 73.6% of patients in England hitting the 62-day target of starting treatment within two months of being urgently referred by their GP with suspected cancer.[4]Longer cancer waiting times has a big impact on patients. Research by Macmillan has shown that 64% of people recently diagnosed with cancer in England have experienced feelings of anxiety, fear or depression whilst waiting for their treatment to start.[5] Delays in treatment will only exacerbate this anxiety.
4.5. Patient needs were not being met pre-Covid. In the most recent Cancer Patient Experience Survey (CPES) in England, nearly 1 in 10 (8%) of respondents were not given the name of a Clinical Nurse Specialist (CNS). The NHS Long Term Plan committed to every person having access to a named CNS by April 2021. CPES also showed that only 84% of respondents said they had confidence and trust in all of the doctors treating them and 74% in the ward nurses treating them. Only 38% of respondents said that whilst in hospital they could definitely find someone to talk to about their worries and fears.[6]
4.6. CPES also showed only 26% of respondents felt they were given enough care and support from wider health or social services during their cancer treatment. In a poll of primary care staff, over 50% of GPs and nurses surveyed said that given current pressures on the NHS workforce, they are not confident it is able to provide adequate care to cancer patients.[7] This is again reflected in CPES where only 39% of respondents felt the GPs and nurses in their general practice did everything they could to support them through their cancer treatment.
4.7. There is a growing gap between patient need and workforce capacity. It is also clear that ongoing pressure on existing staff whilst they act to meet that gap with the resources they have available (which are often overtime, bank and agency staff) is likely to increase levels of burnout and early retirement, further exacerbating the issue.
4.8. A sustained and significant increase in the numbers of health and care professionals working to support people with cancer, is the main route through which the resilience of the workforce will be strengthened to meet the current and future needs of people with cancer. This needs to be delivered through a comprehensive People Plan and fully funded through the upcoming Comprehensive Spending Review.
What has the impact of the COVID-19 pandemic been on resilience, levels of workforce stress, and burnout across the NHS and social care sectors?
The direct impact of Covid-19 on the health and care workforce supporting people with cancer
5.1. Throughout the pandemic, health and care professionals have worked relentlessly to respond to the needs of patients and provide care for Covid-19 patients alongside trying to keep essential cancer services running throughout the peak. Many are mentally and physically exhausted.
5.2. Some cancer professionals were re-deployed during the pandemic to respond to the priorities in the system created by Covid-19. Some were required to take on new responsibilities additional to their day-to-day role. One lead cancer nurse we spoke to was asked to lead on the 2-hour discharge of patients on top of their usual role, they said: ‘It was great being back to being hands on, but because we were still having lots of STP and Cancer Alliance meetings I had to manage that as well. It was like doubling the workload and trying to juggle all the balls at once’ – Macmillan Cancer Lead Nurse working in the Midlands
5.3. A combination of staff needing to self-isolate with Covid-19 symptoms (which was exacerbated at the start by no access to testing), staff shielding for themselves or for members of their household, and staff being re-deployed to respond to Covid-19 meant the workforce to provide cancer services was depleted. As a community palliative care consultant explained, ‘the impact on even fewer staff was even more intense, because where we ordinarily have 10 CNS all of a sudden, we only had 5 who were able to go and see patients’.
5.4. This increased the workload pressure on already stretched members of staff, and we are very concerned that this will result in higher levels of burnout and a less resilient workforce going forward. A Macmillan GP working in London made this observation: ‘there’s an assumption that we’ll just keep on going, and I feel like I’m seeing a change in some people. Those who have been some of the most resilient I’ve worked alongside have started to say they can’t keep going, and I’ve heard that more than ever in the last few months and I’ve worked in this practice for 15 years. So, my message to the Government is this: you know those resilient ones? Well they’re cracking.’
5.5. The impact that Covid-19 has had on society and the health system, and its impacts on people with cancer and their care, has had a profound emotional and psychological impact on cancer professionals. The fear of contracting Covid-19 whilst at work, rapid changes in ways of working to support patients, worries about delayed diagnostics and treatment for cancer patients and the ongoing impacts of Covid-19 on the NHS over the coming months and years, have all tested professionals’ resilience.
5.6. The unofficial pausing of screening programmes in England and the plummet in urgent 2-week wait referrals from primary care has also meant the number of people diagnosed with cancer so far in 2020 is significantly lower than it was in 2019.
