Supplementary written evidence submitted by Cancer Research UK (CSV0056)
Rt Hon Jeremy Hunt MP
Health and Social Care Select Committee
It was a pleasure being able to give evidence to the Health and Social Care Select Committee in September. I was grateful for the opportunity to emphasise the importance of Government investment in growing the cancer workforce and key diagnostic equipment numbers at the upcoming Comprehensive Spending Review. As discussed, this will be vital to support the adoption of research and innovation into the NHS, drive progress against NHS Long Term Plan and Government ambitions, and ultimately improve cancer outcomes.
During the oral evidence session, you asked Cancer Research UK to provide further information on what investment is needed in workforce and diagnostic equipment to achieve Government ambitions to improve cancer outcomes. We are pleased to share our assessment in this additional written evidence, attached to this letter.
Cancer Research UK would welcome the opportunity to continue supporting the work of the Health and Social Care Select Committee to understand how we can deliver the world class outcomes that every cancer patient in England and the UK deserve.
Please do not hesitate to get in touch if you have any further questions.
Michelle Mitchell OBE
Chief Executive Officer
UK cancer services are seriously under-resourced, impacting cancer care
The ‘cancer workforce’ – healthcare professions crucial to the diagnosis and treatment of cancer – is seriously understaffed following years of underinvestment. 1 in 10 of all posts across the NHS in England were vacant in 2018/19 and it was estimated that, with no action taken, this will rise to 1 in 7 posts vacant by 2023/24.[v] Workforce shortages are significant among specialties key to the diagnosis and treatment of cancer. The radiology workforce across the UK is now short-staffed by 33% and needs almost 2,000 more consultants to meet safe staffing levels and pre-coronavirus levels of demand for scans. Without action, by 2025 the radiologist shortfall will hit 44%.[vi]
The last decade has also been marked by underinvestment and a lack of strategic planning for equipment and infrastructure critical to cancer services, with successive spending reviews and budgets providing investment that has sought to plug gaps but failed to tackle fundamental issues. This approach has hampered effective service-delivery and innovation – in 2019, 95% of NHS Trust leaders surveyed said the existing climate of restricted capital funding posed a high or medium risk to productivity and efficiency in the health system.[vii] Ageing kit is inefficient and delays the smooth running of services. Yet across cancer services, including screening, diagnostics and radiotherapy, outdated equipment and infrastructure continues to disrupt patient care.[viii] The UK also compares poorly internationally, ranking close to the bottom on both the average number of MRI and CT scanners per million population out of 39 OECD countries.[ix]
The impact under-capacity in cancer services has on patients is already clear. The important Cancer Waiting Times target to diagnose and treat 85% of cancer patients within two months of their urgent suspected cancer referral has not been achieved for almost 6 years. This means that since December 2015 (the last month this target was hit) almost 55,000 cancer patients should have been diagnosed quicker or started their treatment sooner.[x] While several factors can influence how quickly someone is diagnosed or is able to start their treatment, workforce shortages and a lack of key equipment is a considerable contributor. Capacity constraints mean that once people are in the system they are waiting longer, as there are too few trained NHS staff to diagnose and treat cancer patients in a timely manner.
NHS England’s Long Term Plan (LTP) aims to improve early diagnosis in England from 54% to 75% of cancers diagnosed early by 2028. This would significantly improve cancer survival and help close the gap between the UK and other countries with comparable health systems.[xi] We welcome this ambition but the challenge is now huge. To hit its ambition of diagnosing 3 in 4 patients at the earliest stages in England, the government will need an additional 100,000 patients to be diagnosed early each year from 2028. Currently, workforce shortages and a lack of key equipment are some of the most significant barriers to meeting this ambition.
