1. Introduction


1.1  Macmillan Cancer Support is a registered charity providing information and support for people with cancer. There are around 3 million people currently living with cancer across the UK with over 360,000 people receiving a cancer diagnosis every year.[1]


1.2  Macmillan Cancer Support invests in roles supporting people with cancer across the NHS, including Macmillan Nurses. Macmillan nurses are specialist cancer nurses (SCNs) that treat and manage patient’s health concerns and work to promote health and wellbeing. They use their skills and expertise in cancer care to provide physical and emotional support, coordinate care services and to inform and advice patients on clinical as well as practical issues. In 2018 we funded a total of 6,400 nursing posts across the UK.


1.3  Nurses are an essential part of the health and care workforce supporting people with cancer. Nurses working across primary, secondary and community care support people with cancer from diagnosis through to recovery and rehabilitation, or at end of life.


1.4  Macmillan supports the recognition in the Interim People Plan that ‘the most urgent challenge is the current shortage of nurses’ and how critical addressing this challenge is to delivering the care set out in the NHS Long Term Plan.[2] The commitments set out in the Long Term Plan on personalised cancer care require a significant increase in the number of specialist cancer nurses working in the NHS in England, and the growth of the wider adult nursing workforce is critical in order to increase the specialist cancer nursing workforce in turn.


1.5  Addressing the nursing workforce shortage is one part of a much wider challenge facing the health and care workforce. The Government must publish a fully-funded and comprehensive plan for the whole of the NHS workforce, focusing on the skills and knowledge needed to meet current and future patient demand.


1.6  The Covid-19 pandemic has shed further light on the depths of the nursing workforce crisis. The vulnerability of services supporting people with cancer, many of which were paused, disrupted and slowed due to staffing capacity and re-deployment of nurses, demonstrated clearly the fragility of these services caused by understaffing. Many services adapted pragmatically and flexibly to the challenges of the pandemic and there will be opportunities to capitalise on innovative ways of working moving forward. However, much more must be done to grow and support the nursing workforce to make this a reality.


  1. The current picture of the nursing workforce supporting people with cancer


2.1  Vacancy rates are high across nursing, making up 41% of all NHS vacancies in March 2020. Data from NHS Digital shows vacancy rates across sectors in quarter 4 of 2019/20 at 9.9%. Although these percentages are coming down against previous years, progress is slow.

2.2  In community settings regional vacancy rates were as high as 17.4% (London). Vacancy rates also highlight worrying patterns of geographic variation and variation across different sectors of nursing (these patterns of variation do not necessarily correlate with one another), impacting on the care people with cancer receive at different parts of their cancer pathway in different parts of the country.


2.3  NHS England and Improvement have estimated that around 80% of vacancies are filled by temporary staff.[3] This increases costs and reduces the capacity to deliver high-quality, consistent personalised care for people with cancer.


Specialist cancer nursing


2.4  The number of people living with cancer in England is increasing every year, with the combination of an ageing population and advances in treatment meaning more people with cancer are living longer. The cancer population in England expected to increase from 1.6m in 2015 to 3.1m by 2030. [4]The numbers in the specialist cancer nursing workforce however are not rising at the same pace as patient need.


2.5  Macmillan’s cancer workforce census published in 2018 found there were just 4,020 whole time equivalent specialist cancer nurse roles in England.


2.6  The census also identified several worrying trends in the workforce. These include vacancy rates as high as 15 per 100 filled roles for chemotherapy nurses and 11 per 100 filled roles for tumour-specific cancer nurses; an increase in proportion of nurses aged 50 or over (up from 33% in 2014 to 37% in 2017); and a shift to lower agenda for change banding for specialist cancer nurses (the number of posts at band 7 reduced from 67% in 2014 to 61% in 2017). Whilst we need to better understand the reasons for the reduction in nurses in band 7 posts, Macmillan is concerned that a trend of highly trained specialists taking on increasingly complex caseloads for lower pay is not only economically imprudent but also may exacerbate recruitment and retention problems in the cancer nursing workforce.

