Written evidence submitted by Bowel Cancer UK
About Bowel Cancer UK
Bowel Cancer UK is the UK’s leading bowel cancer charity. We’re determined to save lives and improve the quality of life of everyone affected by bowel cancer. We support and fund targeted research, provide expert information and support to patients and their families, educate the public and professionals about the disease and campaign for earlier diagnosis and timely access to the best treatment and care.
1. Over 42,000 people are diagnosed with bowel cancer each year, making it the fourth most common cancer in the UK[i]. Sadly, around 16,500 people lose their life each year to this disease, making it the second biggest cancer killer. This shouldn’t be the case as bowel cancer is treatable and curable, especially if diagnosed at an early stage.
2. More than 9 in 10 people survive their bowel cancer diagnosis for five years, if diagnosed at the earliest stage (stage I). However, this significantly decreases to around 1 in 10 if diagnosed at stage IV[ii].
3. In recent decades, as a result of national cancer control plans with a focus on early diagnosis and advances, and adoption, in life-saving bowel cancer research, bowel cancer survival has more than doubled in the last 40 years[iii]. Despite these significant improvements, the UK still lags behind comparable countries internationally with similar healthcare systems, levels of wealth and comparable data[iv].
4. England is also poorer at diagnosing cancers at an early, more treatable stage than the best performing countries[v], as only 39.6% of bowel cancers cases were diagnosed at stage I and II in England in 2018. Later stage diagnosis contributes to worse bowel cancer survival with 25.3% bowel cancer cases diagnosed at stage IV in England in 2018[vi]. The reasons for this are multifactorial but one of the biggest barriers is the lack of capacity in endoscopy services.
Impact of COVID-19 on bowel cancer waiting times and backlog
5. Meeting bowel cancer waiting times is crucial to ensure patients receive the best possible care and the best chance of receiving curative treatment. One of NHS England’s key cancer waiting times target – which aims to see at least 85% of patients begin their first cancer treatment within 62 days of an urgent GP referral for suspected cancer – has never been met for bowel cancer since it was introduced[vii].
6. The COVID-19 pandemic has caused significant disruption for bowel cancer services resulting in poor performance against cancer waiting times targets. In September, only 44.3% of people treated for bowel cancer received first treatment within 62 days of being urgently referred by their GP[viii]. Yet, performance against the 31 day target for first definitive treatment for cancer following decision to treat has only been missed by small margins. Whilst treatment services have been clearly impacted, the greatest barrier to meeting bowel cancer waiting times is a lack of capacity within endoscopy and pathology services as only 82% of patient were seen by a specialist within two weeks of urgent referral, against a target of 93.5%[ix].
7. To help measure the performance of diagnostic services for suspected cancer patients, NHS England developed the Faster Diagnosis Standard to ensure patients will be diagnosed or have cancer ruled out within 28 days of being referred urgently for suspected cancer. In September 2021, 52% of patients were waiting longer than 28 days after being urgently referred for suspected bowel cancer[x]. While most of these people won’t be diagnosed with cancer, it’s important that patients can be seen as quickly as possible because the anxiety of waiting is immeasurable. For patients referred for further tests following an abnormal result of their initial bowel screening FIT test, 48% were waiting longer than 28 days to confirm or rule out bowel cancer[xi]. Bowel screening is one of the best ways to detect bowel cancer early, and in some cases prevent it from developing. Yet, the effectiveness of the programme continues to be stifled by the lack of capacity within endoscopy services.
8. From October 2021, NHS England has set a Faster Diagnosis Standard target of 75% of all people should be told if they have cancer or not within 28 days of urgent referral. While this target may be met overall for all suspected cancer patients, this will certainly not be the case for people urgent referred for suspected bowel cancer. The data remains clear, timely access to endoscopy services is a major barrier to bowel cancer patients starting treatment. It is vital to increase capacity in the diagnostic services to meet waiting time targets, provided a good and ultimately, ensuring bowel cancer patients have the best chance at surviving their cancer diagnosis.
9. For patients not urgently referred for suspected cancer, they will be sent on a routine referral for further tests. However, almost a fifth of all bowel cancer patients are diagnosed through this route so increase delays to vital bowel cancer tests will ultimately have an impact on bowel cancer outcomes[xii]. In comparison with September 2020, 40% of patients were waiting six weeks or more for a colonoscopy, with 25% waiting longer than 13 weeks[xiii]. At the end of September 2021, compared to the same month in 2019, there were five times more patients waiting six weeks or more for a colonoscopy, and almost 10 times more patients waiting longer than 13 weeks[xiv].
