Written evidence submitted by Eli Lilly and Company
Lilly is a US-headquartered pharmaceutical company with a major commitment to the UK. We are proud of our heritage in this country: Lilly UK was our first business to open outside the US in 1934, and today we remain a significant contributor to UK innovation and a key partner to the NHS on clinical research and health delivery, advancing science in areas of high unmet clinical need including diabetes, oncology, immunology, COVID-19 and Alzheimer’s disease.
We welcome the opportunity to respond to this inquiry on NHS backlogs and waiting times. Please note that for the purposes of this inquiry our response will focus on disruption in cancer services.
The pandemic has led to unprecedented disruption for cancer patients with significant backlogs across the whole cancer pathway:
- Early diagnosis is key to improving cancer outcomes and improving the proportion of patients diagnosed at an early stage of their cancer a key objective of the NHS Long Term Plan.[i] Cancer screening has a vital role to play in delivering this aim and can help detect the early signs of disease even in patients who are not yet experiencing noticeable symptoms, enabling treatment to be offered when it is most likely to succeed. National screening programmes for breast, cervical, and bowel cancer are predicted to save around 9000 lives each year.[ii]
- Although there was no official suspension of screening programmes in England during the pandemic, invitations from screening hubs were not sent out to patients and the service was effectively halted. For every week these programmes were paused, approximately 210,000 people were not screened.[iii] The charity Breast Cancer Now estimates that up to 1.5 million women across the UK are now thought to have missed out on breast cancer screening alone and that because of this nearly 12,000 women could be living with undiagnosed breast cancer.[iv]
- It is vital that every effort is made to recover screening performance. Some women have received “open invitations” to encourage them to book a screening appointment, however this is known to be less effective in securing appointments and particularly so for women of lower socioeconomic status.[v] To improve early cancer diagnosis – and to avoid exacerbating inequalities in participation – every effort should be made to target those women who have missed out on screening appointments. Alongside more targeted efforts, national public awareness campaigns can also play a role in encouraging patient participation to accelerate the catch-up in screening coverage.
GP Referrals for a suspected cancer diagnosis
- Alongside screening, primary care professionals play a central role in helping to diagnose cancer early. As most patients’ first contact with the NHS, GPs play an important gatekeeper role to more specialist consultation and diagnostic services and are therefore critical in facilitating cross-system efforts for swift and seamless cancer diagnosis.
- Unfortunately, many patients have either purposefully avoided healthcare settings during the pandemic or have struggled to secure appointments with stretched GP services. Disruption during the acute phases of the pandemic was severe, with a drop as high as 76% at some sites and around 40% for England as a whole.[vi] The consequence is a considerable and growing number of ‘missing’ referrals, with the National Audit Office estimating that there was between 240,000-740,000 fewer GP referrals for suspected cancer between March 2020 and September 2021.[vii] A proportion of these missing referrals will inevitably return to the NHS at some point, sadly presenting later and with more advanced and harder to treat disease.
- The pandemic severely disrupted diagnostic services, with an estimated 10% fewer CT scans and 25% fewer MRI scans being carried out in the year to February 2021.[viii] The UK went into the pandemic with a widely recognised and long-standing critical lack of diagnostic capacity, a factor that is likely to hinder attempts to work through the cancer backlog. The UK has the third lowest number of CT scanners per million population in the OECD at 9 per million inhabitants. This compares to 40 per million inhabitants in Denmark, 26.6 per million inhabitants in the US, and 18.8 per million inhabitants in Germany. Similarly, the UK has around 18.8 MRI machines per million population compared to 55.2 in Japan, 34.6 in Germany, and 34.6 in the US. [ix]
- A confounding factor in the lack of capacity in diagnostic services is an acute workforce shortage in radiology. The Royal College of Radiologists reports that in England, the consultant radiologist shortage is 35% short staffed and needs at least another 1,613 full time consultants to keep up with safe staffing quotas.[x] In its latest workforce census (conducted before COVID-19), the College reports that approximately three quarters of trusts in England do not feel there are enough consultant radiologists to meet demand and deliver safe and effective patient care.