In September 2021, the Government announced £15.6bn of extra funding for the NHS over the next three years. This was welcome, however, it does not cover capital or workforce investment. As identified by the Institute for Fiscal Studies and the Health Foundation, a lack of capital investment resource and workforce shortages are a key barrier to making effective use of even well-targeted investment in the NHS.[xii] The NHS People Plan also identified that further work to expand the NHS workforce and make sure that education and training is fit for the future relies on budget clarity from a Government spending review.[xiii] It is vital that the Government use the 2021 Comprehensive Spending Review to invest to grow the cancer workforce, and expand and transform diagnostic services. This will be key to enabling the NHS to drive service transformation, improve cancer waiting times and accelerate progress towards the ambitions for cancer set out in the NHS LTP.
Investing in the cancer workforce
Last year Cancer Research UK and RAND Europe published estimates on how much it would cost to grow the cancer workforce (defined as the seven professions key to the diagnosis and treatment of cancer[xiv]) by 45%, by 2029. This is the growth in the cancer workforce that Health Education England (HEE) has estimated is needed to deliver world class cancer services for all patients.[xv]
The report modelled current trends in workforce numbers across the key specialties that make up the cancer workforce, considering how many new specialists enter the NHS each year and how many leave through retirement, to pursue other careers or other reasons. From this, the report projected how many extra specialists we would need on top of our current trajectory to see 45% growth in each of the seven key specialities by 2029.
Given the impact of COVID-19 on cancer services, and investment made at the 2020 Spending Review, CRUK has now updated this original modelling to understand the investment needed to grow the cancer workforce, meet patient demand and deliver world class cancer services. This update anticipates that the pandemic will have a negative impact on staff retention in the short term[xvi], reflecting evidence that worse wellbeing is likely to lead to a greater number of staff leaving the NHS compared to the pre-pandemic average once the worst of the pandemic recedes.[xvii],[xviii],[xix],[xx] The modelling assumes that the uplift in staff numbers will be delivered through UK workforce education and training rather than through international recruitment. This is a fair assumption, given likely challenges in international recruitment due to COVID-19 related pressures and an ongoing global shortage of health staff.
Our updated modelling found that Government must invest an extra £216 million into Health Education England for cancer at the 2021 Comprehensive Spending Review to reach, by 2029, the 2017 Cancer Workforce Plan target for 45% growth in the cancer workforce and deliver world class cancer services.[xxi]
It takes a minimum of three to five years to train newly qualified staff as specialists in key cancer professions. Therefore, increased investment is needed now, and the CSR is the opportunity to deliver this.
Investing in key diagnostic equipment
Though there were positive commitments for investment in diagnostic services in the 2020 Spending Review, successive spending reviews and budgets have failed to provide sufficient, long-term investment – instead plugging gaps while failing to tackle fundamental issues in ensuring timely diagnosis. Long standing pressures on diagnostic services have become particularly acute through the COVID-19 pandemic. The number of patients waiting for an endoscopy in July 2021 was 39% higher than in July 2019 and there was a 23% increase in the number of patients waiting for diagnostic radiology. Overall, the number of patients waiting for over six weeks for a diagnostic test was six to nine times higher in July 2021 compared to July 2019.[xxii]
Significant, targeted capital investment will be fundamental to accelerating improvements in cancer outcomes by increasing capacity, supporting timely diagnosis and treatment, improving connectivity and enabling transformation programmes. The Comprehensive Spending Review offers a crucial opportunity to invest in diagnostic services, tackle the backlog facing cancer services, and provide longer-term investment to transform cancer services to a world-leading standard.
Crucially, replacing equipment alone is insufficient; as a priority, there must be investment in significantly expanding the amount of diagnostic kit. The UK compares poorly internationally, ranking close to the bottom on both the average number of MRI and CT scanners per million population out of 36 OECD countries.[xxiii] The 2020 Richards Review of diagnostic services in England also identified a lack of capacity across diagnostic services, with a need for an estimated 200 new endoscopy rooms, extra resourcing to expand pathology services and digital connectivity. [xxiv]
Investment will also be vital to introduce innovative new models to diagnostic services. For example, Community Diagnostic Hubs (CDHs) are a new service model in which a single hub, based at NHS sites or other community spaces, provides several services, including imaging, pathology and endoscopy, to diagnose cancer as well as other conditions. This approach introduces a new way of working in diagnostics through consolidating services and maximising resources, increasing productivity, and has the potential to improve access by bringing diagnostic services closer to communities. Though the recent announcement on funding for the establishment of the first tranche of 40 CDHs was welcome, extra equipment is required to fully operationalise CDHs and expand the rollout to deliver on NHS England’s overall target to establish 150 CDHs. Health services are already using the necessary kit at full capacity, and so cancer service productivity will not significantly improve without further resourcing.
