Written evidence submitted by the Macmillan Cancer Support


  1. 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]


  1. Summary of recommendations


2.1 It is vital that the cancer care backlog created by the pandemic is resolved. NHS England’s recently published cancer waiting data indicated that in September 2021 there were approximately 32,000 individuals waiting for first cancer treatment; and the number who waited more than a month to start treatment after a decision to treat, was also the highest-ever on record[3]. The latest Macmillan analysis of this data estimates that the NHS would need to work at 110% capacity for 15 months to catch up on missing cancer diagnoses, and for 13 months to clear the cancer treatment backlog. Efforts to address this should include ongoing public campaigns to raise awareness of cancer symptoms; as well as resources, use of the independent sector, and, where necessary, personalised support to reassure people that it is safe to come forward and what to expect when they do.


2.2 The Government and NHS England must deliver a fully funded long-term workforce plan to grow and support the cancer workforce and ensure it is sustainable. In February 2021, almost 30% of nurses and midwives in England (equivalent to 108,000 staff) said they are more likely to leave the profession, compared to a year ago[4]. To help retain our amazing cancer nurses and cancer workforce– they must be better supported and a key part of this is having the confidence that the Government is investing in staffing and ensuring the reinforcements are coming to help plug the historical gaps in the cancer workforce.


2.3 UK Government should publish with clarity the portion of £30.3 billion for health and social care as detailed in the Comprehensive Spending Review that will be invested in the cancer workforce.


2.4 Investment into a Cancer Nursing Fund, providing £124 million to train an extra 3,371 nurses to make up the projected shortfall in cancer nurses by 2030. This will mean that people with cancer in England are able to access a Cancer Nurse Specialist and receive the personalised care they were promised in the NHS Long Term Plan.


2.5 The Secretary of State for Health and Social Care must, at least once every two years, lay a report to Parliament describing the system in place for assessing and meeting the workforce needs of the health, social care and public health services in England.

This report must include:

2.5.1 An independently verified assessment of health, social care and public health workforce numbers, current at the time of report publication and the projected supply for the following 5, 10 and 20 years.

2.5.2 An independently verified assessment of future health, social care and public health workforce numbers based on the projected health and care needs of the population for the following 5, 10 and 20 years, consistent with the Office for Budget Responsibility long-term fiscal projections.


2.6 Prior to the pandemic, the UK lagged behind many comparable nations for 5-year cancer survival rates, the pandemic will have exacerbated and deteriorated this already worrying position[5]. It is imperative the Government and NHS England build back cancer services better, including making sure we become world-leading for cancer patients’ quality of life and the personalised, holistic care patients need. Macmillan estimates that by 2030 around 4million people will be living with cancer in the UK, therefore it is essential to future-proof cancer care.



  1. Before the pandemic, what were the root causes of the NHS’s deteriorating performance against the standards required for waiting times for elective care and cancer services?


3.1   In June 2018, only 79% of patients in England started treatment within two months of being urgently referred by their GP with suspected cancer, against the target in England of 85%[6]. Pre-pandemic, NHS services and health and care professionals were under pressure and struggling to provide the best care possible for an increasing number of patients, which impacted on timely access to care, care quality and patient experience.


3.2   People living with cancer felt like the provision of information and support for people at diagnosis and through treatment was inconsistent and failed to meet their needs. They also felt like their non-clinical needs weren’t addressed; over half (52%) of the respondents to a Macmillan 2018 survey of primary care professionals, felt that cancer patients do not have enough time to talk through all their concerns6.


3.3   Even before the pandemic, Macmillan’s research highlighted that we had too few cancer nurses – and those in post were struggling to cope with excessive workload pressures and unable to get the professional development and support they needed. As wider pressures on the NHS and social care were impacting on the cancer workforce, cancer nurse specialists found themselves filling general workforce gaps.


3.4   Findings from 2019 show that only a third of specialist cancer nurses we surveyed had protected study time to access and attend CPD training[7]. Individual workload was the biggest barrier to professionals’ ability to access and attending training in the previous year. Nurses were often having to study in their own time, which can be particularly challenging for specialist adult cancer nurses who are already in a physical and emotionally demanding job.