Impact on people living with cancer

2.7  The 2019 National Cancer Experience Survey (NCPES) shows that only 89% of respondents were given the name of a Clinical Nurse Specialist to support them through treatment, with only 76% of those respondents saying it was easy to contact them. This means that a significant minority of people with cancer already do not have access to a specialist cancer nurse, and even more find it difficult to get hold of them even if they do have access.[5]


2.8  Unmanageable workloads are having a significant impact on people living with cancer. Voices From the Frontline also showed nearly half of specialist cancer nurses reporting that their workload is negatively affecting the quality of care they can give.[6]


3        According to Macmillan’s 2019 survey, collecting the experiences of nearly 7000 people living with cancer, 68% of respondents said they are not getting all the support they need with issues relating to their disease. 19% of people living with cancer surveyed said the healthcare professionals who cared for them seemed to have unmanageable workloads, and patients who say healthcare professionals seemed to be overworked were around a third more likely to have physical and emotional needs that are not being addressed compared to those who said that staff had a manageable workload.[7]


Primary care nursing


3.1  People with cancer have contact with nurses working in primary care settings throughout their cancer diagnosis and treatment. People with cancer are likely to come into contact with practice nurses and advanced nurse practitioners working in primary care before or at diagnosis, as well as throughout their treatment and recovery.[8]


3.2  There are 16,797 FTE equivalent nurses working in primary care as of March 2020, a 1.9% (315 FTE) increase from March 2019. This is a headcount of 24,077 nurses, showing a significant proportion of nurses working in primary care do not work full time. Future workforce modelling should be designed with an assumption that the ratio of nurses working part time is likely to continue or even accelerate going forward, particularly in areas where part time working is common as in primary care.


Secondary care nursing


3.3  People with cancer will be supported by the wider general adult nursing workforce in secondary care throughout their cancer treatment, whilst spending time in wards and across different functions within a hospital. NCPES data shows 91% of people with cancer had been a day case or attended an outpatient appointment, and 49% had an overnight stay for their cancer care within the last 12 months of the survey.[9]


3.4  In acute settings regional vacancy rates were as high as 11.7% (East of England) in March 2020, and vacancy rates in acute settings are consistently high across England, with the region with the lowest vacancy rate in England still 6.3% (South West).


3.5  The vacancy rates in secondary care are set against a backdrop of increasing workload caused by an ageing population and growing numbers of people with multiple long-term conditions.


Palliative and community end of life care nursing


3.6  Community and specialist palliative care nurses are essential in supporting people with cancer at end of life. Provision of end of life care is one of the few interventions shown to be effective in reducing reliance on emergency and acute care, largely through preventing avoidable emergency admissions and providing people personalised end of life care.


3.7  Vacancy rates for the palliative care nursing workforce working in cancer remain incredibly high and it is relatively common for these posts to be filled on a part time basis, with only 41% of specialist palliative care nurses working in full time posts. Over 40% of specialist palliative care nurses are also aged 50 and above.[10]


  1. Increasing the general adult nursing workforce


3.1  Increasing the general adult nursing workforce is essential for ensuring people with cancer access high-quality personalised care.


3.2  the specialist cancer nursing workforce relies on a pipeline of nurses from the general adult nursing workforce to train to become SCNs. This requires numbers in the general adult workforce that allow for time off for training and development, as well as opportunities for nurses to spend time caring for people with cancer, shadowing existing specialists and gaining an interest in specialist training.


3.3  Additionally, a range of non-specialist nurses provide direct support across the health and care system to people with cancer. As indicated earlier in this submission, people with cancer are supported by nurses throughout their cancer journey.


3.4  The NHS Long Term Plan set out to reduce the nursing vacancy rate to 5% from 12% by 2028. This will be hard to achieve without fundamental changes to current permanent staffing levels, succession planning and workload pressures across all settings.


3.5  Macmillan recognises the positive steps that the Government and NHS England and Improvement have made since the publication of the NHS Long Term Plan to increase the supply of nurses, in particular the announcement of the nursing bursaries to encourage an increase in the uptake of nursing degree applications, which had caused significant concern with a 23% decline in applications since the bursary was originally removed.[11]


3.6  It is important that the Government and NHS England and Improvement proactively reassess the commitments made in the Interim People Plan on nursing (and the wider workforce) in light of the impact of Covid-19. The coronavirus crisis has had a monumental impact on the way the NHS operates and is extremely likely to require a change in expectations around retention, return to practice initiatives and international recruitment, at least in the short-to-medium term.   


  1. Increasing the specialist cancer nursing workforce


4.1  The NHS Long Term Plan commits to every person living with cancer should have access to a Clinical Nurse Specialist (CNS) or support worker by 2021.


4.2  Macmillan has serious concerns that this ambition will not be met without investment in educating and training new specialist nurses, as well as urgent initiatives to encourage retention and return to practice for existing SCNs.


Education and training of new specialist cancer nurses


4.3  A combination of the existing vacancy rates, an ageing cancer specialist nursing workforce, and a growing number of people living with cancer across England, means there is a need to significantly increase training and education of general adult nurses to create more specialist cancer nurses.


