Written evidence submitted by Breast Cancer Now (CBP0080)

Executive summary

Breast cancer diagnosis and treatment

• In the 15 months since March 2020, 10,162 fewer people started treatment for breast cancer.
• We estimate that if levels were increased to 10% above pre-pandemic levels, it would take 16 months to clear this backlog. It is unclear how the NHS will meet the ambitions set in NHS England's '2021/22 Priorities and Operational Planning Guidance’ to both recover the breast screening programme and address the shortfall in the number of people starting treatment for cancer by the end of March 2022.
• The required resources are not in place to address this backlog, specifically with regards to the right number of staff. The Royal College of Radiologists (RCR) latest Clinical Radiology UK Workforce Census 2020 Report highlighted that breast radiology is the most in demand area.
• We need the Government to tackle the enormity of the crisis facing the cancer workforce by developing a robust, long-term, and fully-resourced plan – which must include investment in expanding and retaining the breast imaging and diagnostic workforce.
• Moreover, any long-term, fully resourced plan for the cancer workforce needs to be backed by regular, published modelling of the workforce, including long-term projections and by speciality.

Breast reconstruction

• We estimate that over 1000 women will have missed out on immediate reconstruction during the first wave of the pandemic, and around another 500 will have had their delayed reconstruction delayed further.
• It is clear that the NHS has limited capacity to deal with the backlog of women waiting for breast reconstruction. Before the pandemic, services were already under strain with waits of 1 to 2 years in many hospitals.
• While we welcome the Government’s previous investments to tackle the elective backlog, it is unclear how much of it will benefit women waiting breast reconstruction surgery. It is vital that NHS England works with Breast Cancer Now, the Association of Breast Surgery and British Association of Plastic, Reconstructive and Aesthetic Surgeons to develop a clear plan to address the issues with breast reconstruction.

About Breast Cancer Now

1.       Size of the backlog

Breast Cancer Diagnosis and Treatment

1.1.             In the 15 months since March 2020, there were a total of 540,090 referrals on the 2 Week Wait urgent GP referrals for suspected breast cancer route. Compared to a pre-pandemic baseline period* (2019/20), there were 19,330 fewer referrals (559,420). See Table 1 for overview:

Table 1 – 2WW urgent GP referral for suspected breast cancer 2019/20 and 2020/21 comparison

*The baseline period uses repeating months to allow  like-for-like monthly comparisons before and during the pandemic.

1.2.             We estimate that, if 2019/20 is a pre-pandemic baseline operating at 100%, in 2021/22 referrals would need to be over 100% to work through the backlog seen during 2020/21. If levels were increased to 10% above pre-pandemic levels, it would take 15 months to clear this backlog. See Table 2 for overview:

Table 2 – 2WW Referrals at 110% capacity to clear backlog

**The total needs to exceed the 2019/20 figure of 559,420 + “backlog” of 19,330 referrals (giving a figure of 578,750).

1.3.             Also, in the 15 months since March 2020, a total of 50,721 people started treatment on the 31-day wait from diagnosis to first definitive treatment for breast cancer which covers those diagnosed via both referrals and screening. Compared to a pre-pandemic baseline period* (2019/20), 10,162 fewer people started treatment (60,883). See Table 3 for overview:

Table 3 – 31-day wait from diagnosis to first definitive treatment for breast cancer 2019/20 and 2020/21 comparison

1.4.             We estimate that if levels were increased to 10% above pre-pandemic levels, it would take 16 months to clear this treatment backlog. See Table 4:

Table 4 – 31-day Referrals at 110% capacity to clear backlog

***The total needs to exceed the 2019/20 figure of 60,883 + “backlog” of 10,162 referrals (giving a figure of 71,045).

1.5.             We also estimate that around 1 million fewer women in England had breast screening between March 2020 and December 2020 due to the programme being effectively paused in March 2020 and running at reduced capacity on re-starting due to infection prevention and social distancing measures. We are currently updating this estimate and will provide a revised figure to the Committee at the end of the month.

Breast Reconstruction

1.6.             Breast reconstruction is a vital part of treatment and recovery from breast cancer for those women that chose it. We estimate that over 1000 women will have missed out on immediate reconstruction during the first wave of the pandemic, and around another 500 will have had their delayed reconstruction delayed further[1].

