Written evidence submitted by Cancer Research UK (ECS0009)
Progress: Was the commitment met overall?
1. Health Education England’s 2017 Cancer Workforce Plan committed to expanding the cancer workforce’s capacity and skills by 2021. This included commitments to increasing net trainee numbers to ensure we have the right numbers and skills for the future and better use existing supply with actions to support growth and transformation. HEE’s strategic framework for the cancer workforce built on this, showing that to deliver world-class cancer services for all patients, growth of at least 45% was needed over the next decade.[11]
2. Almost 6 years later, the failure of Government to match the ambitions of the Cancer Workforce Plan with concerted, long-term action has failed to address chronic shortages across the cancer workforce. While there has been some progress in growing the cancer workforce, CRUK modelling[12] has shown that well off track to meet the 45% target required to deliver world-class cancer services for all patients. These shortages remain a significant and persistent barrier to meeting the UK Government’s cancer ambitions and improving cancer outcomes for patients.
3. Before the pandemic, around 1 in 10 posts across the NHS in England were vacant, and it was estimated that, with no action taken, this would rise to 1 in 7 posts vacant by 2023/24.[13] According to a 2021 British Medical Association (BMA) report, compared to certain comparable countries, the medical workforce in England is short of around 49,000 doctors.[14]
4. There are shortages across specialities identified in the Cancer Workforce Plan as crucial to cancer services. For example:
5. Due to a lack of investment and planning in the cancer workforce, the commitment to expand the capacity of the cancer workforce has not been met.
Rising incidence of cancer and an ageing cancer workforce
6. A growing and ageing population, alongside an ageing cancer workforce, demonstrate how, in the future, it will become increasingly difficult for the Government to meet this commitment and how the Government will not do so without urgent action.
7. The BMA recently found that by 2043, at least one in four adults in England will be aged 65 or over, while the number of people aged 85 years or above will have nearly doubled, from 1.6m in mid-2018 to 3m. Older people are more likely to develop cancer, with half of all cancers in people over the age of 70, and are more likely to have complex care needs due to co-morbidities.[20]
8. Therefore, demand for cancer services is set to grow, increasing demand on the cancer workforce. By 2035, the number of people estimated to be diagnosed with cancer in the UK is expected to reach over half a million per year, increasing 40% since 2015.[21] Of these, 46% will be over 75 (up from 36% in 2015), meaning that thousands more patients will be presenting with more complex needs.[22] This will significantly increase demand on the cancer workforce.
9. The NHS also has an ageing workforce in many areas – and an increasing early retirement trend. According to the BMA, 13% of secondary care doctors and 18% of GPs will be reaching the minimum retirement age in the next decade.[23] Another BMA survey found that 6 out of 10 consultants intend to retire before or at the age of 60.[24] The Royal College of Pathologists has found that around one-third of pathologists are 55 or over, warning that there will not be enough trainees to replace them in numbers, let alone experience when senior consultants retire.[25]
10. To expand the cancer workforce’s capacity and skills, the Government must consider how to tackle this trend. For example, the RCR has found that, on average, Clinical Oncologists working less-than-full-time retired three years later than their full-time colleagues – 59 compared to 62.[26] Flexible approaches to employment are, therefore, an important lever for increasing retention.
Skill-mix approaches
11. The Plan also committed to expanding skills to support growth and transformation, with 200 more clinical endoscopists, 300 more reporting radiographers, and increased pathology capacity. The focus on upskilling the cancer workforce to design roles and responsibilities around the needs of patients, with a focus on the adoption of skill-mix approaches, was welcome.
12. At their best, skill-mix approaches can deliver measurable improvements for patients, staff and finances.[27] They can improve the care cancer patients receive by allowing for a better alignment between the workforce and the needs of service users.[28] They can also increase capacity in the cancer workforce more quickly than the recruitment and training of new staff. Expanding the number of medical students will only impact consultant supply in 2032.[29] Training and development opportunities for non-medical staff can be completed in a much shorter period – for example, the HEE Clinical Endoscopist Training Programme can be completed in 30 weeks.[30]
13. Skill-mix approaches also provide opportunities for the cancer workforce. Understanding the balance of skills needed in a team frees up staff to focus on areas that are best suited to their skills. Macmillan Cancer Support found that many specialist nurses spend a lot of time on administrative tasks that could be done by a support role, freeing up the nurse to focus on clinical work.[31]
14. The proportion of trusts and health boards using radiographer reporting rose from 72% to 82% in the five years to 2020.[32] In the context of severe radiologist shortages, this is important and shows that there has been some welcome progress in adopting these approaches since the commitment was made.
15. However, opportunities remain to further support the cancer workforce in maximising its capacity by adopting skill-mix approaches. To deliver on these opportunities, national and local health leaders should tackle the barriers to adopting skill-mix approaches. NHS Trusts and Health Boards should consider whether they can backfill the roles of upskilled staff and, if not, take steps to enable this, for example, by recruiting more support workers.
16. In driving the implementation of skill-mix approaches, it is important health leaders have the support of the cancer workforce, meaning timely care and staff wellbeing – not cost – should be at the heart of the case they make. Moreover, HEE should design training courses flexibly to maximise their availability, aiming to reduce the geographical and financial barriers to participation.
Covid-19 and workforce retention
17. Workforce burnout, caused by years of staff shortages and the toll taken by the pandemic, could harm retention in the cancer workforce. Unless steps are taken to tackle this, this risks further damaging the capacity and skills of the cancer workforce.
18. The 2019 NHS Staff Survey found that 40.3% of staff reported feeling unwell due to work-related stress, up from 36.8% in 2016. With wellbeing already deteriorating pre-pandemic, COVID-19 saw wellbeing worsen further – the 2020 NHS Staff Survey reporting this figure had risen to 44%.[33]
19. In October, NHS Providers found that 99% of Trusts were concerned about current levels of burnout across the workforce.[34] This has been reflected in record numbers of staff leaving the NHS – with more than 27,000, approximately 2% of the entire workforce, leaving in the third quarter of 2021.[35]
20. There are several steps the Government should take to help mitigate against the risk increased workforce attrition poses to meeting their workforce commitments. A lack of capacity drives burnout and harms retention, meaning that sustained investment to grow the NHS workforce is vital to any NHS workforce retention strategy.
21. In the short and medium-term, supporting wellbeing will help ensure that the health workforce does not lose its existing capacity in the coming years. Measures that may support this include scaled-up and targeted mental health support for staff, including the continued funding and support for mental health and wellbeing hubs established last year and increasing the availability of learning and development opportunities for staff.[36]
22. Normalising and embedding flexible working practices is one area that can aid wellbeing and retention in the health workforce. The NHS People Plan aimed to achieve ‘flexibility by default’ through measures such as e-rostering, management support, and a cultural shift in which conversations about flexible working are normalised.[37] Polling has found that flexible working is, according to health and care leaders, one of the most beneficial changes to maintain after the pandemic.[38]
23. However, ‘Flexibility by default’ remains a long way from reality, and in many cases, barriers remain. The BMA has reported that staff were unable to deliver productive clinical work from home in some areas due to inadequate IT equipment.[39] Similarly, the 2020 NHS Staff Survey found some suggestions that flexible working capabilities were not adopted universally – nationally or within organisations themselves.[40] Funding will be required to overcome these barriers and ensure the flexible working provisions are fairly distributed.
24. A more comprehensive understanding of why people leave the cancer workforce is a prerequisite to an effective plan to reduce this. Any plan to aid retention should consider how both nationally and locally, comprehensive and standardised data on why people leave jobs in the cancer workforce can be collected to feed into future policies that aim to minimise burnout and maximise retention.
Resources: Was the commitment effectively funded (or resourced)?
25. In recent years, there has been insufficient funding to grow the cancer workforce to meet the demand for cancer services and meet this commitment. Long term investment in medical education and training is the single most important step needed in growing the cancer workforce to meet patient needs.
26. At the 2021 Comprehensive Spending Review (CSR), the Government announced ‘hundreds of millions of pounds of additional funding’ to build a bigger, better trained NHS workforce.[41] This was a promising commitment, but it is still far from clear how much this means in practice or how this money will be targeted – meaning we do not yet know whether this increased investment will see growing numbers of staff in the cancer workforce.