4.4  There are a few key factors that will influence the number of general adult nurses training to become specialist cancer nurses: the supply pipeline of general adult nurses, the career pathway for cancer nursing, the exposure to cancer nursing for student and generalist nurses, and adequate time and funding for specialist cancer nurse training.


4.5  The career pathway for cancer nursing is complicated and training and experience needed can vary between different Trusts and regions. A plan for the nursing workforce must create a clearer pathway for general adult nurses to gain the skills and knowledge necessary to be a specialist cancer nurse.


4.6  Exposure to cancer nursing for student and general adult nurses is also a barrier to the number who go on specialise. Individuals need the opportunity to learn about cancer nursing, and the opportunity to work on cancer wards and care for people with cancer, to encourage them to gain an interest in the specialism. Macmillan advocates for more structured opportunities for interest general adult nurses to spend time caring for people with cancer (with adequate backfill available) and for in the inclusion of cancer in the undergraduate curriculum to allow student nurses to learn about caring for people with cancer.


4.7  Adequate time and funding are also essential in the training of new specialist cancer nurses. Nurses are required to complete a Masters degree in their chosen specialism, as well as gain a series of specialist knowledge and skills that require time away from the ward, and funding to cover their education and training as well as the backfill needed to allow for them to be away from the ward.


4.8  Macmillan continues to call for a fully-funded national programme to support the training of new specialist cancer nurses in England. This programme should provide adequate funding for Trusts pay for education and training, as well as backfill for nurses in training.


Retention and return to practice of existing specialist cancer nurses


4.9  Retention of existing specialist cancer nurses and return to practice programmes to incentivise recently retired staff to return to work will be an important way of increase numbers, particularly in the short-to-medium term.


4.10          Retention was recognised in the Interim People Plan as a route to increase the wider workforce. Achieving higher retention rates is challenging, however, and the Government and the NHS must recognise the scale of this challenge and respond accordingly with an adequate and well-funded strategy for increasing retention. This must include addressing unmanageable workloads, provision of adequate Continued Professional Development (CPD) for existing specialist cancer nurses, effective mental health and wellbeing support for staff and allowing for flexible ways of working.


Addressing unmanageable workload to improve retention


4.11          Unmanageable workload is linked to increased levels of stress, then linked to increased levels of sickness absence and ultimately to more of the workforce leaving. Macmillan’s Voices from the Frontline report found that 39% of specialist cancer nurses did not feel their current workload is manageable and 44% felt that their workload is negatively affecting their morale. [12]


4.12          This is echoed in the wider nursing population, with a recent NMC survey of those who left the register recently showed staffing levels (19%) and too much pressure (30%) as top reasons for leaving.[13]


4.13          The quality of care they are able to provide for patients is tied to job satisfaction for the health and care workforce. A 2017 RCN survey showed 53% nurses saying that patient care was compromised on their last shift, with the resultant impact on nursing staff showing 53% feeling ‘upset/sad’ that they could not provide the level of care they wanted, 45% feeling demoralised and less than half (43%) actually felt satisfied with the care they provided and the job they had done.


Increasing access to Continued Professional Development (CPD) to improve retention


4.14          Access to adequate Continued Professional Development (CPD) for specialist cancer nurses is also needed to improve retention. Investment in the development of the workforce can significantly improve retention. NHS Improvement identified the lack of CPD training as the biggest area for nurses leaving the profession.[14]


4.15          Without this long-term commitment, staff retention will be negatively impacted on, exacerbating the current and predicted shortages in the workforce. Macmillan continues to call for ringfenced funding within the CPD budget to ensure the training and development of the cancer nursing workforce, ensuring that the appropriate skills and competencies needed to provide personalised care for cancer patients can be safeguarded now and for the future.


4.16          Macmillan’s Voice from the Frontline 2019 report highlighted three key barriers to accessing CPD for specialist cancer nurses.


4.17          These three barriers were protected time, funding and the local availability of courses.[15] Only a third (36%) of specialist cancer nurses had protected study time to access and attend CPD, with 22% taking annual leave to undertake CPD. 43% of specialist cancer nurses cited lack of funding as the main barrier to accessing CPD and 22% had self-funded their CPD, and funding from charitable or professional grants accounts for another 54% of the overall funding for CPD.


4.18          Since 2015/16, the CPD budget for nurses and AHPs has significantly reduced from £205 million to £83.5 million in 2017/18[16]. The commitment in the September spending round to an additional £150m[17] for 2020/21 for CPD is positive, but this must be continued as a minimum annual investment in the development of the existing workforce over the period covered at the next Comprehensive Spending Review.