10. Pressures on cancer diagnostic and treatment services are only likely to increase. Provisional data for England, show from April 2020 – March 2021, 4,300 fewer bowel cancer cases were diagnosed during the pandemic compared to pre-pandemic times[xv]. This is a result of the pause of the bowel cancer screening programme, a significant drop in urgent suspected cancer referrals and removal of endoscopy tests, unless in an emergency, at the beginning of the pandemic. While these decisions were made for patient safety this has created a growing cancer backlog, with many of these patients still waiting to come forward.
Investing in the bowel cancer workforce to increase capacity
11. Gastroenterology has developed and expanded at a greater rate than any other acute major medical specialty over the past 30 years[xvi]. This is due in part to increased demand for both diagnostic and therapeutic endoscopy because of a growing ageing population, the drive for earlier cancer diagnosis, including the introduction and expansion of the national Bowel Cancer Screening Programme and a lower referral threshold for investigative cancer tests.
12. Before COVID-19, staff shortages affected every part of the cancer pathway. One in 10 posts across the NHS were vacant in 2018/19 and it was estimated that, with no action taken, this would rise to one in seven posts by 2023/24[xvii]. These shortages are more acutely seen in gastroenterology with 43% of advertised posts being unfilled in 2018[xviii], and the NHS is addressing this with 50% of Trusts using insourcing and 16.7% of Trusts using outsourcing to keep waiting lists down, which are costly to the NHS[xix].
13. Sadly, staff shortages are already limiting the ability to implement initiatives in the Long Term Plan, and optimise evidence-based interventions such as lowering the bowel screening age to 50. Yet, the pressure NHS staff has experienced since the beginning of the pandemic is immense and the toll this has taken on the ability to retain and retrain staff is still to be realised. As it takes a minimum of 3-5 years to train new cancer specialists, meaning that in order to effectively tackle backlogs, and provide timely and swift access to crucial tests and treatment long-term workforce investment is needed now.
14. Bowel Cancer UK, alongside 50 other cancer charities as part of the One Cancer Voice coalition, have been calling on the Government to deliver vital investment in the cancer workforce at the Comprehensive Spending Review to help deliver the ambitions in the NHS Long Term Plan and meet the needs of cancer patients today, and in the future[xx].
15. At the 2021 Spending Review, we welcomed the Government’s commitment to “provide hundreds of millions of pounds in additional funding over the spending period to ensure a bigger and better trained NHS workforce”. However, this commitment lacks the detail required to understand whether this funding will be enough to grow the cancer workforce needed now and in the future, therefore the Government must provide clarity on this as a matter of urgency.
16. A growing and ageing population – alongside the need to tackle backlogs from the pandemic – mean that demand for the NHS workforce is only set to grow. However, the previous approach to workforce planning has not worked, therefore, Bowel Cancer UK alongside over 70 other health and care organisations have been supporting an amendment to the Health and Care bill to strengthen provisions on workforce planning[xxi]. The amendment would require the Secretary of State for Health and Social Care to publish independent assessments every two years of current and future workforce numbers consistent with long-term fiscal projections. While regular, independent and public workforce projection data will not solve the workforce crisis. It will provide strong foundations to understand how many staff will be needed in future to meet demand. This data should act as a tool to make strategic long-term decisions about investment in the workforce based on evolving changes in patient demand, disease incidence and working patterns among staff.
Investing in NHS capital and infrastructure to improve services
17. Whilst there were waits for cancer diagnosis and treatment before the pandemic, the disruption caused by COVID-19 means that diagnostic waiting times have significantly worsened, with more patients waiting for longer. We therefore welcome the Comprehensive Spending Review commitment of £2.3bn in health capital spending to transform diagnostic services, which will play an essential part in growing diagnostic capacity to meet patient need. The investment will be targeted to Community Diagnostic Centres, enabling the much-needed expansion of endoscopy services recommended in the 2020 review of diagnostic services led by Professor Sir Mike Richards[xxii].
18. However, the benefits of investment in equipment, facilities and infrastructure will not be fully realised without investment in the cancer workforce as well. Staff shortages are a significant barrier to increasing efficiency in the health system, and making best use of funding to improve outcomes.
