Written evidence submitted by Prostate Cancer UK (RTR0064)
Are there specific roles, and/or geographical locations, where recruitment and retention are a particular problem and what could be done to address this?
Prostate Cancer UK wants a future where lives are not limited by prostate cancer. We pursue this by investing in ground-breaking research and providing award-winning support for men.
Seeking to address the concerns of prostate cancer patients and clinicians regarding any aspect of the treatment pathway, including the healthcare workforce, is an important part of our responsibilities.
Prostate cancer is the most common cancer in men in the UK1-5 and is set to be the most common cancer by 2030.6 Coupled with the NHS Long Term Plan, endorsed by the government, to see 55,000 more people in England surviving cancer every year with three out of four of all cancers detected at an early stage (stage one or two),7 the recruitment and retention of staff working in urology and associated roles is a matter of national urgency. Given some of the workforce issues detailed below, significant and targeted improvements are required to make sure the NHS is prepared for current and future demand.
In 2018 Health Education England estimated that, to provide a world-class service for NHS cancer patients, the cancer workforce in seven priority professions related to diagnosis and treatment would likely need aggregate growth of 45 per cent by 2029.8 This includes clinical and medical oncology, gastroenterology, histopathology, clinical radiology, diagnostic radiography, therapeutic radiography and specialist cancer nursing.
Having access to a Clinical Nurse Specialist (CNS) is a critical aspect of care for patients undergoing treatment for prostate cancer. UK-wide cancer patient experience surveys have demonstrated that having access to a CNS has a statistically significant impact on patient experience and understanding of the disease. Men who have access to a CNS are more likely to be positive about their care and treatment.9-11
There is a chronic shortage of clinical nurse specialists in all areas of cancer care in the UK and England in particular.12 This is, however, particularly acute for prostate cancer where the number of urology CNSs is lower than other cancer types. In some parts of England only 60 per cent of men with prostate cancer are given access to a named CNS.13
Incidence rates for prostate cancer in the UK are highest in men aged 75 to 79, and along with shifts in demography there has been a steady increase in incidence,14 creating increased need for timely and dedicated care. This has created a significant problem in the workforce, which has been exacerbated by recent attrition rates. A 2020 Royal College of Nursing survey showed 36 per cent of respondents were considering leaving nursing in the next year, up from 28 per cent before the pandemic.15
It is worth noting that, according to the Nursing & Midwifery Council’s own survey of why people had left the profession, pay was less of a concern than a sense of inadequate support and perceived value.16
Overstretched workloads are a significant factor within those concerns. Based on cancer prevalence, Prostate Cancer UK estimates that each urological cancer nurse has an average caseload of around 700 patients in England compared to approximately 160 for each breast cancer CNS in England.3,17 In a recent survey by Prostate Cancer UK, many nurses reported seeing less than 600 patients, suggesting that some nurses are experiencing exceptionally high workloads to make up these numbers.
To continue to provide good services to men, nursing as a career needs to be a more attractive proposition with Urology CNS as the ultimate goal. An overall increase in nursing figures would help this by easing the strain on the existing workforce. Simultaneously, decision makers can improve retention through providing the support and sense of value currently seen as lacking. Adequate resourcing, continuing professional development opportunities, incentives to train, and mature succession planning are all important aspects to this so that NHS Trusts can account for any changes in staff before the service is left under resourced.
Similar issues persist within other critical areas of the prostate cancer pathway,18-19, 22 and many clinicians are finding their workload stretched up to and beyond capacity. With the rollout in recent years of the mpMRI-led diagnostic pathway, the requirement for specially trained radiologists to read these MRI scans has increased. As of 2021 the RCR reported that the consultant radiologist workforce is now short staffed by 33 per cent with increasing calls from radiology leaders saying the shortfall is affecting patient safety.22
The Royal College of Radiologists (RCR) have found that more than half of UK cancer service leaders in clinical oncology reported shortages negatively impacting patient care.19 If nothing is done to retain staff and expand the workforce, by 2025 the shortfall of clinical oncology consultants in the NHS is set to rise to 28 per cent.19
Similarly, rising patient numbers have increased the workload facing pathologists in reporting prostate biopsy results. Some centres are implementing digital pathology solutions, but this is not enough to overcome the need for more trained staff. Indeed, for the histopathology workforce, the Royal College of Pathologists have found that just 3% of histopathology departments surveyed have enough staff to meet clinical demands.20 Cancer Research UK report that without targeted action and investment, the number of histopathologists is forecast to reduce from the existing shortfall by an additional 2% by 2029.21
At the other end of the pathway, the treatment options are becoming more complex for patients with advanced prostate cancer. This is increasing the pressure on the medical oncologists who oversee the treatment of these patients.
For all of these roles, throughout the pathway, the picture is one of increasing workloads with less support. Staff sickness, leave or retirement can cause significant delays for patients, particularly in centres where only one consultant bears responsibility for prostate cancer patients in any of the roles mentioned above.
An increase in the overall workforce in any of these roles would therefore be welcomed. Clearly however it is impossible to simply instantly hire more consultants. That measure must be joined up with policies to induce senior staff to stay in post for longer. Providing flexible working solutions and reforming the NHS pensions scheme are two such measures that would stem the erosion of the consultant workforce. Where currently highly qualified doctors retire earlier than they would otherwise choose as they lack the incentives and support to meet the increasing workloads and pressures of their role.23
Pressure can also be alleviated by opening up clinical tasks to junior staff and allied health professionals thus reducing the burden on consultants. For instance, by allowing therapeutic radiographers to prescribe independently the RCR has seen this as a reasonable method of relieving clinical oncology workloads.24 Equally training Clinical Nurse Specialists as independent prescribers or to carry out tasks such as Local Anaesthetic Trans-Perineal Biopsy can offer professional development that supports retention25 – but must be part of a wider investment in the growth of the CNS workforce. Finding more of these opportunities that are safe and quality assured can provide greater relief to an overstretched workforce.
January 2022