In the short-term, replacing and expanding diagnostic equipment will significantly boost the capacity of cancer services. With full funding, this will help reduce the backlog and deliver a transformational recovery through introducing more efficient equipment and different ways of working. In the future, investing in new technology and interoperable IT systems will help ensure cancer services are agile, able to adapt to innovation, and can continue progress towards important cancer ambitions of improving early diagnosis and survival rates. Without immediate action and long-term investment, it will most likely be impossible to transform UK’s cancer services to improve early cancer diagnosis and ultimately increase cancer survival rates.
The UK Government must ensure that funding is provided to expand diagnostic capacity and fully implement the recommendations of the 2020 Richards review of diagnostic services in the 2021 Comprehensive Spending Review, including:
For more information, please contact Matt Sample (Health Policy Manager) – Matt.Sample@cancer.org.uk
[i] NHS England. 2021. Cancer Waiting Times. Accessed August 2021 via https://www.england.nhs.uk/statistics/statistical-work-areas/cancer-waiting-times/.
[ii] Cancer Research UK. 2020. Cancer incidence for all cancers combined. Accessed September 2021 via https://www.cancerresearchuk.org/health-professional/cancer-statistics/incidence/all-cancers-combined.
[iii] Maddams, J. et al. 2012. Projections of cancer prevalence in the United Kingdom, 2010-2040. British Journal of Cancer. Accessed June 2021 via https://pubmed.ncbi.nlm.nih.gov/22892390/.
[iv] Cancer Research UK modelling based on J. George, E. Gkousis, A. Feast, S. Morris, J. Pollard & J. Vohra. 2020. Estimating the cost of growing the NHS cancer workforce in England by 2029. Accessed April 2021 via https://www.cancerresearchuk.org/sites/default/files/estimating_the_cost_of_growing_the_nhs_cancer_workforce_in_england_by_2029_october_2020_-_full_report.pdf.
[v] NHS England and Improvement, 2019. Interim NHS People Plan https://www.longtermplan.nhs.uk/wpcontent/uploads/2019/05/Interim-NHS-People-Plan_June2019.pdf
[vi] Royal College of Radiologists. 2021. Clinical radiology UK workforce census 2020 report. Accessed August 2021 via https://www.rcr.ac.uk/system/files/publication/field_publication_files/clinical-radiology-uk-workforce-census-2020-report.pdf
[vii] NHS Providers. 2020. Rebuilding Our NHS: Why It’s Time to Invest. Accessed September 2021 via https://nhsproviders.org/rebuilding-our-nhs
[viii] NHS Providers. 2020. Rebuilding Our NHS: Why It’s Time to Invest. Accessed September 2021 via https://nhsproviders.org/rebuilding-our-nhs; Richards, M. October 2019. Report of the Independent Review of Adult Screening Programmes in England. Accessed September 2021 via https://www.england.nhs.uk/wp-content/uploads/2019/02/report-of-the-independent-review-of-adult-screening-programme-in-england.pdf
[ix] OECD. 2019. Health at a Glance 2019: OECD Indicators (Summary).OECD Publishing, Paris. Accessed September 2021 via https://www.oecd-ilibrary.org/docserver/4dd50c09-en.pdf?expires=1628245352&id=id&accname=guest&checksum=A7AFC90F1C8171794202764A28D00FBC
[x] Analysis by Cancer Research UK based on NHS England Monthly Cancer Waiting Times data from December 2015 – July 2021.