For further information, please contact Corrie Drumm, Policy and Campaigns Manager (England) (firstname.lastname@example.org)
[i] Cancer Research UK https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bowel-cancer September 2021
[ii] Office for National Statistics, Cancer survival by stage at diagnosis for England, 2019
[iii] Cancer Research UK https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bowel-cancer/survival September 2021
[iv] International Cancer Benchmarking Partnership 5-year net survival changes (1995-1999 to 2010-2014), Cancer Research UK https://www.cancerresearchuk.org/sites/default/files/cancer-stats/icbp_5_year_survival_countries/icbp_5_year_survival_countries.pdf
[v] IBCP SURVMARK-2 stage distribution for colon cancer 2010-2014 https://gco.iarc.fr/survival/survmark/visualizations/viz8/?groupby=%22country%22&cancer=%22Colon+cancer%22&country=%22Australia%22&gender=%220%22&age_group=%2215-99%22&show_ci=%22%22
[vi] Public Health England National Disease Registration Service: Staging data in England https://www.cancerdata.nhs.uk/stage_at_diagnosis
[vii] NHS England Cancer Waiting Times for Q3 https://www.england.nhs.uk/statistics/2012/02/24/waiting-times-cancer-q3/ September 2021
[viii] NHS England Provider-based Cancer Waiting Times for September 2021-22 (Provisional) https://www.england.nhs.uk/statistics/statistical-work-areas/cancer-waiting-times/monthly-prov-cwt/2021-22-monthly-provider-cancer-waiting-times-statistics/provider-based-cancer-waiting-times-for-september-2021-22-provisional/
[ix] NHS England Provider-based Cancer Waiting Times for September 2021-22 (Provisional) https://www.england.nhs.uk/statistics/statistical-work-areas/cancer-waiting-times/monthly-prov-cwt/2021-22-monthly-provider-cancer-waiting-times-statistics/provider-based-cancer-waiting-times-for-september-2021-22-provisional/
[x] NHS England Provider-based Cancer Waiting Times for September 2021-22 (Provisional) https://www.england.nhs.uk/statistics/statistical-work-areas/cancer-waiting-times/monthly-prov-cwt/2021-22-monthly-provider-cancer-waiting-times-statistics/provider-based-cancer-waiting-times-for-september-2021-22-provisional/
[xi] NHS England Provider-based Cancer Waiting Times for September 2021-22 (Provisional) https://www.england.nhs.uk/statistics/statistical-work-areas/cancer-waiting-times/monthly-prov-cwt/2021-22-monthly-provider-cancer-waiting-times-statistics/provider-based-cancer-waiting-times-for-september-2021-22-provisional/
[xii] National Cancer Registration and Analysis Service Routes to Diagnosis 2016 http://www.ncin.org.uk/publications/routes_to_diagnosis
[xiii] NHS England, Monthly Diagnostic Waiting Times and Activity Provider data for September 2021 https://www.england.nhs.uk/statistics/statistical-work-areas/diagnostics-waiting-times-and-activity/monthly-diagnostics-waiting-times-and-activity/monthly-diagnostics-data-2021-22/
[xiv] NHS England, Monthly Diagnostic Waiting Times and Activity Provider data for September 2019 https://www.england.nhs.uk/statistics/statistical-work-areas/diagnostics-waiting-times-and-activity/monthly-diagnostics-waiting-times-and-activity/monthly-diagnostics-data-2019-20/
[xv] Cancer Research UK, Evidence of COVID-19 impact across the cancer pathway https://www.cancerresearchuk.org/sites/default/files/covid_and_cancer_key_stats_october_2021.pdf December 2021
[xvi] 7 Rutter, C. (2019) British Society of Gastroenterology Workforce Report, British Society of Gastroenterology www.bsg.org.uk/workforce-reports/workforce-report-2019/
[xvii] NHS England and Improvement, 2019. Interim NHS People Plan https://www.longtermplan.nhs.uk/wpcontent/uploads/2019/05/Interim-NHS-People-Plan_June2019.pdf
[xviii] Gastroenterology GIRFT report 2021, NHS Getting It Right First Time https://www.gettingitrightfirsttime.co.uk/girft-reports/ September 2021
[xix] Gastroenterology GIRFT report 2021, NHS Getting It Right First Time https://www.gettingitrightfirsttime.co.uk/girft-reports/ September 2021
[xx] One Cancer Voice 2021 Comprehensive Spending Review letter https://www.cancerresearchuk.org/sites/default/files/ocv_csr_letter.pdf
[xxi] The Royal College of Physicians, Guidelines and Policy https://www.rcplondon.ac.uk/guidelines-policy/70-organisations-unite-behind-call-strengthened-workforce-planning-health-and-care-bill December 2021
[xxii] DIAGNOSTICS: RECOVERY AND RENEWAL Report of the Independent Review of Diagnostic Services for NHS England https://www.england.nhs.uk/wp-content/uploads/2020/11/diagnostics-recovery-and-renewal-independent-review-of-diagnostic-services-for-nhs-england-2.pdf October 2020