Written evidence submitted by Breast Cancer Now (RTR0073)

About Breast Cancer Now

1.       What are the main steps that must be taken to recruit the extra staff that are needed across the health and social care sectors in the short, medium, and long-term? What is the best way to ensure that current plans for recruitment, training and retention are able to adapt as models for providing future care change?

1.1.             Plans for recruitment, training and retention need to adapt for the future to consider the increasing number of people with breast cancer, otherwise the growth in the NHS workforce will continue to fail to match patient demand. Around 55,000 women and 370 men are diagnosed with breast cancer every year in the UK.[1] Every 10 minutes in the UK one woman is diagnosed with breast cancer, and one man is diagnosed every day. If nothing changes, this will rise to one woman every eight minutes by 2030.[2] Breast cancer incidence rates have increased by 23% in women in the UK since the early 1990s.[3] In addition to the number of breast cancer patients increasing, they are also living for longer and experiencing long term effects of treatment. This is because breast cancer survival is improving and has doubled in the last forty years in the UK[4] due to a combination of improvements in treatment and care, earlier detection through screening and a focus on targets, including faster diagnosis. An estimated 600,000 people are alive in the UK after a diagnosis of breast cancer.[5] This is predicted to rise to 1.2 million in 2030.[6]

1.2.             Plans for recruitment, training and retention also need to be informed by precise and robust data on breast cancer prevalence, treatment, care, and survivorship to ensure staffing numbers and skill mix is matched to patient need. For example, it is estimated there are around 35,000 people with secondary (also known as metastatic) breast cancer in the UK, but we still don’t have an accurate, up-to-date figure. Although in England it has been mandatory for hospital Trusts to collect data on new diagnoses of metastatic breast cancer since 2013, this has not routinely happened in practice. In addition, Breast Cancer Now’s Freedom of Information request sent in 2018 found that 40% of trusts and health boards were unable to say how many patients with secondary breast cancer were in their care.[7] We welcome NHS England’s commitment to an audit on breast cancer, which will include primary and metastatic breast cancer. This will enable the NHS to understand the needs of people living with breast cancer, who often share feeling overlooked and forgotten, and to plan and resource services to give people the best chance to live well for as long as possible. In the interim, NHS Digital should ensure that data is available on diagnosis and treatment of secondary breast cancer, even if this is currently incomplete so that it is possible to start building a picture of secondary breast cancer ahead of the audit commencing in 2022.

1.3.             A well-staffed and highly trained breast imaging and diagnostic workforce is imperative to the successful delivery of the NHS Long-Term Plan commitments to improve screening uptake and early diagnosis. Covid-19 has significantly exacerbated pressures that the breast imaging and diagnostic workforce were already experienced, through increased staff shortages, disruption to services, burnout and creating a concerning backlog in demand. A fully resourced workforce is fundamental to the recovery of breast cancer services. However, to support this, significant modelling of this part of the workforce is required.

1.4.             Specifically, the breast radiology workforce is experiencing significant and sustained pressure. The Royal College of Radiologists’ most recent Clinical Radiology UK Workforce Census found that for the third year in a row, breast radiologists were one of the most in-demand specialists in 2020, with 41 vacancies in 2020. Despite being in such high demand, there have been minimal increases in the numbers of breast clinical radiology consultants. Over a five-year period, the number of full-time clinical radiology consultants grew from 435 in 2015 to just 466 in 2020, demonstrating that there are issues with recruitment. Worryingly, a high proportion of consultant breast radiologists are expected to retire within the next five years - 23% in England compared to the clinical radiologist consultant average of 19%.[8] This means it is extremely likely that breast consultant shortages could increase over the same period unless urgent action is taken to mitigate against workforce shortages. This highlights the critical and urgent need for the government to tackle the crisis facing the breast cancer workforce by developing a robust, long-term, and fully resourced plan, which must include investment in expanding and retaining the breast radiology workforce. Only then can we give everyone the best possible chance of early diagnosis, which we know is critical to improving chances of survival.

2.       What changes could be made to the initial and ongoing training of staff in the health and social care sectors in order to help increase the number of staff working in these sectors? To what extent is there an adequate system for determining how many doctors, nurses and allied health professionals should be trained to meet long-term need?