3.5   Workforce gaps are at the very root cause of problems in dealing with the backlog. The cancer workforce is seriously understaffed following years of underinvestment. The current vacancy rate for NHS radiotherapy workforce is the highest since records began in 2012 (7.7%) and there is currently a 10–20% workforce shortage across all three multidisciplinary professional groups within radiotherapy[8]. Cancer Research UK has highlighted that 1 in 10 diagnostic posts across the NHS in England were vacant in 2018/19, and it was estimated that, with no action taken, this would rise to 1 in 7 posts vacant by 2023/24[9].




  1. What did the NHS do well and what could it have done better in providing elective care and cancer services during the pandemic?


4.1   There was huge flexibility and responsiveness from the NHS; the NHS worked to find alternative ways, other than face-to-face, to support cancer patients through their diagnosis, treatment and life after that. Although we know that moving support online and digital consultations was not for everyone and should be a choice, for a lot of patients this worked well.


4.2   The use of surgical and cancer hubs maximised Covid-safe capacity, with dedicated facilities bringing skills and resources together under one roof. As well as this, the NHSE cancer programme increased engagement with the Voluntary and Community Sector during the pandemic, and there are now monthly calls with cancer charities.


4.3   However, the COVID-19 pandemic has had a profoundly disruptive impact on cancer services in England. It has impacted all parts of the cancer pathway, including screening, diagnosis, treatment and ongoing support. It has affected the care of people with a cancer diagnosis and led to the delay in many other diagnoses. The number of people starting treatment for cancer in September 2021 was higher than the pre-pandemic average. However, the total number since the start of the pandemic is still more than 32,000 lower than expected, and the number who waited more than a month to start treatment after a decision to treat was also the highest-ever on record3.


4.4   There are things that could have been done better during the pandemic to reduce this impact. For example, NHSE messaging in the first wave of Covid gave people the impression that services weren’t open for cancer which reflected in reduced urgent referrals. For many complex reasons, communications on shielding to people living with cancer and healthcare professionals were disorganised and last minute.


4.5   Staff being redeployed added to shortages and meant that people couldn’t get essential personalised support. Disruption to surgery and procedures such as breast reconstruction surgery has resulted in people not feeling like they can move on or recovery emotionally and physically from their cancer. There was disruption to cancer screening services as screening programmes were paused from March to June 2020.



  1. What are the biggest challenges faced by local healthcare providers in recovering performance on waiting times for elective care and cancer services?


5.1   Availability of sufficient numbers of the specialist cancer workforce is the rate limiting factor for improving waiting times because it’s mostly about people – people to do tests, people qualified to read and interpret scans, people qualified to perform surgery (some of whom aren’t specialist cancer people but generalists e.g. anaesthetists).


5.2   Significant numbers of staff are reportedly leaving or planning to leave the NHS following the pandemic and high staff absence and sickness levels continue to constrain cancer services. 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. Unless our governments act now to address the gap and better support the dedicated workforce that we have, this crisis is set to get worse.


5.3   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. In February 2021, almost 30% of nurses and midwives in England (equivalent to 108,000 staff) said they are more likely to leave the profession, compared to a year ago[10].


5.4   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[11]. 



  1. How should DHSC and NHSE support local providers to recover their performance?


6.1   In the immediate term, it’s important to prioritise cancer care and protect it from any further disruption. Services should have access to all resource necessary, for example waiting list initiatives and independent sector access. They should also ensure that the forthcoming NHS elective recovery strategy prioritises cancer care and helps relieve pressure on the NHS and cancer services.


6.2   In the slightly longer term, they can support with urgent investment in workforce growth and development. This highlights the need for a costed workforce strategy to support recruitment and retention of staff and more support for staff wellbeing.


6.3   The Health and Care Bill is a once in a decade opportunity to finally address a long-standing recurrent problem of training enough staff to run the NHS and deliver the care and support that constituents deserve. The Secretary of State for Health and Social Care must lay a report to Parliament describing the system in place for assessing and meeting the workforce needs of the health, social care and public health services in England, which should be updated every two years at a minimum.



  1. Are plans and funding announced to date enough to help the system recover or, if not, what in your view is still missing?


