Organisation objective

• NHS Long Term Plan
• NHS Mandate from Government

Working with people and communities

What approaches have been used to ensure people and communities have informed this programme of work?

• recruited Patient and Public Voice (PPV) Partners
• consultation / engagement
• qualitative data and insight, for example, national surveys; complaints
• quantitative data and insight, for example national surveys
• partnership working with voluntary, community and social enterprise organisation
• other (please list below) – working with Cancer Alliances

The NHS Cancer Programme has an active engagement programme spanning the breadth of its work, covering operational performance, early diagnosis and improving treatment and care.

Our Patient & Public Voices (PPV) Forum of patients and carers with lived experience of cancer are predominantly recruited from the 20 Cancer Alliances’ own patient groups. PPV partners provide advice and insight to inform policy design and implementation, and the programme involves representatives of cancer charities at every level of its governance. This includes the National Cancer Board, which oversees progress across the programme as a whole, as well as the many task and finish groups which advise on different aspects of the programme’s work including cancer behaviour change campaigns and targeted surveillance programmes.

The NHS Cancer Programme also draws on findings from the annual Cancer Patient Experience Survey (CPES) and under-16 CPES survey to drive quality improvement.

Action required

The Board is asked to consider and discuss the information provided in the report.

Background and context

1. The purpose of this paper is to update Board members on the challenges and opportunities for NHS England as it seeks to improve operational performance and outcomes for people with cancer.

2. England has historically seen lower cancer survival than comparable countries, attributed in large part to patients having their cancers diagnosed at a later stage. The NHS has been working over the past decade to correct this by promoting earlier referral of people with symptoms and optimising national screening programmes for those without symptoms. This has resulted in a substantial increase in the number of people referred for investigation, with growth running at around 10% per year. This has placed a strain on diagnostic services, such that waiting times for investigation and treatment have, until the last year, been worsening. Recent investments in diagnostic capacity have started to reverse this trend, but the system remains under great pressure. Treatment capacity, notably surgery, will need to be increased to return to the 62 day standard.

3. The paper also builds on the NHS Cancer Programme’s Spring Update (published 9 May 2024), which summarised our strategy for, and progress in, delivering on the NHS Cancer Programme’s three main priorities for cancer:

• improving performance;
• increasing early diagnosis to improve survival; and,
• improving treatment and personalised care

4. In headline terms, the Spring Update reported that:

4.1. Over 3m people were referred for urgent cancer checks in 2023-24 compared to around 1m in 2010-11. Despite this record demand, thanks to the hard work of its staff, in March 2024 the NHS exceeded its interim targets to: provide at least 75% of people with a definitive diagnosis or ruling out of cancer within 28 days of an urgent referral; and, reduce to pre-pandemic levels the number of people waiting longer than 62 days following an urgent suspected cancer referral. However, further progress is required to meet all three cancer waiting times standards.

4.2. Survival is higher the earlier the stage at which cancer is diagnosed, but the proportion of people diagnosed at Stage 1 or 2 had flatlined at about 55% between 2013 and the start of the pandemic. Based on the Rapid Cancer Registration Datset, early diagnosis rates are now 2.4% above the 2019-20 pre-pandemic level – the first sustained rise in early diagnosis in a decade. Despite this, we remain some way short of our ambition to diagnose 75% of cancers at Stage 1 or 2.

4.3. The most recent Cancer Patient Experience Survey (CPES 2022, published in 2023) found that, among the 61,000 cancer patients who responded to the survey, their average overall rating of care was 8.88 out of 10. Data from this survey is used to drive quality improvement, including via the national Cancer Experience of Care Improvement Collaborative, which this year is co-chaired by one of our PPV partners.

Discussion and considerations

Improving operational performance

5. Cancer waiting times are crucial to patients and are seen as an important indicator of wider NHS performance. There are three core measures of performance for cancer:

• 28-day Faster Diagnosis Standard (75%)
• 62-day referral to treatment standard (85%)
• 31-day decision to treatment standard (96%)

6. The NHS met the 28-day Faster Diagnosis Standard in May 2024 (76.4%) but did not meet the 62-day standard (65.8%) or the 31-day standard (91.8%). Further improvements are needed to meet our waiting times standards and deliver the timely diagnosis and treatment patients need. As part of planning guidance for this financial year, stretching interim targets for cancer performance have been set.

7. To improve operational performance, the NHS Cancer Programme has been leading a strategy with three main strands. The NHS will need to build on these approaches to deliver against its more challenging targets:

7.1. Prioritising cancer within a £2.3 billion capital investment in diagnostic capacity. By June 2024, 165 community diagnostic centres (CDCs) were operational which, since the first CDC was launched in July 2021, have provided 9.2 million tests, checks and scans. Investment in acute imaging services has created additional capacity for over 400,000 scans per year.

7.2. Providing expertise and support for trusts facing the biggest challenges through an approach called tiering. Reductions in the backlog have been 45% higher in these tiered trusts than those not receiving additional support. It has also reduced variation in performance between trusts and is having a significant impact locally. University Hospitals Birmingham reduced its 62-day backlog from a peak of over 1,500 patients in September 2022 to around 300 patients in March 2024.