2.1.             The government must tackle the enormity of the crisis facing the breast cancer workforce by developing a robust, long-term, and fully resourced plan, which must include investment in expanding and retaining the breast cancer workforce including breast imaging, diagnostic and nursing workforce. However, any long-term, fully resourced plan for the cancer workforce needs to be backed by regular, published modelling of the workforce, including long-term projections by speciality. We know that the current workforce pressures are set to increase, however without regular demand led workforce modelling it is impossible to accurately predict and prepare for future demand. This is a consensus shared across the health and care sector. Breast Cancer Now, along with around ninety other organisations has supported an amendment to the Health and Care Bill currently going through parliament to require the Government to publish independently verified projections of the future supply of the healthcare workforce for England at least every two years.

2.2.             Specifically for nursing, there should be an adequate assessment of how many different types of nurses are needed for a range of specialities as the Government’s current target for 50,000 more nurses by 2025 does not factor the numbers needed to fill specialist roles such as clinical nurse specialists (CNS) in breast cancer.

2.3.             Despite the Long-Term Plan commitment to all patients including those with secondary cancers having access to a CNS or other support worker by 2021, not all patients with breast cancer are able to access CNSs. For example, the national Cancer Patient Experience Survey for England found that 89% of respondents said that they were given the name of a CNS who would support them through their treatment,[9] with 25% of respondents to our secondary breast cancer survey in 2019 said they had not seen a CNS since diagnosis.[10] Only 73% of respondents to our 2019 survey of secondary breast cancer patients were given the name of a CNS at diagnosis, 25% of respondents said they had not seen a CNS since diagnosis, less than a third (30%) said they had seen a CNS regularly and only 65% said that their CNS had enough time to spend with them.[11] In addition, our 2020 survey found 41% of respondents felt they had less contact with their CNS during the coronavirus outbreak.[12] A survey of CNSs in early 2020 found only 35% felt that they have enough time to offer each secondary breast cancer patient the opportunity to discuss their wider concerns and needs in the weeks following diagnosis, and even less (31%) have the time to offer this as treatment changes or the cancer progresses.[13]

2.4.             We recommend Health Education England and NHS England reviews the current number of full-time equivalents CNS supporting people with breast cancer and how much time they dedicate to primary and second breast cancer patients. Based on this estimates, insight and examples of best practice, Health Education England and NHS England should then develop a recommended ratios for how many CNSs are needed for the treatment and care of primary and secondary breast cancer to inform the numbers which are recruited and trained. This will ensure an equitable approach across the country and ensure levels of safe staffing. In the short-term trusts and ICSs should look at what is the best model of care that uses the skill and knowledge mix of nurses a unit currently has.

3. What are the principal factors driving staff to leave the health and social care sectors and what could be done to address them?

3.1.             There are multiple factors which are driving nursing staff to leave the health sector. There are broader issues which stakeholders, such as the Royal College of Nursing, have highlighted, concerns in terms of pay, staffing issues, lack of support, risk, and personal impact which should be taken into consideration which sit outside the scope of Breast Cancer Now.[14]   

3.2.             Specifically reflecting on specialist breast cancer care nurses, staffing levels, workload and stress all have a significant impact on job satisfaction and therefore retention. Our survey of specialist breast care nurses found that only 35% of breast nurse specialists say their current workload is manageable, 44% said they experience work-related stress or burnout as a result of their current workload and less than half (45%) said they have a good work-life balance. 39% said that their current workload is negatively affecting the quality of care they can give to patients. Increasing the number of CNSs supporting people with secondary breast cancer would reduce the workload for existing CNSs and increasing job satisfaction, therefore improving retention of the current workforce.  

3.3.             Our survey of breast nurse specialists also found that less than half (48%) felt they had received sufficient training and development to provide the support and care that patients with secondary breast cancer need, with 57% said this was due to lack of time for training and development, 51% said this was due to lack of relevant training available, and 40% said this was due to lack of funding for training and development. [15]

3.4.             To address the lack of access to training Health Education England (HEE), or NHS England when HEE is integrated within it, should support the development of a clear, supported and protected professional development pathways for a nurse to become a breast cancer CNS. This should include developing competencies and criteria for CNS roles in breast cancer, which should include basic knowledge of secondary breast cancer, it’s treatment and support required. This document could be informed by Breast Cancer Now secondary breast cancer toolkit which provides guidance on developing and maintaining core competencies and an overview of opportunities for CNSs to develop skills and knowledge.[16] We know that nurses who undertake CNS breast cancer roles come from a range of backgrounds such as chemotherapy, palliative care, therefore developing competencies can help identify skills required for the role and help identify gaps in the knowledge.