Providing adequate mental health and wellbeing support for staff

4.19          The availability of adequate mental health and wellbeing support, as well as ways of working that protect the wellbeing of staff, is also essential to retention. Specialist cancer nurses are providing care for people with cancer in the most unimaginably difficult times in their lives, and the emotional strain of this on top of the wider impact of stretched workloads and complex professional roles can be overwhelming. National and local retention initiatives must put adequate support in place for staff, with adequate funded to ensure this support is meaningful.


4.20          This support will be even more paramount following the impact of Covid-19 on hospitals. Specialist cancer nurses, many of whom were re-deployed in response to the crisis, will not be returning to a huge backlog of patients whose diagnosis and treatment have been disrupted by the pandemic. Ensuring that they are fully supported is essential in preventing them from leaving the NHS when they are most needed.

Improving flexible ways of working for staff

4.21          New and more flexible ways of working will be essential in improving retention and allowing staff to work flexibly will benefit the whole workforce and allow more of the workforce to fit their career around their personal lives and not have to choose between the two. The inclusion of flexible working in the new ‘offer’ for NHS staff as part of the Interim People Plan is an important step.


4.22          Flexible working initiatives will be particularly effective if harnessed to encourage those at the end of their careers to continue to work on a more flexible basis, sharing their skills and knowledge with less experienced staff before retirement. Macmillan’s 2017 census of the cancer workforce showed an ageing workforce with 37% of specialist cancer nurses over the age of 50, risen from 33% in 2014.


4.23          Macmillan is also encouraged by the continued commitment to return-to-practice initiatives and hopes to see this continue and expand in the final People Plan, with the necessary funding attached.


  1. Wider workforce planning and ensuring appropriate skills mix


5.1  Addressing the nursing workforce challenge is not the silver bullet to solving the workforce crisis in health and care or delivering the ambitions in the NHS Long Term Plan. The Government and the NHS must publish a comprehensive and fully-funded plan for the whole workforce that is demand-based and ensures responsibility and accountability for workforce planning is clear across local, regional and national bodies. Effective workforce planning must ensure multi-disciplinary teams with a range of competencies are able to operate effectively, with those who reach advanced practice being able to work to their fullest competency.

5.2  A skills mapping approach should be employed to support this, with the aim of clarifying what competencies and skills are needed at what level in the workforce to address common unmet needs. Development of a needs-based competency framework with enable assessment of existing roles and support future planning for national workforce priorities.


July 2020
















[1] Macmillan Cancer Support, 2019, Statistics fact sheet https://www.macmillan.org.uk/_images/cancer-statistics-factsheet_tcm9-260514.pdf

[2] NHS England, Long Term Plan, 2018 https://www.longtermplan.nhs.uk/wp-content/uploads/2019/05/Interim-NHS-People-Plan_June2019.pdf

[3] https://www.nao.org.uk/wp-content/uploads/2020/03/The-NHS-nursing-workforce-Summary.pdf

[4] Estimates of prevalence are based on the method developed by Maddams J, Utley M and Møller H. 2012. Projections of cancer prevalence in the United Kingdom.

[5] National Cancer Patient Experience Survey in England, 2019-20 https://www.ncpes.co.uk/wp-content/uploads/2020/06/CPES-2019-National-Report_V1.pdf

[6] Macmillan Cancer Support, Voices from the frontline: Challenges facing cancer clinical nurse specialists right now, 2017

[7] Macmillan Cancer Support and Populus paper and online survey of 6905 people recently treated for, or diagnosed in the last 5 years with, cancer across the UK. Fieldwork July-September 2019. Survey data has been weighted to be representative of recently treated cancer population (Cancer Registration data) in terms of age, gender and cancer type within England.

[8] cancer research website

[9] National Cancer Patient Experience Survey in England, 2019-20 https://www.ncpes.co.uk/wp-content/uploads/2020/06/CPES-2019-National-Report_V1.pdf

[10] Cancer workforce in England census, 2017 https://www.macmillan.org.uk/_images/cancer-workforce-in-england-census-of-cancer-palliative-and-chemotheraphy-speciality-nurses-and-support-workers-2017_tcm9-325727.pdf 

[11] UCAS Nursing applicants at the 15 January deadline (2018 cycle). https://www.ucas.com/file/147216/download?token=wuwe_zbe

[12] Macmillan Cancer Support, Voices from the frontline: Challenges facing cancer clinical nurse specialists right now, 2017

[13] Nursing & Midwifery Council, The NMC register March 2019


[15] Macmillan Cancer Support, Voices from the frontline: Challenges facing cancer clinical nurse specialists right now, 2017

[16] House of Commons Health Committee, The Nursing Workforce: Second Report of Session 2017-19, 2018

[17] UK Government, Spending round September 2019