1.7.             These numbers will be continuing to grow as a result of units operating under capacity and the fact that breast reconstruction is considered the lowest priority (priority 4) in the clinical guide to surgical prioritisation during the pandemic[2].

2.       NHS capacity to deal with the backlog

Breast Cancer Diagnosis and Treatment

2.1.             It is vital that women are diagnosed and start treatment as early as possible to ensure their treatment has the best chance of being successful. In the worst cases, some women could die as a result of delayed diagnoses.

2.2.             According to our estimations, the NHS would need to work consistently at 110% for the next 15/16 months to clear the backlogs in referrals and people starting treatment. It is unclear how the NHS will meet the ambitions set in NHS England’s ‘2021/22 Priorities and Operational Planning Guidance’ to both recover the breast screening programme and address the shortfall in the number of people starting treatment for cancer by the end of March 2022.

2.3.             The required resources are not in place to address this backlog, specifically with regards to the right number of staff. The Royal College of Radiologists (RCR) latest Clinical Radiology UK Workforce Census 2020 Report highlighted that:

• In terms of vacancies, breast radiology is the most in demand area (41 vacant breast radiologist positions across the UK).
• Despite demand, breast radiology has minimal growth – breast radiologist numbers are growing, but only at 1% p.a. (average workforce growth is 4%).
• A quarter of breast radiologists (24%) are due to retire in the next five years.

2.4.             The backlogs create a demand for diagnosis and imaging services that threatens to overwhelm a workforce that was already stretched before the pandemic.

Breast Reconstruction

2.5.             Before the pandemic, breast reconstruction services were already under strain, with waits of 1 to 2 years for delayed reconstruction in many hospitals. The pandemic has further exacerbated this pressure as a result of breast reconstruction being suspended during the peak of the first wave.

2.6.             It is clear that the NHS has limited capacity to deal with the backlog of women waiting for breast reconstruction. It is vital that NHS England works with Breast Cancer Now, the Association of Breast Surgery and British Association of Plastic, Reconstructive and Aesthetic Surgeons to develop a clear plan to address the issues with breast reconstruction.

2.7.             A survey we carried out in July 2020[3] showed that of those respondents that experienced changes to their reconstructive surgery nearly half (48%) told us they were unhappy with their body image. 59% were concerned that they would need more operations as they were unable to have reconstruction at the same time as their mastectomy.

3.       Financial investment needed

Breast Cancer Diagnosis and Treatment

3.1.             We welcome the Government’s previous £1 billion investment to tackle the elective backlog, £50 million to recover the breast screening programme, £325 million for new investments in diagnostics equipment, and an additional £260 million for Health Education England in 2021-22 to support the training and retention of our vital NHS workforce.

3.2.             However, if we are to ensure the recovery of the breast screening backlogs and that all patients with symptoms of breast cancer have access to the timely investigation they need- both now and in the future - the diagnostic workforce must be properly and sustainably resourced and sufficiently supported.

3.3.             We need the Government to tackle the enormity of the crisis facing the cancer workforce by developing a robust, long-term, and fully-resourced plan – which must include investment in expanding and retaining the breast imaging and diagnostic workforce.

3.4.             Moreover, any long-term, fully resourced plan for the cancer workforce needs to be backed by regular, published modelling of the workforce, including long-term projections and by speciality.

3.5.             Whilst we welcome the new duty on the Health and Care Bill on the Secretary of State to publish a report describing the system in place for assessing and meeting the workforce needs of the health service in England, we urgently need the Government to go further and send a stronger signal of its commitment to invest in the NHS staff that people affected by cancer rely on, both now and in the future.

3.6.             With the current workforce crisis, we must take this important legislative opportunity to improve the way NHS workforce planning is carried out. Alongside an additional duty, there should also be a specific provision to ensure a long-term NHS workforce plan is put in place and regularly reviewed and that the Secretary of State sets out the necessary funding required to deliver it. Without this, we fear the Government will be unable to meet its commitment to deliver world class care for patients and build back better from the pandemic.

Breast Reconstruction

3.7.             While we welcome the Government’s previous investments to tackle the elective backlog, it is unclear how much of it will benefit women waiting breast reconstruction surgery. It is vital that NHS England works with Breast Cancer Now, the Association of Breast Surgery and British Association of Plastic, Reconstructive and Aesthetic Surgeons to develop a clear plan to address the issues with breast reconstruction.

Sept 2021