3.5.             NHS England, Local Education and Training Boards (LETBs) and Regional People Boards, along with Integrated Care Systems, Cancer Alliances and local Trusts also need to develop roles for breast nurse specialists, and then allocate funding and time to enable future or current post holders develop in their role and undertake CPD. This should be developed as part of a recruitment and retention strategy linked to patient numbers. As outlined by Macmillan, funding should be provided for advance training for an individual to become a specialist cancer nurse, along with undergraduate training and additional employment costs.[17] Other considerations should include exploring rotational opportunities for future CNSs to gain experience and ensuring performance reviews and appraisals are undertaken, to show progression and receive recognition of achievement or expertise.

3.6.             The Royal College of Radiologists’ annual census cited concerns from radiology clinical specialists that increased pressure on staff negatively affects recruitment and retention as well as reducing moral.[18] We know that prior to Covid-19 the breast imaging and diagnostic workforce were already under resourced, but the pandemic has exacerbated the pressure facing this part of the workforce. Breast screening programmes were paused in March 2020 because of Covid-19. Although, screening restarted in the summer of 2020, there is now a significant backlog and we have previously estimated almost 1.2 million fewer women in England had breast screening, compared to pre-pandemic levels.[19] The NHS People Plan, launched in July 2020 aimed to address workforce challenges, however, this was a short-term plan for 2020/21. The Government needs to set out how it intends to deal with the cancer workforce challenges the sector is currently facing, taking into account the screening backlog and the impact the pandemic has had on morale. To meet the backlog, it is vital that breast services fully recovery, but this is only possible by developing a fully funded long-term plan, which includes supporting the workforce so that they can deliver the best care possible.

4. Are there specific roles, and/or geographical locations, where recruitment and retention are a particular problem and what could be done to address this?

4.1.             Breast cancer CNSs play a crucial role in coordinating care and providing the information and support people need to manage their breast cancer diagnosis and treatment. Their role is vital for patients with incurable secondary breast cancer, who will be on lifelong treatment and often have very complex emotional and supportive care needs. CNS are the single most important contributing factor to people’s positive experience of care, with our survey finding[20]:

• Those who have not seen a CNS since diagnosis were three times as likely to feel they were not given enough emotional and psychological support from healthcare professionals during their treatment and care as those who saw their CNS regularly.
• We also found that those who saw their CNS regularly were nearly three times more likely to have had the opportunity to discuss their wider concerns and needs, known as a Holistic Needs Assessment (HNA), compared to those that had not seen a CNS since diagnosis.
• In fact, for all but one type of support included in our survey, people who saw their CNS regularly were at least twice as likely to be referred or signposted and receive the support they needed, when compared to those who had not seen a CNS since diagnosis.
• For some types of support, such as support with childcare or care for other family members, and support with body image, sex, and intimacy, those who saw their CNS regularly were more than five times as likely to be referred or signposted and receive the help they need.

4.2.             Breast Cancer Now also have a range of case studies which demonstrate the key role a CNS can play in delivering breast cancer care.[21]

4.3.             However, as outlined in our response to question ‘to what extent is there an adequate system for determining how many doctors, nurses and allied health professionals should be trained to meet long-term need?’ there are an insufficient number of CNSs to meet the needs of breast cancer patients.

4.4.             In terms of geographical variation there are currently no specific CNSs posts supporting secondary breast cancer patients in East Anglia and the north of England according to our Secondary Breast Cancer Nursing Group. To address this regional variation, there needs to be national guidance on pathways and competencies and recommended staffing ratios, as outlined in our response to ‘What is the role of integrated care systems in ensuring that local health and care organisations attract and retain staff with the right mix of skills?’