The indirect impact on the health and care workforce of the impact of Covid-19 on the health system and on cancer care
5.7. Both the backlog of people with cancer whose treatment was paused during the pandemic and the inevitable backlog caused by those who are yet to be diagnosed means that a workforce that was already stretched is now faced with a huge backlog of diagnostics and treatment in cancer care.
5.8. The ongoing impact of Covid-19 on capacity will also have an impact on the workforce. Social distancing measures, more intensive cleaning procedures, and usage of PPE, all decrease the number of cancer patients moving through the system. Some procedures, like endoscopy which is used for diagnosis of some cancers, require a significantly lengthened process to ensure they are Covid-19 secure, and require a huge amount of surge capacity to meet even ‘normal’ levels of capacity. The number of colonoscopies performed in April and May was only one-eighth of the same period in 2019.[8]
5.9. Recovery plans for cancer services and health systems must be integrated with workforce planning to ensure that adequate surge capacity created by increasing staff numbers and altering ways of working can, at least in part, mitigate against the impact of the backlog on the resilience of staff. This should include a guarantee of staffing capacity through increased outsourcing, for example ongoing usage of Independent Sector capacity where available.
- What are the causes and contributing factors of burnout in the NHS workforce? What further measures will be required to tackle and mitigate the causes of workforce stress?
Ensuring manageable workloads
6.1. Unmanageable workload is linked to increased levels of stress, then linked to increased levels of sickness absence and ultimately to more of the workforce leaving. The most important measure to mitigate the causes of workforce stress and burnout is to increase the supply across the health and care workforce so that workload is manageable.
6.2. The increasing number of people living with cancer in England and the increasingly complex nature of diagnosis and treatment in cancer care have increased the capacity, skills and time needed to provide care for cancer patients.
6.3. Macmillan’s Voices from the Frontline 2019 report found that 39% of specialist cancer nurses did not feel their current workload is manageable and 44% felt that their workload is negatively affecting their morale.
New ways of working and ensuring appropriate skills mix
6.4. Ways of working that best utilise the skills and experience in the workforce will be essential in strengthening the resilience of the existing workforce and increasing productivity.
6.5. Learning from service innovations which were accelerated during Covid-19 and implementing what worked well for staff and patients will be a significant part of creating a sustainable workforce. New ways of working including remote consultations (video and telephone) where appropriate and beneficial for patients, stratified follow up, development of new non-clinical roles including support workers and navigators, and personalising pathways to better suit patient need, can all increase workforce effectiveness if piloted and evaluated properly.
6.6. Effective workforce planning must ensure multi-disciplinary teams with a range of competencies are able to operate effectively, with those who reach advanced practice being able to work to their fullest competency.
6.7. A skills mapping approach should be employed to support this, with the aim of clarifying what competencies and skills are needed at what level in the workforce to address common unmet needs. Development of a needs-based competency framework with enable assessment of existing roles and support future planning for national workforce priorities.
Continued Professional Development (CPD) and improving career pathways
6.8. There is a positive link between opportunities for training and development and retention of staff. The General Medical Council (GMC) highlights the fact that ‘CPD can support specific changes in your practice, which may enhance your career opportunities and work satisfaction’ as a reason why CPD is important for doctors.[9] NHS Improvement has said that ensuring staff feel like they have a future with the organisation they work for is key to retaining them.[10] NHS Improvement also identified the lack of CPD training as the biggest area for nurses leaving the profession.[11]
6.9. Macmillan’s 2019 report, Voices from the Frontline highlighted three main barriers to accessing CPD for specialist cancer nurses: adequate protected time, adequate protected funding and local availability of courses. Only a third (36%) of specialist cancer nurses had protected study time to access and attend CPD, with 22% taking annual leave to undertake CPD. 43% of specialist cancer nurses cited lack of funding as the main barrier to accessing CPD and 22% had self-funded their CPD, and funding from charitable or professional grants accounts for another 54% of the overall funding for CPD.
Importance of clinical supervision, mentoring and peer support
6.10. Consistent and structured supervision and mentoring is an important way of ensuring staff feel well supported, confident in the clinical aspects of their role, and valued as a member of staff.
6.11. Often the workforce is so busy with day-to-day work that time is not protected for activities like peer support, mentoring or even clinical supervision. All of the professionals we spoke to as part of this inquiry identified it as an important part of supporting staff resilience. One chemotherapy sister working in the North West explained ‘we work as a group of nurses but there’s no facilities for us to actually offload to another professional’ and explained ‘there needs to be time and space for senior nurses to support junior nurses’.