27. Underinvestment in the NHS workforce is not new – with Health Education England’s (HEE) budget falling by 25% in real terms between 2013/14 and 2019/20.[42] Further, demand for the NHS workforce is set to grow, with the Health Foundation estimating that by 2030/31, up to an extra 488,000 health care staff would be needed to meet demand pressures and recover from the pandemic. This is the equivalent of a 40% increase in the workforce – double the growth seen in the last decade.[43]
28. Before the CSR, CRUK modelled the long-term investment in medical education and training needed to grow the cancer workforce by 45% by 2029 – as estimated by HEE as being necessary to deliver world-class cancer outcomes. This modelling estimated that the Government would have to invest an additional £216 million in medical workforce education and training over the Spending Review period for key cancer professions.
29. Recruiting and training the health workforce is a long process, with it taking a minimum of three to five years to train newly qualified staff as specialists in key cancer professions. Because of this long process, this investment is needed now. Otherwise, we push the benefits of this investment even further into the future, with cancer patients bearing the cost of this delay.
Impact: Did the commitment achieve a positive impact for patients?
Impact on patients
30. The failure to make adequate progress in meeting the commitment has had a negative impact on the care and outcomes patients receive.
31. Important cancer waiting times targets are being routinely missed in all four UK nations. In England, almost 55,000 patients should have been diagnosed quicker or started their treatment sooner in the last six years but were not because the NHS continued to miss its target to treat 85% of cancer patients within two months of their urgent suspected cancer referral.[44] Furthermore, this is likely to be the tip of the iceberg, as the figures only capture cancer patients who had an urgent suspected cancer referral. [45] Those diagnosed through a different route – following a routine referral, for example – are likely to have waited even longer.
32. Diagnostic workforce shortages are among the most significant barriers to the Government achieving the NHS Long Term Plan ambition to diagnose 75% of stageable cancers at stage I and II by 2028, for which, based on current trajectory, we are well off track, and to delivering its manifesto commitment to increase cancer survival.[46]
33. The Royal College of Radiologists (RCR) 2020 clinical radiology workforce census found that more than half (58%) of radiology leaders say they do not have enough radiologists to keep patients safe. Further, almost half of trusts, health boards and health and social care trusts (47%) do not have the staff or transfer arrangements needed to run safe 24/7 interventional radiology services, meaning patients are potentially missing out on life-saving procedures.[47] The RCR 2020 clinical oncology census found that over half (52%) of cancer service leaders reported that workforce shortages have negatively impacted the quality of patient care.[48]
Regional variation
34. The commitment has also failed to address significant geographical variation in the cancer workforce, widening health inequalities. For example, within the clinical oncology workforce, growth over the last five years has averaged around 3% but has been minimal in the East and North West of England.[49] Any further commitments to expand the capacity and skills of the cancer workforce must consider how these disparities between regions can be tackled.
35. Even before the pandemic, systemic and long-standing gaps in capacity in diagnostic services were putting a strain on the cancer pathway. As shown in the diagrams below, which break down diagnostic waiting times in radiology and endoscopy by Clinical Commissioning Group (CCG), there is regional variation in the proportion of patients waiting over six weeks for key diagnostic tests.
36. While the number of people waiting over six weeks for an endoscopy increased rapidly from March 2020 until May 2020 for all regions, some regions such as the North West experienced a greater increase and were slower to recover. The pandemic may have increased this disparity, and some areas appear to have recovered their diagnostic services more quickly than others. Health system resilience and the ability of services to tackle the backlog will likely be influenced by existing pressures on the system, including workforce shortages and factors directly related to COVID-19, such as staff sickness and redeployment and level of hospitalisations.
Appropriateness: Was it an appropriate commitment?
Workforce planning
37. Shortages in the cancer workforce are a significant barrier to delivering on the Government cancer ambitions and improving outcomes for patients, meaning a commitment to expand the capacity and skills of the professions key to the diagnosis and treatment of cancer was welcome. However, the detail of the commitment demonstrated the challenge of making workforce commitments – with targets often appearing either arbitrary or vague due to a lack of data. This demonstrates the challenge posed by insufficiently transparent and regular workforce planning.
38. Clear responsibility for projecting future demand for the cancer workforce, supply trends within the cancer workforce, and plans to grow the cancer workforce accordingly is vital to recruiting the right number of staff with the right skills to improve cancer outcomes in England.
39. The UK Government’s Health and Care Bill proposes a duty for the Secretary of State for Health and Social Care to publish a report every Parliament setting out roles and responsibilities to support greater clarity and transparency around workforce planning. However, there is no detail on how this duty would ensure that steps would then be taken to grow the cancer workforce in line with growing demand. Additionally, reporting every Parliament, rather than more frequently, will not provide the clarity needed to highlight key areas of persisting or new need, project future demand and grow the cancer workforce accordingly.
40. The recently rejected amendment, proposed by Jeremy Hunt MP and supported by organisations across the health and care sector, including CRUK, could have helped address this. It would have mandated regular, independently verified projections of the future supply of and demand for the health and social care workforce – similar to the economic projections published by the Office for Budget Responsibility (OBR).[50] This would have improved accountability in workforce planning, making it more likely the correct numbers of staff with the right skills would be recruited. The amendment has now been re-tabled in the House of Lords by Baroness Cumberledge. CRUK continues to believe this amendment is necessary and urges the Government to accept it.
HEE merger with NHSE
41. In 2021, the Government announced that HEE is to be merged into NHS England by April 2023. As the actions outlined in the Cancer Workforce Plan often centre around HEE, this may have important implications for improving progress against meeting the target.
42. Having recruitment and training under the same roof as service provision has the potential to make workforce planning clearer and make it easier to develop an effective workforce strategy. This could foster a more coherent workforce policy, aligned with service users’ needs, and help achieve the Government’s cancer workforce commitment. However, this will not happen unless workforce policy is given the priority within NHSE that the challenges it faces merit.
43. Once HEE is merged into NHSE, medical education and training budgets must be protected. HEE’s budget was cut by 25% in real terms between 2013/14 and 2019/20, while the NHS England budget has been protected.[51] This has contributed to the workforce challenges evident today – with HEE lacking the resources to deliver the workforce growth to meet rising demand. Moving HEE within this protected budget could help avoid similar cuts in the future. However, NHSE is a huge organisation with many competing interests for funding. Before establishing HEE, medical education and training budgets were often cut to fund other short-term goals.[52] NHSE is currently under significant pressure to meet goals such as cutting the elective backlog, and medical education and training budgets mustn’t suffer as a result.
44. As with any service reorganisation, this will likely lead to disruption in HEE and NHSE. Given the pressing challenges faced across workforce recruitment, retention and training in the NHS, it is vital that merging when the workforce challenges the NHS faces are so great does not interfere with the work being done in both organisations to tackle them.
Research and the future of cancer care
45. Another theme missing from the Cancer Workforce Plan is the important role that participation in research conducted by the NHS workforce can have in delivering better outcomes for both staff and patients. For example, it should have highlighted the role participation in research can have in supporting wellbeing and retention across the health workforce. The enthusiasm for research in the cancer workforce offers a significant opportunity to expand the NHS’s capacity to deliver life-saving and innovative research that drives forward improvements in care quality and patient outcomes.
46. However, this opportunity is limited by the scarcity of support and resources available to NHS researchers, with 60% of research directors saying there is insufficient funding to support NHS research studies.[53] CRUK’s report Creating Time for Research found that NHS staff struggle to conduct research because they face an inadequate supply of dedicated research time and funding, limited opportunities to begin and build research careers, and an organisational culture that insufficiently promotes research within the NHS. [54]
47. To address these challenges and unlock research capacity in the NHS workforce, the Government must now increase investment in research staff and infrastructure – developing pathways for research careers and strengthening national- and organisational-level research cultures.
48. It should also focus on how to equip the health workforce with the skills needed to deliver the future of cancer care. For example, genomics is rapidly changing the cancer pathway – with the potential to improve screening, diagnosis and treatments. A healthcare workforce with role-appropriate and up-to-date genomics knowledge is needed to achieve this. This requires expansion of the workforce and training and development of existing staff.
Primary care
49. Primary care is a key component of cancer care, with over 6 in 10 cancer patients beginning their journey to diagnosis and treatment following a GP referral.[55] Despite the Government’s manifesto commitment to increase the number of GPs in England by 6,000 by 2024, the number of fully qualified full-time equivalent GPs in England has fallen by 1,803 since 2015,[56] contributing to 65% of patients finding it easy to reach their GP practice by phone in 2020, compared with 80% in 2012.[57] Any commitment to expand the cancer workforce considers how to ensure timely and equitable access to primary care in the face of significant workforce shortages.