[xi] NHS England, 2019. NHS Long Term Plan. Accessed September 2021 via https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf
[xii] Charlesworth, A., Johnson, P. Securing the future: funding health and social care to the 2030. Accessed September 2021 via https://ifs.org.uk/uploads/R143%20executive%20summary.pdf .
[xiii] NHS England. 2020. NHS People Plan 2020/21. Accessed October 2021 via https://www.england.nhs.uk/wp-content/uploads/2020/07/We-Are-The-NHS-Action-For-All-Of-Us-FINAL-March-21.pdf.
[xiv] This includes clinical and medical oncology, gastroenterology, histopathology, clinical radiology, diagnostic radiography, therapeutic radiography, and specialist cancer nurses
[xv] Health Education England, July 2021. Strategic Framework for Cancer Workforce. Accessed September 2021 via https://www.hee.nhs.uk/sites/default/files/documents/Cancer-Workforce-Document_FINAL%20for%20web.pdf
[xvi] The model assumes around a 14% - 28% increase on pre-pandemic annual leaver rates in the short term following the end of the most acute period of the pandemic. This assumption was based on a study of healthcare staff wellbeing and use of support services during COVID-19 in the UK, with the prevalence of self-reported ‘poor/fair’ mental health rising from 17% pre-outbreak to 47% post-outbreak. As a result, the updated modelling assumes that immediately after the worst of the pandemic, the number of ‘leavers’ would increase.
[xvii] : Petrella AR, Hughes L, Fern LA, et al. Healthcare staff well-being and use of support services during COVID-19: a UK perspective. General Psychiatry 2021. Accessed September 2021 via https://gpsych.bmj.com/content/gpsych/34/3/e100458.full.pdf
[xviii] Nursing Times, July 2021. ‘Even more’ nurses considering quitting profession, survey reveals. Accessed September 2021 via https://www.nursingtimes.net/news/workforce/even-more-nurses-considering-quitting-the-profession-survey-reveals-17-07-2020/
[xix] RCR, April 2021. New RCR census shows the NHS needs nearly 2,000 more radiologists. Accessed September 2021 via https://www.rcr.ac.uk/posts/new-rcr-census-shows-nhs-needs-nearly-2000-more-radiologists
[xx] BMA, May 2021. Thousands of overworked doctors plan to leave the NHS, BMA finds. Accessed September 2021 via https://www.bma.org.uk/bma-media-centre/thousands-of-overworked-doctors-plan-to-leave-the-nhs-bma-finds
[xxi] Cancer Research UK modelling based on J. George, E. Gkousis, A. Feast, S. Morris, J. Pollard & J. Vohra. 2020. Estimating the cost of growing the NHS cancer workforce in England by 2029. Accessed April 2021 via https://www.cancerresearchuk.org/sites/default/files/estimating_the_cost_of_growing_the_nhs_cancer_workforce_in_england_by_2029_october_2020_-_full_report.pdf.
[xxii] CRUK analysis of NHS England Diagnostic Waiting Time data. NHS England. 2021. Diagnostic Waiting Times. Accessed August 2021 via https://www.england.nhs.uk/statistics/statistical-work-areas/diagnostics-waiting-times-and-activity/monthly-diagnostics-waiting-times-and-activity/
[xxiii] OECD. 2019. Health at a Glance 2019: OECD Indicators (Summary).OECD Publishing, Paris. Accessed September 2021 via https://www.oecd-ilibrary.org/docserver/4dd50c09-en.pdf?expires=1628245352&id=id&accname=guest&checksum=A7AFC90F1C8171794202764A28D00FBC
[xxiv] Richards, M. 2020. Diagnostics: Recovery and Renewal. Report of the Independent Review of Diagnostic Services for NHS England. Accessed September 2021 via https://www.england.nhs.uk/wp-content/uploads/2020/11/diagnostics-recovery-and-renewal-independent-review-of-diagnostic-services-for-nhs-england-2.pdf