6.12. Workforce planning should allow for adequate time and backfill to allow for structured supervisions to support personal and professional development for staff.
Flexible working and return to practice
6.13. New and more flexible ways of working will be essential in improving retention and allowing staff to work flexibly will benefit the whole workforce and allow more of the workforce to fit their career around their personal lives.
6.14. Flexible working initiatives will be particularly effective if harnessed to encourage those at the end of their careers to continue to work on a more flexible basis, sharing their skills and knowledge with less experienced staff before retirement. Macmillan’s 2017 census of the cancer workforce showed an ageing workforce with 37% of specialist cancer nurses over the age of 50, risen from 33% in 2014.[12]
6.15. Macmillan is also encouraged by the continued commitment to return-to-practice initiatives and hopes to see this continue and expand in the next iteration of the People Plan, with the necessary funding attached.
- What long term projections for the future health and social care workforce are available?
7.1. The number of people living with cancer is increasing every year, with someone being diagnosed with cancer on average every 90 seconds. In England, there are currently an estimated 2.4 million people living with cancer. By 2030, this figure is projected to reach 3.3 million, and by 2040 it is projected to reach 4.4 million.[13]
7.2. The specialist cancer workforce is not growing at a pace to meet the future needs of people with cancer. Urgent action needs to be taken in specialist cancer roles across diagnostics and treatment to ensure there is an adequate workforce available and prevent burnout and pressure on the frontline, as well as ensuring the delivery of high-quality and personalised care for people with cancer.
7.3. Specialist cancer nurses, who are usually but not always Clinical Nurse Specialists (CNSs), are experienced cancer nurses who advise, treat and manage the health concerns of people with cancer. Specialist cancer nurses reduce treatment costs, increase efficiency, drive innovation and provide valuable information for service re-design as well as enable multidisciplinary care and communication between different teams.[14]
7.4. In the specialist cancer nursing workforce, new modelling developed by Macmillan Cancer Support this year demonstrates that the specialist cancer workforce currently needs an additional 2,500 specialist cancer nurses just to meet current need (this is an increase of 84%). The modelling shows that by 2030, the gap between patient need and workforce capacity will have grown to the equivalent of 3,700 nurses, an increase of 123%.[15]
7.5. The model used published data to predict the size of cancer populations in England in 2017 and 2030 for ten cancer type groupings. Macmillan made assumptions and used published cancer statistics to estimate the number of people in each cancer grouping at each stage of the pathway. Over 50 lead and clinical nurses then provided insight into the scope of the role across the patient pathway and informed assumptions about time spent with patients and the proportion of patients seen. The required number was then compared to data from the Macmillan census on current (2017) supply.
7.6. This modelling does not account for some concerning trends that are likely to exacerbate the stalling numbers of specialist cancer nurses in the workforce. These include: significant and growing shortages in the adult nursing population (as identified by NHS England and Improvement in the Interim People Plan)[16]; barriers accessing CPD preventing new and existing training for specialist cancer nursing; an ageing population of specialist cancer nurses with over 37% over the age of 50 in 2017, an increase from 33% in 2014; and a lack of a clear structured pathway from general adult nursing into specialist cancer nursing preventing many nurses specialising.
7.7. Vacancy rates are high across general adulting nursing, making up 41% of all NHS vacancies in March 2020. Data from NHS Digital shows vacancy rates across sectors in quarter 4 of 2019/20 at 9.9%. The specialist cancer nursing workforce relies on a pipeline of nurses from the general adult nursing workforce to train to become specialist cancer nurses. This requires numbers in the general adult workforce that allow for time off for training and development, as well as opportunities for nurses to spend time caring for people with cancer, shadowing existing specialists and gaining an interest in specialist training.
7.8. In the 2017 Cancer Workforce plan, Health Education England identified 7 priority areas in cancer where the workforce needed to grow most urgently. These were histopathology, gastroenterology, clinical radiology, diagnostic radiography, medical and clinical oncology, therapeutic radiography and specialist cancer nursing.
7.9. Although the workforce in each of the priority areas has increased, it is not growing to meet the increasing numbers of people living with cancer in England and the workforce is still overstretched.
7.10. Long-term modelling of the specialist cancer workforce against projected increase in demand should be prioritised by Health Education England and NHS England and Improvement, and should inform the commitments made around the cancer workforce in national workforce planning.
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