50. In addition to severe shortages, recent studies have shown regional variation in the distribution of the primary care workforce and turnover rates of GPs, with the most deprived areas being the worst affected.[58],[59] General practice in areas of high socioeconomic deprivation is relatively underfunded and under-doctored.[60] Given the pivotal role of primary care in the early diagnosis of cancer and the increased incidence of cancer in areas of deprivation, an inequitable primary care workforce may have implications for driving cancer inequalities. More targeted policies addressing workforce inequalities are needed to expand access to primary care and reduce health inequalities, for example, financial incentives.
January 2022
51. Assuming patients receive prompt access to the best treatment for their individual case, achieving this commitment would deliver a meaningful improvement in measurable outcomes for patients. Early diagnosis plays a critical role in improving someone’s chance of surviving cancer – and there is significant evidence of this across different cancer sites. In England, when bowel cancer is diagnosed at its earliest stage (I), at least 9 in 10 will survive their disease for five years or more. When diagnosed at the latest stage (IV), this figure plummets to less than 1 in 10 patients.[61] Almost 9 in 10 lung cancer patients will survive their disease for at least a year if diagnosed at the earliest stage, falling to around 1 in 5 people when lung cancer is diagnosed at the most advanced stage.[62] And for breast cancer, almost all patients who are diagnosed at the earliest stage survive their disease for at least five years.[63]
52. This means that achieving a meaningful all-cancer stage shift, with more cancers diagnosed at stage I or II and an absolute reduction in the number of cancers diagnosed at stage III or IV, will have a positive impact on survival outcomes for patients.
Progress: Was the commitment met overall?
Does the commitment have a clear and fixed deadline for implementation?
53. The NHS England Long Term Plan set the target date of 2028 for increasing the proportion of stageable cancers diagnosed at Stage I and II to 75%.[64] As outlined further below, based on the current trajectory, the NHS is off-track to meet this target. However, improving early diagnosis (ED) rates and reducing the incidence of advanced disease will remain vital to transforming cancer survival outcomes in England. The NHS must therefore accelerate efforts to improve progress towards achieving this target within the timeline.
To what extent has the NHS’s COVID-19 response affected progress on targets?
54. Before the COVID-19 pandemic, we were already off track to meet this target. However, the pandemic led to unprecedented disruption in the NHS and impacted how people respond to and act on their health. While it was vital to mount a concerted national response to the pandemic, there was a devastating impact on cancer services, which has stalled further progress against the commitment.
55. We estimate more than 326,000 fewer people were urgently referred for suspected cancer in England between March 2020 and March 2021 compared to before the pandemic.[65] Emerging evidence suggests that this was mostly driven by people not coming forward with symptoms rather than changes to how GPs referred patients.[66] Many factors drove this fall in GP presentation, including worries about COVID-19, difficulties accessing health services, and concerns about burdening the NHS.[67]
56. For the seven key diagnostic tests used to diagnose cancer, there were 4.6 million fewer tests carried out between March 2020-March 2021 in England compared to pre-pandemic – a fall of 22%.[68] With cancer screening programmes across the country initially paused, we estimate that 42% fewer people began treatment in England following a positive cancer screening test between March 2020 and March 2021 compared with pre-pandemic.[69]
57. Disruption to patient presentation and key diagnostic services means that people will be living unaware they have cancer who would otherwise have been diagnosed, with the risk that their disease may progress and be diagnosed late, making it much harder to treat and worsening survival chances. It is also likely that people contracted and died from COVID-19 before they were diagnosed with cancer, and so we may not see the full impact realised in the cancer data.
58. We do not yet have gold standard, complete data on how the pandemic has impacted cancer stage for those who were diagnosed, and it is likely, given the time lag in data publication, that we may not have a complete picture until well into 2023. However, we anticipate the impact on patient presentation and delays to diagnoses, including the de facto pausing of cancer screening programmes, will at least slow efforts to improve early diagnosis statistics and, at worst, worsen stage distribution for some cancer sites.
59. We are pleased that there is a rapid registration dataset, which is useful for providing an early indication of progress against the target. However, the quality does not match that of gold standard registration, which has a lag of about 18 months. This delay in availability and publication of high-quality, complete data on cancer outcomes, therefore, demonstrates the need for more timely data collection and publication.
Does data show achievement against the target (if applicable)?
60.
Over the last decade, the proportion of all stageable cancers diagnosed at stage I and II has remained stubbornly stable, with only around 55% of cancer patients who could be staged being diagnosed at these stages in 2018, with this trend looking set to continue in 2019.[70] Whilst we await the publication of quality data covering the current time period, if the current trajectory continues, we will not achieve the early diagnosis ambition.
61. With a growing and ageing population, the number of people being diagnosed with cancer each year will increase – this means we estimate that by 2028, to meet the 75% ambition, the NHS in England will need to diagnose an extra 100,000 patients at an early stage each year.[71] Patients are also likely to have a greater number of co-morbidities, meaning the care they require will be more complex and time-consuming.[72]
Resourcing: Was the commitment effectively funded (or resourced)?
62. The Long Term Plan set out a number of interventions which, if fully implemented, NHSE believed would enable significant progress towards the commitment. NHSE was able to direct some funding to these initiatives based on the 2018 funding settlement.
63. However, a lack of investment in key areas, particularly workforce, has hindered the implementation of these initiatives and means there has been insufficient funding and resource to deliver the commitment. For example, one of the key changes which the Long Term Plan committed to support this ambition was rolling out FIT in bowel screening and extending the lower age range of the programme to 50. However, shortages in the endoscopy workforce have meant that FIT screening has been rolled out at a less sensitive level in England than in Scotland. This means that more than 1,000 cancers and nearly 7,000 potentially pre-cancerous growths might be missed every year, compared to if England used the same sensitivity level as used in Scotland.[73] The expansion of the age range for bowel screening has begun but there is variation in the progress of this across different geographies, linked to challenges in endoscopy capacity.
64. CRUK has developed the ‘Improving Early Diagnosis of Cancer Waterfall’, which sets out the interventions which have the potential to drive an all-cancer stage shift and meet the early diagnosis commitment.
65. As the Waterfall shows, whilst interventions set out in the Long Term Plan will support significant progress if fully implemented, there remains a significant gap that demands we must go further and faster, including early detection and diagnosis research to develop new interventions that can be adopted into the NHS. Government should strengthen the UK’s medical research and development (R&D) base, vital for the pipeline of early diagnosis technologies and interventions that could accelerate progress towards the commitment. It is also critical that the NHS has the capacity and capability to implement innovative approaches and technologies once we know they are effective.
66. Furthermore, as the Waterfall identifies, initiatives to improve early diagnosis cannot be fully realised without expanding diagnostic services’ capacity through investment in the diagnostic workforce and key diagnostic equipment. Expanding capacity in the NHS through investment in training key diagnostic professions and procuring more diagnostic kits is vital to ensuring timely patient care and allowing the NHS time and space to innovate. Therefore, it is welcome that the 2021 Comprehensive Spending Review allocated £2.3bn over the Spending Review period to transform diagnostics services. This will fund the expansion of Community Diagnostic Centres (CDCs), with the Government committing to rolling out at least 100 CDCs. However, as discussed above, we have still not seen sufficient action to address the major workforce shortages in diagnostic services, which will be vital to delivering the interventions required to meet the early diagnosis commitment.
Impact: Did the commitment achieve a positive impact for patients?
What was the impact on equity of outcome for different groups?
67. There are significant, persistent inequalities in stage at diagnosis based on deprivation. Data shows that, in 2019, 36.6% of cancers diagnosed for the least deprived group were at stage I, and this fell to 31% for the most deprived group.[74] In contrast, 22.3% of cancers were diagnosed at stage IV for the least deprived group, whereas this proportion was much higher for the most deprived at 29.1%.[75]
68. It is essential that increasing the proportion of cancers diagnosed early is achieved for all patients. To help ensure this, early diagnosis initiatives must specifically seek to address need in marginalised communities, as taking a broad approach risks maintaining or even exacerbating these inequalities.
Has the commitment been met/is it on track to be met equally across England or are there regional variations?