4.5.             As mentioned, breast clinical radiologists were one of the most in demand specialists in 2020, and yet this group has experienced minimal growth over the past five years, increasing by just 1% per year on average (average workforce growth is 4% for the consultant radiologist). This demonstrates the pressures the breast diagnostic workforce is under, and these challenges are expected to increase in the next five years with a quarter of breast radiologists due to retire, therefore it is important that we address these workforce issues now.  NHS staff have worked tirelessly to adapt how breast clinics are run, and to restart and continue to deliver breast screening. However, the increase in demand for imaging and diagnostic and the large number of GP referrals is further increasing the pressure on a workforce that was already chronically under-resourced and over-stretched before the pandemic and could be suffering from burnout as a result of the significant demands placed on them.

4.6.             In January 2022, NHS England published cancer waiting times for November 2021. Breast Cancer Now was extremely concerned to see that record numbers of women with potential breast cancer symptoms were facing increasingly long waits to be seen by a specialist – wait that we know cause many women unimagine distress and anxiety. We are very worried to see performance against the two week wait for breast cancer referrals specifically drop so sharply, and well below the figures seen across all suspected cancers. This is a further indication of the immense ongoing pressures on the NHS breast cancer workforce.

4.7.             To enable us to identify and plan for future need we urgently need robust workforce modelling, exploring the mix of roles within the breast imaging and diagnostic workforce alongside current and future demand, which takes into account prevalence, treatment, care, and survivorship.

4.8.             The National Breast Imaging Academy (NBIA) programme is a collaborative, multidisciplinary initiative which aims to provide a range of solutions to address the severe workforce issues faced in the delivery of breast imaging services across the country. It is clinician led and supported by a number of bodies and organisations including Breast Cancer Now, Health Education England, the Royal College of Radiologists, and the Association of Breast Clinicians. Key proposals include the establishment of a national centre of excellence for training, the development of high-quality training programmes for all staff and an online, technology-enhanced learning hub. The NBIA is an important innovative programme which has already made positive strides in addressing workforce challenges facing the breast cancer workforce through the introduction of new roles. However, to ensure the continued expansion and success of the NBIA and to sustain the new roles, long term support and investment is needed.

5. What should be in the next iteration of the NHS People Plan, and a people plan for the social care sector, to address the recruitment, training, and retention of staff?

5.1.             The NHS People Plan for 2020/21 recognised the severe pressures the NHS workforce has been under during the pandemic and set out broad ambitions to recruit more staff. However, it did not go far enough in addressing the enormity of the crisis facing the cancer workforce. Further action is urgently needed in the short and longer-term to ensure there is an appropriately resourced and supported workforce.

5.2.             There is currently a lack of clarity regarding timings for the next iteration of the NHS People Plan, along with how this will sit with Framework 15 which is expected to be published in spring 2022. Without significant investment in the workforce, alongside a clear demand-led NHS People Plan which recognises the specific cancer workforce shortages and addresses specific shortages, recovery plans from the pandemic could be undermined whilst the NHS also risks failing to achieve broader ambitions on early diagnosis, treatment, and care. Urgent investment is required to ensure breast cancer services are not overwhelmed resulting in people waiting longer to be diagnosed and ultimately receive the treatment and care they need. Alongside this we need to see a focus on training, retention, recruitment, and investment in new models of care and skills mixes. We recommended the new People Plan incorporates the recommendations we have outlined in our submission.

6. What is the role of integrated care systems in ensuring that local health and care organisations attract and retain staff with the right mix of skills?

6.1.             Integrated Care Systems (ICSs) should ensure they work with their local Cancer Alliance to prioritise the care and treatment of breast cancer, including planning for and recruiting for a cancer workforce which meets the needs of patients. For example, the 2021/22 priorities and operational planning guidance for ICSs requires them to draw on advice and analysis from their Cancer Alliance, to ensure there is sufficient diagnostic and treatment capacity in place, and to draw up a single delivery plan and an action plan for improving operational cancer services performance. All these activities should require ICS and Cancer Alliances to reflect on their cancer workforce and address any shortfalls in staffing. Going forward NHS England needs to ensure the 2022/23 priorities and operational planning guidance for ICSs should specify the role ICSs and Cancer Alliances in workforce planning and development and outline how they will work in partnership with Local Education and Training Boards (LETBs) and Regional People Boards.

6.2.             An important element of planning and developing the workforce is ensuring that the current workforce has access to the training and education it needs to meet demand. Local systems should assess the needs of the local workforce and what training and resources are required. It is important that local cancer workforce plans are published and made available to ensure transparency and accountability.

Jan 2022