7.1   Specialist cancer nurses advise, treat and manage the health concerns of people with cancer. They provide both clinical and emotional support for patients, as well as providing appropriate and personalised information. They also provide an essential role coordinating the multi-disciplinary team supporting an individual through their cancer journey.

7.2   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.[12] The NHS Long Term Plan committed that everyone should have access to the right expertise and support, including a Clinical Nurse Specialist or other support worker.


7.3   Evidence has shown that patients with a named CNS were more likely to completely understand the explanation of what was wrong with them and to agree that they had definitely been involved in decisions about their care and treatment[13].


7.4   Macmillan estimates that in order to deliver personalised care for everyone living with cancer, the specialist cancer nurse workforce will need to grow by 3,371 by 2030. In addition to this financial investment, improvements must be made to the structured pathways from general adult nursing to specialist cancer nursing, in order that nurses are fully supported to pursue a career in cancer care.


7.5   In order to fund the additional 3,371 specialist cancer nursing posts, £124 million will be required to train this nursing workforce. This will be in addition to investment in other aspects of the cancer workforce. A cancer nursing fund needs to be part of HEE funding and commitment made through that.


7.6   Although additional funding has been made available within the Health and Social Care Levy from April 2022, there has yet to be clarity or announcement on how much of the £30.3 billion will be apportioned towards specific workforce funding. Although it is welcome that Government have committed to building 40 new hospitals, 100 community diagnostic centres and investing billions into new innovative equipment, capital investment without workforce investment is an inefficient model of operation. For example, the NHS Nightingale Hospitals highlighted this, with thousands of available beds remaining unused due to staff shortages.


7.7   It is therefore absolutely crucial that the NHS has significant and sustained long term funding to invest in training the workforce, in conjunction investment into cutting-edge technology and research, to future-proof cancer care and to ultimately  improve outcomes for people affected by cancer.


7.8   Della’s story: “From the point I was diagnosed my specialist cancer nurse, Antonia, has been by my side. Antonia helped me to understand different elements of my treatment, from helping me get a bed for my first consultation to checking I had all the paperwork needed for my blood tests before chemotherapy started. 


“When I was hospitalised for a few days before I started treatment, Antonia ensured I was seen immediately for my tests rather than being in the queue whilst feeling unwell. It was such a relief knowing that Antonia was going to be there for me during all the critical moments.


It makes me feel so sad to know that not everybody will get a specialist cancer nurse to support them like I had. I have chatted to a few cancer patients who express that they feel alone, and they’ve received little to no support through their experience, including no support from a specialist cancer nurse.


“Having my cancer nurse’s support made all the difference in helping to navigate through the labyrinth of dealing with cancer treatment. Till this day, I have her telephone number and email and she acts as my support system when I need to speak to my oncologist. Without her, my cancer treatment would have felt lonely, confusing and isolating and I’m grateful for her support every single day.”


December 2021


[1] Statistics fact sheet, Macmillan Cancer Support, 2019

[2] Macmillan annual report, Macmillan Cancer Support, 2018

[3] Cancer Waiting Times: National Time Series Oct 2009 — September 2021 with Revisions, NHS England, 2021

[4] Cancer nursing on the line, Macmillan Cancer Support, 2021

[5] Global surveillance of trends in cancer survival 2000–14 (CONCORD-3), The Lancet, 2018

[6] One Size Doesn’t Fit All, Macmillan Cancer Support, 2018

[7] Voices from the frontline: Challenges facing cancer clinical nurse specialists right now, Macmillan Cancer Support, 2019

[8] Radiotherapy Radiographic Workforce UK Census 2020, College of Radiographers, 2020

[9]  Interim NHS People Plan, NHS England and Improvement, 2019

[10] Recover, Reward, Renew: A post-pandemic plan for the healthcare workforce, Institute for Public Policy Research, 2021

[11] Cancer Workforce in England: A census of cancer, palliative and chemotherapy speciality nurses and support workers in England in 2017, Macmillan Cancer Support, 2018 

[12] Cancer Clinical Nurse Specialists: An Evidence Review, Macmillan Cancer Support, 2012

[13] Being assigned a clinical nurse specialist is associated with better experiences of cancer care: English population-based study using the linked National Cancer Patient Experience Survey and Cancer Registration Dataset, Eur J Cancer Care (Engl). 2021