69. There is evidence of existing variation between Cancer Alliances, which signals geographical variation, for stage at diagnosis.
70. The proportion of lung cancer cases diagnosed at stage I and II ranged from 25% to 35% across Cancer Alliances in 2016-2018. In currently unpublished analyses, we estimate that around 2,300 extra lung cancer patients each year could be diagnosed at stage I or II (rather than III or IV) if every Cancer Alliance had the same proportion of lung cancer patients diagnosed early as the Cancer Alliance with the highest proportion. In turn, this would increase the proportion of lung cancer patients diagnosed at stage I or II in England from 29% currently to 35%.[76]
71. We found similar evidence of the importance of reducing geographical variation for bowel cancer. The proportion of bowel cancer cases diagnosed at stage I and II ranged from 40% to 47% across Cancer Alliances in 2016-2018. If every Cancer Alliance had the same proportion of bowel cancer patients diagnosed early as the Alliance with the higher proportion, we estimate that this would increase the proportion of bowel cancer patients diagnosed at stage I and II in England from 44% currently to 46%.[77]
72. Some of this variation may be due to differences in socio-demographics between Alliances. However, some of the variation could be due to reasons that are potentially avoidable and could be reduced or removed with existing early diagnosis interventions.
Appropriateness: Was it an appropriate commitment?
Was (or is) the commitment likely to achieve meaningful improvement for service users, healthcare staff and/or the healthcare system as a whole? If not, why not?
Is the target contained in the commitment an effective measure of policy success (if applicable)?
Was the commitment addressing an identified need and relevant to the problem?
73. CRUK strongly supports the commitment to improve early diagnosis and reduce the burden of late stage cancer. It is based on the recognition that diagnosing cancer at its earliest stages gives patients the best chance of accessing curative treatments options and would ultimately accelerate improvements in cancer outcomes.
74. Yet, despite the importance of early diagnosis, data from the International Cancer Benchmarking Partnership shows that England lags comparable countries. Recent international stage data on colorectal, lung and ovarian cancers shows that, though England does not have the worst stage distribution, overall patients in England were diagnosed at a later stage than comparable countries with the best cancer survival outcomes.[78] This commitment, therefore, was a relevant, welcome response to England’s poorer performance in this critical area. However, slow progress against the ambition means it is likely that there will be a delay in seeing improved outcomes.
Is the commitment specific enough?
75. Whist this bold ambition is welcome, a delivery plan is essential for setting out how the NHS will work towards achieving it. Whilst the Long Term Plan outlined some interventions for improving early diagnosis, it is only more recently that the NHS has mapped out what changes will be required to meet this ambition by 2028. This is a welcome start, but full funding and more detailed action plans will be required to deliver meaningful change.
76. We note that achieving this ambition has been marked as a priority objective by the NHS Cancer Programme. We urge that efforts to reach the ambition do not overlook the importance of meaningfully reducing late-stage diagnosis, as well as improving early diagnosis. To help avoid this, any future stage ambitions should seek to address this explicitly in the ambition.
A faster diagnosis standard from 2020 to ensure most patients receive a definitive diagnosis or ruling out of cancer within 28 days of referral from GP or from screening
Progress: Was the commitment met overall?
77. A Cancer Waiting Times (CWTs) metric to capture the whole diagnostic interval was initially proposed in the 2015 cancer strategy for England. The Independent Cancer Taskforce recommended the new metric should measure the number and proportion of patients who were either definitively diagnosed with cancer or had cancer definitively ruled out – with the result communicated to the patient – within 4 weeks. The taskforce outlined that the standard should be set at 95% of patients, with 50% of patients receiving their diagnosis or having cancer ruled out within 2 weeks, to be achieved by 2020.[79]
78. The NHS accepted the recommendation and, following understandable delay due to COVID-19, monitoring of FDS performance began in April 2021, and systems have been expected to meet the standard from October 2021. However, the scope of the standard was narrowed. Whilst the original vision looked to include all referrals, FDS only includes urgent suspected cancer referrals and cancer screening referrals. NHSE also decided to set the threshold for the standard at 75%, much lower than originally proposed, as discussed below.
To what extent has the NHS’s COVID-19 response affected progress on targets?
79. The COVID-19 pandemic has impacted the ability of systems to meet the standard. Since its introduction, the FDS has not been met nationally. In November (the latest data available), only 71.3% of people in England (who had urgent suspected cancer referral or cancer screening referrals) received a diagnosis/all clear within the timeframe. The huge pressure that diagnostic services have faced is a key cause of this. Major workforce shortages mean that there has not been sufficient capacity to meet patient needs and keep up with the increased pace of referrals, creating a bottleneck in the cancer pathway.
Does data show achievement against the target (if applicable)?
80. The original commitment to introduce a faster diagnosis standard has been achieved. However, it has been introduced at a much lower standard than was originally proposed by the NHS. To date, it has not achieved the 75% threshold.
81. Whilst it is therefore welcome that this commitment has been implemented, systems must be supported to increase their diagnostic capacity, which will be critical to meeting and going beyond the standard’s threshold.
Resourcing: Was the commitment effectively funded (or resourced)?
82. The FDS commitment was restated in the NHSE Long Term Plan, published in 2019. The Long Term Plan provided some detail on how commitments to improve the diagnostic section of the cancer pathway would be resourced, including rolling out rapid diagnostic centres and investing in new equipment, including MRI and CT scanners.
83. However, the last decade has been marked by underinvestment from Government and a lack of strategic thinking, with insufficient annual financial settlements hindering longer-term planning based on patient need and workforce projections. This has resulted in a lack of diagnostic capacity in cancer-relevant modalities.
84. The 2021 Comprehensive Spending Review is welcome to allocate £2.3bn over the Spending Review period to transform diagnostics services. This will fund the expansion of Community Diagnostic Centres (CDCs), with the Government committing to rolling out at least 100 CDCs. Importantly, this will significantly increase diagnostic capacity and the availability of key equipment, including CT and MRI scanners and endoscopy and pathology facilities.
85. However, we have still not seen sufficient funding or plans to deal with the major workforce shortages facing diagnostic services, an issue which is recognised across the sector, as discussed in the workforce section above.
86. Ultimately, funding decisions to date appear to have been led by cost rather than patient need. This means that diagnostic capacity has not grown sustainably and is now incredibly overstretched, leading to long patient waits and a consistent failure to meet cancer waiting times, including FDS.
Impact: Did the commitment achieve a positive impact for patients?
87. As the FDS has not been in operation for a full year, with systems only expected to meet it for the last four months, there is not data available yet to understand if the commitment has achieved a positive impact for patients. Over time, it will be important to assess if measuring this part of the patient pathway has driven an improvement in performance to ensure more patients are receiving a diagnosis/all-clear within 28 days.
What was the impact on equity of outcome for different groups?
88. Transparent data collection and reporting will be critical to ensure that the FDS is delivering for all cancer patients. In particular, the NHS must monitor how many people who subsequently go on to be diagnosed with cancer do not receive their diagnosis with 28 days, with a breakdown by cancer site and demographic factors such as socioeconomic status. This will not only be important to ensure transparency in how the FDS is performing but will also help avoid perverse incentives to seek ‘quick wins’ in more common cancer site pathways to the detriment of other cancers with more complex challenges in diagnostic pathways.
89. It is also important to note that the target currently only includes patients with an urgent suspected cancer referral or a cancer screening referral – a smaller scope than was first proposed for this target. Expanding the FDS to be more inclusive of other routes to diagnosis could have the potential to be more transformative for stage and survival, if it were accompanied with more investment in diagnostic capacity, ensuring shorter waits for more patients. This would help improve cancer outcomes and progress toward NHS Long Term Plan goals and must be considered in the longer term.
Has the commitment been met/is it on track to be met equally across England or are there regional variations?
90. Data on FDS performance is already showing clear variation nationally against the threshold. In November 2021, 71.3% of patients in England as a whole received their diagnosis or had cancer ruled out within the standard, but while some NHS Trusts reported they had met the standard for 90% or more of patients, others reported that they had done so for less than 50% of patients.
91. We are concerned that the threshold being set lower than originally proposed may make it more likely that in the future, the standard will be met but it may mask significant geographical variation. This could detract from efforts to tackle geographical variation in diagnostic services and result in the failure to effectively tackle cancer inequalities, as well as representing a failure to drive improvements for significant numbers of patients across the country.