7.3. National action to improve the productivity of cancer pathways facing the biggest challenges – for example, the use of faecal immunochemical test (FIT) in primary care so fewer people will require an invasive colonoscopy. The proportion of colonoscopies taking place without a FIT decreased from 47% in Q1 2022/23 to 17% in Q4 2023/24.

Improving early cancer diagnosis

8. Improving early cancer diagnosis is a major priority for the NHS. The NHS Long Term Plan set an ambition to diagnose 75% of cancers at stage 1 or 2 by 2028, which in turn will support the ambition for 55,000 more people each year to survive for five or more years following their cancer diagnosis.

9. The Rapid Cancer Registration Dataset, which gives a timely indication of progress, suggests early diagnosis rates are now 2.4% points above the pre-pandemic level. While this provides a foundation to build from, there remains a long way to go to realise our ambition.

10. Demand for cancer diagnostic and treatment services is rising, driven by a combination of age-related increases in cancer incidence, the increasing complexity of cancer treatment and our ambitions to improve cancer performance and outcomes. The fundamental challenge now facing the NHS is how to make further progress on early cancer diagnosis against this backdrop or rising demand.

11. To meet this challenge, we need to focus on:

11.1. Improving access to, and managing demand for, cancer pathways.  This includes improving access to primary care, GP direct access to diagnostic tests, trialling new routes into cancer services, and triaging people to direct them to appropriate care more quickly, so that we prioritise diagnostic capacity for those who need it most.

11.2. Modernising diagnostic and treatment capacity to improve the timeliness of treatment and maximise productivity. This includes exploiting digitisation and AI to deliver histopathology and imaging more efficiently and investing in state-of-the-art scanners and radiotherapy equipment to improve productivity.

11.3. Targeting resources to people at risk. This includes expanding the lung health check programme, identifying people at higher risk of cancer (e.g. people with cirrhosis who are at higher risk of a form of liver cancer) so we can offer them regular checks, and expanding germline testing for BRCA and Lynch syndrome carriers.

12. Successful delivery of improvements in early diagnosis and performance will also require investment in the cancer workforce with the right numbers and right skills, addressing known shortfalls in areas like diagnostic and therapy radiography, cancer nursing, and endoscopy, through improved recruitment, retention and maximising skill mix.

Innovation

13. Accelerating the take up of innovation will also be core to our approach. The NHS Cancer Programme is already laying the groundwork for this through both technical and service innovation.

Technical innovation

14. In January 2024, the NHS Cancer Programme launched its third innovation open call to fast-track high quality and developed innovations into front-line settings. Innovations already being funded include: DERM (Skin Analytics) – an AI tool used to diagnose or rule out skin cancers; and Endoscope-i – an adapter that can turn an iPhone into diagnostic equipment for head and neck cancers.

15. The NHS Cancer Vaccine Launch Pad (CVLP) is accelerating access for NHS patients to mRNA personalised cancer vaccine clinical trials. The initial collaboration with BioNTech is aiming to reduce the risk of recurrence for people treated for bowel cancer. Over time, the CVLP will extend to other commercial partners and trials.

16. In 2024/25, the NHS is extending the use of circulating DNA (ctDNA) testing to 10,000 patients with non-small cell lung cancer (NSCLC). The aim is to detect DNA shed from cancerous cells in the blood, which can support the rapid diagnosis of, and treatment planning for, cancers. This is important for patients and much more productive for the NHS as we implement precision diagnostics and treatment.

Service Innovation

17. The Targeted Lung Health Check (TLHC) programme helps find cancers in those most at risk by offering checks in the local community. Since April 2019 more than 1.5 million people have been invited for a check and over 4,000 lung cancers have been diagnosed – 76% at stage 1 or 2 when cure is possible compared with 29% of all lung cancers in 2020. The biggest increases have been achieved for people from the most disadvantaged communities, with early diagnosis rates having increased 8.6 percentage points in the most deprived quintile since 2019/20 compared to between 6.4 and 7.3 percentage points for the other four quintiles. In June 2023, the then government announced that TLHCs will become a National Lung Screening Programme by 2028-29.

18. Since its expansion in June 2022, the Community Liver Health Checks programme has scanned more than 48,000 people in 19 areas for liver disease, which can lead to hepatocellular carcinoma. These areas were chosen in co-ordination with charity partners and PPV representatives. Over 3,700 people at increased risk of developing the disease have been referred for regular checks.

19. We are piloting a new programme to identify people aged 50 or over with new onset diabetes and weight loss which could be suggestive of pancreatic cancer. PPV members played an integral role in designing the pilot’s inclusion criteria.

20. We are offering testing to the Jewish population, who are ten times more likely to have an altered BRCA gene that is linked to the development of several cancers. Since January 2023, over 20,000 people have requested a BRCA test, and 112 people with the BRCA mutation have been identified and offered a consultation with a view for a referral to discuss treatment and management options.

Publication reference:  Public Board paper (BM/24/29(Pu))