- The NHS Long Term Plan recognised the need to improve diagnostic services in the UK and subsequent independent reviews – such as Professor Sir Mike Richards’ independent review for NHS England – have made recommendations to improve delivery of screening and diagnostic programmes, focusing on the need for investment in equipment and the workforce alongside delivery of new models of service provision (e.g. Community Diagnostic Hubs).[xi] It was announced at the Spending Review that the Department of Health and Social Care would receive an additional £5.9bn capital investment to help address the backlog. A significant proportion of this (£2.3bn across the next 3 years) is to be used to support the expansion of diagnostic services, including the roll out of Community Diagnostic Hubs. This new investment is wholly welcome, although as others have pointed out the capital budget is only now returning to the level it was at more than a decade ago.[xii] Continued and sustained support is required to bring NHS diagnostics up to the standard of international peers, to support accelerated recovery from the backlog, and to enable delivery of the highest standards of care for NHS patients.
- Disappointingly, investment in equipment has not been complemented with additional funding for the staff required to operate it. While the Spending Review promised hundreds of millions for a “bigger and better trained NHS workforce” there remains little detail on how this funding will be directed to address the serious and growing workforce challenges across NHS diagnostics and the wider health system. Workforce is key not only to recovering NHS performance post-pandemic but also the continuing sustainability of the health service. It is in short, a long-term problem in urgent need of longer-term thinking to address.
- Lilly has been encouraged by efforts to sustain safe delivery of care for at risk, immunocompromised, or otherwise vulnerable cancer patients. The utilisation of “covid free” hubs such as those at the Royal Marsden and the Christie have helped maintain capacity to deliver routine treatment through the pandemic. Nevertheless, treatment has still been significantly affected, with an estimated 7% reduction in chemotherapy episodes in the year to February 2021.v We are concerned that without focused and sustained action disruption may persist for some time, in part due to residual backlogs earlier in the pathway coupled with the follow through of delayed patient presentation of new cancer cases. Adaptations made to the cancer care pathway that have allowed for treatment in outpatient or community settings, for example by enabling preferential prescribing of oral formulations rather than those taken via IV, have been helpful and may provide useful learnings for the future.
- Disruption in clinical research not only impedes the development of innovation but also denies patients access to new and potentially breakthrough treatment options. Lilly’s own trials, including those in oncology, were severely impacted during the pandemic to an extent not seen in other countries across Europe or globally. This is partly a reflection of the limited capacity available in the NHS to deliver research at a time when many healthcare professionals have had to prioritise frontline care, while also being a consequence of clinics seeing many patients virtually where they cannot be recruited into studies.
- Through 2021, while restart and recovery of clinical research has recovered, it has done so at a much slower rate in the UK than in other countries. While the MHRA demonstrated flexibility in supporting research activities in response to the pandemic, including allowing use of direct-to-home shipments of trial materials and remote monitoring of patients already on studies, these flexibilities did not tackle the primary rate limiting step in initiating new trials in the UK, which is the slow and complex process trial sponsors are required to undergo to contract new trial sites. Opportunities exist to significantly streamline these processes, which would both support ongoing recovery of NHS clinical research while also enhancing UK competitiveness in attracting future clinical trials investment.
[i] NHS Long Term Plan: Cancer.
[ii] Richards M. (2019). Independent review of national cancer screening programmes in England: interim report of emerging findings.
[iii] CRUK (2020). Over 2 million people waiting for cancer screening, tests and treatments.
[iv] Breast Cancer Now (2021). 50% rise in number of women in UK who have not had vital breast screening since services restarted.
[v] Hudson S et al. (2016). Effectiveness of timed and non-timed second appointments in improving uptake in breast cancer screening.
[vi] NHS England (2020). Cancer waiting times.
[vii] National Audit Office (2021). NHS backlogs and waiting times in England.
[viii] IPPR (2021). Building back cancer services in England.
[ix] OECD (2021). Health Care Quality Indicators.
[x] Royal College of Radiologists (2020). Clinical radiology England workforce census 2019.
[xi] Richards, M. (2020). Diagnostics: Recovery and Renewal. Report of the Independent Review of Diagnostic Services for NHS England.
[xii] NHS Confederation analysis of 2021 Autumn Statement and Spending Review.