Appropriateness: Was it an appropriate commitment?
Was (or is) the commitment likely to achieve meaningful improvement for service users, healthcare staff and/or the healthcare system as a whole? If not, why not?
Is the target contained in the commitment an effective measure of policy success (if applicable)?
Was the commitment addressing an identified need and relevant to the problem?
92. CRUK strongly supports the introduction of the FDS commitment. Patients face major, persistent challenges and delays securing a diagnosis in a timely manner, with diagnostic capacity being a key blocker. FDS captures a previously unmeasured part of the cancer pathway (for patients in scope) – the time taken to reach a diagnosis. Positively, FDS will enable greater scrutiny of the diagnostic part of the cancer pathway, supporting the identification of best practice and problem areas that require greater attention to improve. In turn, this should help ensure clearer milestones for care and more consistency across England.
93. Improving and ensuring strong performance in diagnostic services is also important when considering patient experience. For patients and their loved ones, waiting for a diagnosis or ruling out for cancer is a very anxious time, and so it is important to avoid undue delays. In some cases, a slower diagnosis can also mean that aggressive cancers may have more chance to progress. The FDS could therefore help improve the patient experience by reducing the anxious time between having a diagnostic test and receiving results.
94. This means that meeting the FDS is an effective measure of policy success. However, we are concerned that the current performance threshold of 75% is too low and risks failing to achieve its stated aim, to improve more timely diagnosis for many cancer patients. It will also likely do little to contribute to the NHS Long Term Plan ambition to diagnose 75% of cancer patients at an earlier stage. There are currently no clear plans for increasing the performance threshold towards more ambitious standard, which will be important if the FDS is going to achieve meaningful improvement for patients and the healthcare system.
Is the commitment specific enough?
95. The commitment only looks at the introduction of FDS, not the standard it is set. Whilst it is important that the standard aligns with other CWTs, the commitment means it has been introduced at a much lower level than originally proposed. As noted, without an ambitious threshold and with the current scope, we are concerned that this will not deliver improvements for patients.
Has the commitment had any unintended consequences on other aspects of care?
96. It is too early to assess if the implementation of FDS has had any unintended consequences.
97. More generally, there is evidence that performance measures can lead to systems focusing only on what is being targeted, leading to a failure to tackle issues not included, such as quality. For the FDS, this could mean that while performance for the one-third[80] of patients urgently referred is improved by the new target, those diagnosed through other pathways who are not recorded through FDS do not see similar improvements.
98. As the FDS develops, NHS must keep the scope of the target under review to ensure that opportunities to make the standard, and the transformation that hopefully follows from it, more inclusive of cancer patients across the various routes to diagnosis, are identified. This is particularly important given the planned removal of the two-week wait standard in the future.
Commitment: Safer and more precise treatments, including advanced radiotherapy techniques and immunotherapies, will continue to support improvements in survival rates.
Was the commitment met overall?
To what extent has the NHS’s Covid-19 response affected progress on targets?
99. The NHS’s COVID-19 response has both negatively and positively affected progress on targets. General service disruption and patients’ inability or hesitation to present have meant that over 45,000 fewer people began treatment for cancer in the UK in the first year of the pandemic, compared with the previous year[81]. This has also affected the delivery of the specific treatment types highlighted in the commitment. For example, according to the Institute for Public Policy Research, around 15,000 fewer episodes of radiotherapy was performed between March 2020 and February 2021 compared to the previous 12 months, a drop of 13%[82].
100. According to the Department of Health and Social Care (DHSC), the impact of COVID-19 was one of the reasons the opening of the Proton Beam Therapy centre at the University College London Hospital (UCLH) was delayed in 2020 and 2021[83]. The new centre started treating its first patients in January 2022.
101. The impact of the pandemic on clinical trials was significant, forcing many cancer trials to pause recruitment – thereby reducing patient access to innovative treatments and slowing the progress of medical research crucial to improving cancer outcomes for patients now and in the future. According to the NIHR, recruitment to cancer studies dropped to 8% of pre-pandemic levels in April 2020.[84] Following a moderate recovery in Summer 2020 and a further decline in Winter 2020, overall recruitment to cancer studies increased to around half of pre-pandemic levels in Spring-Summer 2021. In November 2021, recruitment stood at 72% of pre-pandemic levels[85], but winter pressures on the health service combined with pressures arising from the Omicron wave of infections is likely to have impacted research capacity further.
102. To keep cancer services running throughout the disruption caused by the pandemic, health systems had to adapt to vastly different and challenging circumstances. This meant developing frameworks for prioritising cancer treatments and adapting treatment types and regimens. Some changes to treatment regimens were necessary, for example, increased use of less immunosuppressive targeted therapies earlier in the treatment pathway to mitigate the likelihood of patients becoming seriously ill during the pandemic.[86]
103. This has, in some cases, resulted in the temporary practice of greater and earlier use of immunotherapies. Some of these have subsequently been implemented as standard of care, for example, as seen with the option to give nivolumab with ipilimumab as immunotherapy instead of chemotherapy for some colorectal cancers. NHS England and the NHS Cancer Programme should continue to evaluate the impact of changes to cancer treatment by monitoring cancer outcomes data from March 2020 and support the timely communication of up to date clinical guidance to health care professionals and patients.
104. As a result of the COVID-19 pandemic, hypofractionation approaches in radiotherapy services such as stereotactic ablative radiotherapy (SABR) have been rolled out, offering more advanced and precise treatment while requiring fewer doses of radiation in each treatment cycle. While these approaches are in response to the pandemic, they have the potential to offer benefits to patients through expanding the treatment options for people with a range of oligometastatic cancers, requiring fewer trips to hospital, and potentially causing less severe side effects from less radiation exposure.
105. SABR could also increase capacity by helping to reduce the number of hospital visits for some patients receiving radiotherapy, as well as offering an evidence-based alternative to surgery for some cancer types, including non-small cell lung cancer. In 2020, NHS England announced that, rather than full rollout by 2022, SABR would be rolled out by the end of March 2021 so that every part of the country would be offering SABR treatment for non-small cell lung cancer and those with lung, lymph nodes and non-spine bone oligometastatic disease[87]. In September 2021, the DHSC said SABR was available to treat non-small cell lung cancer patients in every radiotherapy provider in England.[88]
Was the commitment effectively funded (or resourced)?
Were specific funding arrangements made to support the implementation of the commitment? If not, why? If so, what were these, when and where were they made?
106. NHS England invested £130 million from 2016 to 2018 to enable the replacement or upgrade of linear accelerators at the end of their lifespan. According to the DHSC, following the 2020 Spending Review, £32 million was made available to support the replacement of 17 linear accelerators (LINACs) over 10 years old, with a commitment to deliver these by 31 March 2022.[89]
Do healthcare stakeholders view the funding as sufficient?
107. The £130 million investment in the replacement of LINACs announced in 2016 was vital and contributed to the replacement of LINACs between 2018 and 2020. However, it was a short-term solution. To ensure radiotherapy services can consistently deliver optimal treatment for patients, they need a central process for the rolling replacement of LINACs at the end of their 10-year lifespan.
108. The RCR estimate that replacing LINACs on a rolling basis will cost £68m per annum. A LINAC costs approximately £2 million (including software and installation). According to the RCR there are 340 LINACs in the UK, all of which need replacing every ten years.[90] Last year, the DHSC said that as of 31 March 2021, approximately 63 LINACs in routine NHS use were aged 10 years or more and that around two-thirds of those have a locally agreed replacement plan that is due to be implemented in 2021-22.[91]
109. The shift to Radiotherapy Operational Delivery Networks (ODNs) is a positive step towards improving the workforce’s ability to manage demand for treatment, provide high-quality care, and undertake research. However, this is subject to certain caveats and must be considered in the context of significant workforce shortages. Addressing these shortages with a long-term, fully funded workforce plan will be key to realising the ambitions of the ODNs.
110. The RCR estimates the cost to be £1.5m for each of the 11 networks, which is £16.5m per annum and £49.5m for the period of the 2021 comprehensive spending review. According to the RCR, this money could help fund the clinical time needed for ongoing system leadership, quality improvement, and audit activities, allowing rapid rollout of innovative techniques safely using mentorship and supporting new innovations via clinical trials.[92] It is unclear whether sufficient funds have been committed to radiotherapy ODNs following the comprehensive spending review and clarity on this is needed.
Did the commitment achieve a positive impact for patients?
What was the impact on equity of outcome for different groups?
111. Since the commitment is broad and has no clear targets or deadlines, it is challenging to assess the direct equity of impact for different groups. Surgery is often the most optimal treatment for cancer, especially in primary treatment of tumours diagnosed at stage I and II. However, as surgery is not reflected in this commitment, presumably because it is not a cancer-specific treatment type, it can be argued that the commitment’s impact on cancer patients is not equal as it focuses on those patients that receive radiotherapy and systemic anti-cancer treatment (SACT) as part of their treatment. Additionally, surgery has been the type of cancer treatment most negatively impacted by COVID-19. In the early stages of the pandemic, staff redeployment and restrictions on surgical capacity meant the number of cancer surgeries fell by an estimated 24% in England between April and November 2020 compared to 2019.[93]
Has (or will) there been (or be) a meaningful improvement in measurable outcomes, reasonably attributable to the commitment?
112. The commissioning of proton beam therapy facilities at the Christie NHS Foundation Trust and the University College Hospital has the potential to improve outcomes for people with certain types of brain cancer, spinal cord cancer, or cancers that develop in the head and neck area. However, work was underway to establish these facilities prior to this commitment, so this service improvement is not necessarily directly attributable to the commitment.
113. The expanded provision of SABR may improve outcomes for patients with certain types of non-small cell lung cancer, primary pelvic tumours, and metachronous extracranial oligometastases. This could reasonably be attributable to the commitment, although, as described above, the increased use of SABR and hypofractionation can also be ascribed to the circumstances of the COVID-19 pandemic. For this approach to be expanded further and thereby provide further improvement in outcomes, ODNs need a properly funded and trained workforce, system leadership, and functional kit. The commitment is less clear on how these improvements will be supported.
Will (or have) service users benefit(ted) directly, indirectly or both?
114. Patients receiving radiotherapy will directly benefit from upgraded kit, which allows for more optimal radiotherapy to be delivered and more innovative treatments to be offered. This may also allow more research to be carried out in radiotherapy centres, paving the way for innovative forms of treatment to be delivered more widely, in turn benefitting future patients. However, the improvements described above (a properly funded and trained workforce and system leadership) are an important prerequisite for this.
Was it an appropriate commitment?
Was (or is) the commitment likely to achieve meaningful improvement for service users, healthcare staff and/or the healthcare system as a whole?
115. Safer and more precise treatments have the potential to provide meaningful improvements for service users, healthcare staff, and the healthcare system due to more treatment options, more personalised care, fewer visits to hospital, and less severe side effects for patients. However, the lack of clear targets and deadlines, as well as gaps in the available data to capture and determine the use of treatment in as near to real-time as possible, makes it challenging to assess progress against the commitment.
116. Neither the headline commitment nor the expanded commitments have a clear and fixed deadline for implementation.
Is the commitment wide enough in scope? Is it specific enough? Does the commitment have a clear and fixed deadline for implementation?
117. The commitment is not specific enough. The headline commitment ‘safer and more precise treatments including advanced radiotherapy techniques and immunotherapies will continue to support improvements in survival rates’ is broad and lacks clear targets and deadlines for implementation. Given how broad the commitment is, it is difficult to make the explicit link between the commitment on the one hand and access to treatment and improved outcomes on the other. As mentioned above, this also makes it challenging to assess progress against the commitment.
Has the commitment been met equally across England or are there regional variations?
118. Similarly, it is difficult to assess regional variations in progress against the commitment given its lack of specificity as well as clear targets and deadlines.
Is the target contained in the commitment an effective measure of policy success (if applicable)?
119. No. The lack of a clear target means the commitment lacks an effective measure of policy success.
For more information, please contact Heather Lafferty, Westminster Public Affairs Officer, at Heather.Lafferty@Cancer.org.uk.
[1] Cancer Research UK analysis of: Quaresma M, Coleman MP, Rachet B. 40-year trends in an index of survival for all cancers combined and survival adjusted for age and sex for each cancer in England and Wales, 1971-2011: a population-based study. Lancet 2014 pii: S0140-6736(14)61396-9.; ISD Scotland. Trends in Cancer Survival 1983-2007, and Northern Ireland Cancer Registry. Incidence & Survival 1993-2012.
[2] Ahmad AS, Ormiston-Smith N, Sasieni PD. Trends in the lifetime risk of developing cancer in Great Britain: comparison of risk for those born from 1930 to 1960. Br J Cancer. 2015 Mar 3;112(5):943-7. doi: 10.1038/bjc.2014.606. Epub 2015 Feb 3. PMID: 25647015; PMCID: PMC4453943.
[3] Conservative Party. 2019. The Conservative and Unionist Party Manifesto 2019. Accessed August 2021 via https://assets-global.website-files.com/5da42e2cae7ebd3f8bde353c/5dda924905da587992a064ba_Conservative%202019%20Manifesto.pdf.
[4] Health Education England, 2017. Cancer Workforce Plan. Phase 1: Delivering the cancer strategy to 2021. [online] NHS England. Available at: <https://www.hee.nhs.uk/sites/default/files/documents/Cancer%20Workforce%20Plan%20phase%201%20-%20Delivering%20the%20cancer%20strategy%20to%202021.pdf> [Accessed 30 January 2022].
[5] HEE, 2018. Strategic Framework for Cancer Workforce. Accessed January 2022 via https://www.hee.nhs.uk/sites/default/files/documents/Cancer-Workforce-Document_FINAL%20for%20web.pdf
[6] Cancer Research UK modelling based on Health Education England data. For methodology, please see ‘George, J., Gkousis, E., Feast, A., Morris, S., Pollard, J. and Vohra, J (2020). Estimating the cost of growing the NHS cancer workforce in England by 2029: supplementary information pack.
[7] Independent Cancer Taskforce. 2015. Achieving world-class cancer outcomes: a strategy for England 2015-2020. Accessed January 2022 via https://www.cancerresearchuk.org/sites/default/files/achieving_world-class_cancer_outcomes_-_a_strategy_for_england_2015-2020.pdf.
[8] Based on Public Health England. 2021. National Disease Registration Service: Staging data in England. Accessed July 2021 via https://www.cancerdata.nhs.uk/stage_at_diagnosis. Please contact Cancer Research UK for further detail.
[9] Public Health England. 2021. National Disease Registration Service: Staging data in England. Accessed July 2021 via https://www.cancerdata.nhs.uk/stage_at_diagnosis.
[10] Cancer Research UK. 2020. Early Detection and Diagnosis of Cancer Roadmap. Accessed July 2021 via https://www.cancerresearchuk.org/funding-for-researchers/research-opportunities-in-early-detection-and-diagnosis/early-detection-and-diagnosis-roadmap.
[11] HEE, 2018. Strategic Framework for the Cancer Workforce. Accessed January 2022 via https://www.hee.nhs.uk/sites/default/files/documents/Cancer-Workforce-Document_FINAL%20for%20web.pdf
[12] https://www.cancerresearchuk.org/sites/default/files/estimating_the_cost_of_growing_the_nhs_cancer_workforce_in_england_by_2029_october_2020_-_full_report.pdf
[13] NHS England and Improvement, 2019. Interim NHS People Plan https://www.longtermplan.nhs.uk/wpcontent/uploads/2019/05/Interim-NHS-People-Plan_June2019.pdf
[14] BMA, 2020. Medical staffing in England. Accessed January 2022 via https://www.bma.org.uk/media/4316/bma-medical-staffing-report-in-england-july-2021.pdf
[15] RCR, 2021. Clinical radiology: UK workforce census report 2020. Accessed January 2022 via https://www.rcr.ac.uk/press-and-policy/policy-priorities/workforce/radiology-workforce-census
[16] RCR, 2021. Clinical oncology: UK workforce census report 2020. Accessed January 2022 via https://www.rcr.ac.uk/system/files/publication/field_publication_files/clinical-oncology-uk-workforce-census-2020-report.pdf
[17] British Society of Gastroenterology, 2021. British Society of Gastroenterology Workforce Report. Accessed January 2022 via https://www.bsg.org.uk/wp-content/uploads/2021/05/British-Society-of-Gastroenterology-Workforce-Report-2020.pdf
[18] Sor, 2021. Radiography census highlights staff bravery amid workforce shortages. https://www.sor.org/news/college-of-radiographers/radiography-census-highlights-staff-bravery-amid-w
[19] Macmillan Cancer Support, 2021. Accessed January 2022 via https://www.macmillan.org.uk/assets/forgotten-c-nursing-report.pdf
[20] CRUK, 2021. Age and cancer. Accessed August 2021 via https://www.cancerresearchuk.org/aboutcancer/causes-of-cancer/age-and-cancer
[21] CRUK, 2016. Annual UK cancer cases set to soar to half a million in less than 20 years. Accessed August 2021 via https://news.cancerresearchuk.org/2016/10/12/annual-uk-cancer-cases-set-to-soar-to-half-a-million-inless-than-20-years/
[22] Smittenaar et al., Cancer Incidence and Mortality Projections in the UK until 2035. British Journal of Cancer, 2016. DOI: 10.1038/bjc.2016.304
[23] BMA, 2021. Medical staffing in England: a defining moment for doctors and patients. Accessed December 2021 via https://www.bma.org.uk/media/4316/bma-medical-staffing-report-in-england-july-2021.pdf
[24] BMA, 2020. Consultant workforce shortages and solutions: Now and in the future. Accessed December 2021 via https://www.bma.org.uk/media/3429/bma-consultant-workforce-shortages-and-solutions-oct-2020.pdf
[25] Cath, 2021. HEE Strategic Framework Call for Evidence 2021: summary response. Accessed December 2021 via https://www.rcpath.org/uploads/assets/fcb04da2-89d4-425f-8da2f12db2be18b8/HEE-Strategic-Framework-Call-for-Evidence-2021-RCPath-summary-response.pdf
[26] Royal College of Radiologists. 2021. Clinical oncology UK workforce census 2020 report. Accessed August 2021 via https://www.rcr.ac.uk/system/files/publication/field_publication_files/clinical-oncology-ukworkforce-census-2020-report.pdf
[27] Nuffield Trust, 2015. Facing future challenges: do changes in skill mix offer some solutions? Accessed July 2021 via https://www.nuffieldtrust.org.uk/news-item/facing-future-challenges-do-changes-in-skill-mix-offer-some-solutions
[28] Macmillan Cancer Support, 2018. Mixing it up: what is ‘skill mix’ and how can it transform the cancer workforce? Accessed July 2021 via https://think.macmillan.org.uk/mixing-it-up-what-is-skill-mix-and-how-can-it-transform-the-cancer-workforce-2d450b42c9ae
[29] BMA, 2021. Consultant retention in Scotland in 2021. Accessed July 2021 via https://www.bma.org.uk/media/3840/bma-scotland-consultants-retention-report-feb-2021.pdf
[30] HEE. Clinical Endoscopy Training Programme. Accessed July 2021 via https://www.hee.nhs.uk/our-work/cancer-diagnostics/clinical-endoscopist-training-programme/30-week-clinical-endoscopist-programme
[31] Macmillan Cancer Support, 2018. Mixing it up: what is ‘skill mix’ and how can it transform the cancer workforce? Accessed July 2021 via https://think.macmillan.org.uk/mixing-it-up-what-is-skill-mix-and-how-can-it-transform-the-cancer-workforce-2d450b42c9ae
[32] RCR, 2021. Clinical radiology UK workforce census 2020 report. Accessed January 2022 via https://www.rcr.ac.uk/system/files/publication/field_publication_files/clinical-radiology-uk-workforce-census-2020-report.pdf
[33] NHS England, 2021. NHS Staff Survey 2020 National results briefing. Accessed August 2021 via https://www.nhsstaffsurveyresults.com/wp-content/uploads/2021/03/ST20-national-briefing-doc.pdf
[34] NHS Providers, 2021. Trust leaders fear staff burnout as winter pressures loom. Accessed December 2021 via https://nhsproviders.org/news-blogs/news/trust-leaders-fear-staff-burnout-as-winter-pressures-loom
[35] i, 2022. Record numbers of NHS staff quit as frontline medics battle Covid pandemic trauma. Accessed January 2022 via https://inews.co.uk/news/health/nhs-staff-quit-record-numbers-ptsd-covid-pandemic-trauma-1387115
[36] The Guardian. 2021. NHS sets up mental health hubs for staff traumatised by Covid. Accessed January 2022 via https://www.theguardian.com/society/2021/feb/22/nhs-sets-up-mental-health-hubs-for-staff-traumatised-by-covid
[37] NHS England. 2020. We are the NHS: People Plan for 2020/2021 – action for us all. Accessed August 2021 via https://www.england.nhs.uk/wp-content/uploads/2020/07/We-Are-The-NHS-Action-For-All-Of-Us-FINALMarch-21.pdf
[38] P. Patel, C. Thomas, H. Quilter-Pinner, 2021. State of Health and Care: The NHS Long Term Plan after COVID19. IPPR. Accessed August 2021 via https://www.ippr.org/files/2021-03/state-of-health-and-care-mar21.pdf
[39] BMA, 2020. Consultant workforce shortages and solutions: now and in the future. Accessed August 2021 via https://www.bma.org.uk/media/3429/bma-consultant-workforce-shortages-and-solutions-oct-2020.pdf
[40] NHS England, 2021. NHS Staff Survey 2020 National results briefing. Accessed August 2021 via https://www.nhsstaffsurveyresults.com/wp-content/uploads/2021/03/ST20-national-briefing-doc.pdf
[41] M. Sample, 2021. Spending Review 2021: Promising commitments, unanswered questions. Cancer Research UK. Accessed December 2021 via https://news.cancerresearchuk.org/2021/10/27/spending-review-2021-promising-commitments-but-a-lot-of-unanswered-questions/
[42] M. Warner, B. Zaranko, 2021. Pressures on the NHS. IFS. Accessed January 2022 via https://ifs.org.uk/uploads/Green-Budget-2021-Pressures-on-the-NHS.pdf
[43] The Health Foundation, 2021. Over a million more health and care staff needed in the next decade to meet growing demand for care. Accessed January 2022 via https://www.health.org.uk/news-and-comment/news/over-a-million-more-health-and-care-staff-needed-in-the-next-decade
[44] Cancer Research UK, 2021. Cancer target missed for 55,000 patients over 6 years. Accessed November 2021 via https://news.cancerresearchuk.org/2021/09/22/cancer-target-missed-for-55000-patients-over-six-years/
[45] Cancer Research UK, 2021. Cancer target missed for 55,000 patients over 6 years. Accessed November 2021 via https://news.cancerresearchuk.org/2021/09/22/cancer-target-missed-for-55000-patients-over-six-years/
[46] CRUK, 2021. Early Diagnosis Initiative. Accessed January 2022 via https://www.cancerresearchuk.org/health-professional/diagnosis/early-diagnosis-initiative
[47] RCR, 2021. Clinical radiology UK workforce census 2020 report. Accessed January 2022 via https://www.rcr.ac.uk/system/files/publication/field_publication_files/clinical-radiology-uk-workforce-census-2020-report.pdf
[48] RCR, 2021. Clinical oncology UK workforce census 2020 report. Accessed January 2022 via https://www.rcr.ac.uk/system/files/publication/field_publication_files/clinical-oncology-uk-workforce-census-2020-report.pdf
[49] Royal College of Radiologists. 2021. Clinical oncology UK workforce census 2020 report. Accessed August 2021 via https://www.rcr.ac.uk/system/files/publication/field_publication_files/clinical-oncology-ukworkforce-census-2020-report.pdf
[50] NHS Providers, 2022. Health and Care Bill – ensuring we have enough staff to meet demand. Accessed January 2022 via https://nhsproviders.org/media/692940/briefing-on-workforce-amendments-from-sector-coalition_hol-cttee_jan-22.pdf?utm_source=The%20King%27s%20Fund%20newsletters%20%28main%20account%29&utm_medium=email&utm_campaign=12935730_NEWSL_HMP%202022-01-21&dm_i=21A8,7P99U,7ASC4Y,VED7P,1
[51] M. Warner, B. Zaranko, 2021. Pressures on the NHS. IFS. Accessed January 2022 via https://ifs.org.uk/uploads/Green-Budget-2021-Pressures-on-the-NHS.pdf
[52] The Guardian, 2007. Government unveils new deal for NHS workforce training. Accessed January 2022 via https://www.theguardian.com/society/2007/may/24/health.highereducation
[53] Peckham, S. (2021). Creating Time for Research: Identifying and improving the capacity of healthcare staff to conduct research. Cancer Research UK. Accessed December 2021 via https://www.cancerresearchuk.org/sites/default/files/creating_time_for_research_february_2021_-_full_report-v2.pdf
[54] Peckham, S. (2021). Creating Time for Research: Identifying and improving the capacity of healthcare staff to conduct research. Cancer Research UK. Accessed December 2021 via https://www.cancerresearchuk.org/sites/default/files/creating_time_for_research_february_2021_-_full_report-v2.pdf
[55] CRUK, 2021. Health and Social Care Committee inquiry: The future of General Practice. Accessed January 2022 via https://www.cancerresearchuk.org/sites/default/files/cancer_research_uk_submission_hsc_commmitee_inquiry_the_future_of_general_practice_dec2021.pdf
[56] BMA, 2021. Pressures in general practice. Accessed December 2021 via https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressures-in-general-practice
[57] The King’s Fund, 2021. General practice: our position. Accessed January 2022 via https://www.kingsfund.org.uk/projects/positions/general-practice
[58] Nussbaum C, Massou E, Fisher R, Morciano M, Harmer R, Ford J. 2021. Inequalities in the distribution of the general practice workforce in England: a practice-level longitudinal analysis. BJGP Open. Accessed August 2021 via https://pubmed.ncbi.nlm.nih.gov/34404634/
[59] Parisi R, Lau Y, Bower P, et al. 2021. Rates of turnover among general practitioners: a retrospective study of all English general practices between 2007 and 2019. BMJ Open. Accessed August 2021 via https://bmjopen.bmj.com/content/11/8/e049827
[60] R. Fisher. 2021. ‘Levelling up’ general practice in England. The Health Foundation. Accessed August 2021 via https://www.health.org.uk/publications/long-reads/levelling-up-general-practice-in-england
[61] PHE, Cancer survival in England for patients diagnosed between 2014 and 2018, and followed up until 2019. Accessed June 2021 via https://www.gov.uk/government/statistics/cancer-survival-in-england-for-patients-diagnosed-between-2014-and-2018-and-followed-up-until-2019
[62] Cancer Research UK. 2021. Why is early diagnosis important? Accessed January 2022 via https://www.cancerresearchuk.org/about-cancer/cancer-symptoms/why-is-early-diagnosis-important
[63] Cancer Research UK. 2021. Why is early diagnosis important? Accessed January 2022 via https://www.cancerresearchuk.org/about-cancer/cancer-symptoms/why-is-early-diagnosis-important
[64] NHS England. 2019. The NHS Long Term Plan. Accessed January 2022 via https://www.longtermplan.nhs.uk/publication/nhs-long-term-plan/
[65] Cancer Research UK analysis.
[66] Nicholson, B. et al. 2021. Consultations for clinical features of possible cancer and associated urgent referrals before and during the COVID-19 pandemic: an observational cohort study from English primary care. British Journal of Cancer. Accessed January 2022 via https://doi.org/10.1038/s41416-021-01666-6
[67] Cardiff University, Cancer Research UK, King’s College London and the University of Surrey. COVID Health and Help-Seeking Behaviour Study. Accessed January 2022 via https://cabs-study.yolasite.com/
[68] Cancer Research UK analysis of Cancer Waiting Times data for England. For full analysis, see - https://www.cancerresearchuk.org/sites/default/files/cruk_covid_and_cancer_key_stats_june_2021.pdf.
[69] CRUK estimate based on pre-pandemic averages of the number of people screened with FIT/FOBT bowel screening, breast screening mammogram and cervical smear programmes across the UK countries.
[70] Public Health England. 2021. National Disease Registration Service: Staging data in England. Accessed July 2021 via https://www.cancerdata.nhs.uk/stage_at_diagnosis.
[71] Projections based on incidence projections to 2028 in England from Smittenaar et al. 2016.
[72] Kingston, A. 2018. Projections of multi-morbidity in the older population in England to 2035: estimates from the Population Ageing and Care Simulation (PACSim) model. Accessed July 2021 via https://academic.oup.com/ageing/article/47/3/374/4815738.
[73] Internal CRUK analysis with estimates are based on the rate of participation and the cancer detection rate for the relevant threshold from the England FIT pilot in 2014 (data based on Moss et al., Gut; 2016), and assume 4.6 million screening programme invites for 60-74 years olds in England per year. Estimates are for the years immediately following the introduction of FIT.
[74] National Disease Registration Service. Stage group by deprivation by cancer type for 21 cancer types. Accessed January 2022 via https://www.cancerdata.nhs.uk/stage_at_diagnosis
[75] National Disease Registration Service. Stage group by deprivation by cancer type for 21 cancer types. Accessed January 2022 via https://www.cancerdata.nhs.uk/stage_at_diagnosis
[76] Unpublished analysis with estimates based on the annual average number of patients diagnosed at stage 1 and 2 (2016-2018), using data from: Staging Data in England, https://www.cancerdata.nhs.uk/stage_at_diagnosis
[77] Unpublished analysis with estimates based on the annual average number of patients diagnosed at stage 1 and 2 (2016-2018), using data from: Staging Data in England, https://www.cancerdata.nhs.uk/stage_at_diagnosis
[78] International Cancer Benchmarking Partnership. 2021. Distribution by stage. Accessed August 2021 via https://gco.iarc.fr/survival/survmark/visualizations/viz8.
[79] Independent Cancer Taskforce, 2015. Cancer Strategy for England 2015-2020. Accessed January 2020 via https://www.cancerresearchuk.org/sites/default/files/achieving_world-class_cancer_outcomes_-_a_strategy_for_england_2015-2020.pdf.
[80] National Cancer Intelligence Network. Routes to Diagnosis 2006-2013 workbook (a). London: NCIN; 2015. Accessed July 2021 via http://www.ncin.org.uk/publications/routes_to_diagnosis.
[81] Cancer Research UK analysis of Cancer Waiting Time data, published in each UK nation.
[82] Institute for Public Policy Research. 2021. Building back cancer services in England. Accessed January 2022 via: https://www.ippr.org/files/2021-09/building-back-cancer-services.pdf
[83] Parliamentary question for Department of Health and Social Care. 2020. Accessed January 2022 via: https://questions-statements.parliament.uk/written-questions/detail/2020-06-01/51865
[84] National Institute for Health Research. Open Data Platform. Accessed January 2022 via: https://nihr.opendatasoft.com/pages/homepage/
[85] National Institute for Health Research. Open Data Platform. Accessed January 2022 via: https://nihr.opendatasoft.com/pages/homepage/
[86] NICE. 2021. NHS England interim treatment options during the COVID-19 pandemic. Accessed January 2022 via https://www.nice.org.uk/guidance/ng161/resources/interim-treatment-change-options-during-the-covid19-pandemic-endorsed-by-nhs-england-pdf-8715724381
[87] NHS England. 2020. Convenient modern cancer treatment for patients during COVID-19 pandemic. Accessed January 2022 via: https://www.england.nhs.uk/2020/06/convenient-modern-cancer-treatment-for-patients-during-covid-19-pandemic/
[88] Parliamentary question for Department of Health and Social Care. 2021. Accessed January 2022 via: https://questions-statements.parliament.uk/written-questions/detail/2021-09-17/50968
[89] Parliamentary question for Department of Health and Social Care. 2021. Accessed January 2022 via: https://questions-statements.parliament.uk/written-questions/detail/2021-06-21/19571/
[90] RCR. Comprehensive Spending Review (CSR) Submission. 2021. Accessed January 2022 via: https://www.rcr.ac.uk/sites/default/files/final_csr_submission_for_upload.pdf
[91] Parliamentary question for Department of Health and Social Care. 2021. Accessed January 2022 via: https://questions-statements.parliament.uk/written-questions/detail/2021-07-14/33205
[92] RCR. 2021. Comprehensive Spending Review (CSR) Submission. Joint statement from the RCR, SCoR and IPEM. https://www.rcr.ac.uk/sites/default/files/royal_college_of_radiologists_comprehensive_spending_review_submission_2021.pdf
[93] Public Health England. 2021. COVID-19 rapid cancer registration and treatment data. Accessed April 2021 via https://www.cancerdata.nhs.uk/covid-19/rcrd.