Paul Midgley, Oli Hudson and Sarah Shield, of Wilmington Healthcare, explore how the NHS is taking on cancer in line with the Long Term Plan
Faster cancer diagnosis is a key ambition of the NHS Long Term Plan, which calls for the proportion of cancers diagnosed at stages one and two to rise from around half now to three-quarters of cases by 2028.
Achieving this goal will mean that, from 2028, 55,000 more people each year will survive cancer for at least five years after being diagnosed. This is because patients diagnosed early, at stages one and two, have the best chance of curative treatment and long-term survival.
Raising greater awareness of the symptoms of cancer, lowering the threshold for referral by GPs, accelerating access to diagnosis and treatment and maximising the number of cancers identified through screening will be key.
In this article, we look at parts of the new infrastructure that the NHS is putting in place to achieve its goals, and how different stakeholders will be required to collaborate in order to drive change in cancer care.
Local or regional ‘system empowerment’ and integrated working are the order of the day in cancer, as well as in many other areas of the NHS. Consequently, the Long Term Plan gives Cancer Alliances – groups of cancer clinicians responsible for driving the development of cancer pathways at a local level – a central role.
The Long Term Plan also makes it clear that the 19 Cancer Alliances should be aligned with Sustainability and Transformation Partnership (STP) and Integrated Care System (ICS) footprints as well as NHS England and NHS Improvement regions.
The Cancer Alliances will advise ICS/STP board members on cancer services and help to ensure that local cancer strategies are delivered. ICSs which have integrated boards will already have a relationship with Cancer Alliances, so they will be redesigning services much faster than other parts of the country, particularly those that may not gain ICS status for another 18 months or so.
This means there will be significant regional variation in the development of local cancer pathways; consequently, it will be important for pharma to keep abreast of the plans that regional health economies must produce by the end of November, in accordance with the Long Term Plan, as they will include details on cancer services. Pharma also needs to keep an eye on board meeting minutes from ICSs, STPs and Cancer Alliances.
On a national level, Cancer Alliances have been tasked with helping the NHS to achieve a new faster diagnosis standard. The standard, which will be introduced from 2020, is designed to ensure that most patients receive a definitive diagnosis or ruling out of cancer within 28 days of referral from a GP or from screening.
The Cancer Alliances will also implement a new timed diagnostic pathway for specific cancers, building on the timed pathways already being introduced in lung, colorectal and prostate cancer.
To work effectively, Cancer Alliances must have the right diagnostic technologies and pathology laboratory testing facilities. Aside from cancer specialists, they also need access to other clinicians who can ensure that the patient is referred to the correct person if he or she are diagnosed with a condition other than cancer.
Rapid Diagnostic Centres
Rapid Diagnostic Centres (RDCs), which were originally launched in pilot form in 2018, will underpin a radical overhaul of the way in which diagnostic services are delivered for patients with suspected cancer.
RDCs comprise multidisciplinary teams which provide a single point of access to a diagnostic pathway for all patients with symptoms that could indicate cancer. These symptoms can be non-specific – for example, at an early stage, lung cancer can resemble a common cold.
RDCs aim to provide a personalised, accurate and timely diagnosis of patients’ symptoms. They combine all existing diagnostic provision and use networked expertise and information.
In addition to supporting the faster diagnosis standard, RDCs will complement work to improve screening programmes, augment the potential of artificial intelligence (AI) and genomic testing, and utilise Primary Care Networks (PCNs) to improve early diagnosis in their localities.
The success of RDCs will depend on corralling many disparate resources in the NHS – including GPs, who will form a big part of the service as they will refer patients with suspected symptoms to RDCs, supported by the local Cancer Alliance’s clinical network.
The ten pilot RDCs are mostly clustered around the cancer vanguard areas of London and Manchester, with five in London, two in Manchester and one each in Leeds, Oxford, and Airedale in the north west of England.
In 2019/20, all Cancer Alliances are expected to set up at least one RDC for patients with non-specific symptoms which could indicate cancer, as well as for a cohort of patients with site-specific symptoms who are currently served by an underperforming two week wait or 62-day pathway.
This is significant for pharma given that patients living in areas that are not served by RDCs often struggle to access precision medicines. This is because the companion diagnostic equipment and expertise needed to determine whether a patient will respond favourably to a precision medicine is concentrated in the RDC areas.
Primary Care Networks
As the NHS aims to move more care out of hospitals, PCNs are expected to play an important role in transforming cancer services. Indeed, the Long Term Plan states that PCNs will be required to help improve early diagnosis of patients in their neighbourhoods by 2023/24. In line with this, early cancer diagnosis is one of seven new service specifications that PCNs must deliver and it is due to start by April 2020.
We expect to see multidisciplinary teams working within PCNs to deliver cancer services and this could mean more cancer specialists, such as cancer nurses, working in the community, as well as other specialists, such as gastroenterologists.
Screening and diagnostic services will be increasingly provided in the community, where pilot schemes such as ‘MOTs for lungs’ and on-the-spot scans for patients at high risk of developing lung cancer, have shown the value of bringing these kinds of services closer to patients’ homes. Earlier this year, the NHS announced that lung cancer scanning trucks that operate from supermarket car parks would be rolled out across the country in a bid to save lives by catching the condition early. When the project was pioneered in Manchester, 2,541 patients were scanned and 65 lung cancers were detected.
We can also expect to see some chemotherapy services, previously owned by NHSE, begin to become the responsibility of ICSs, particularly homecare services.
According to the Long Term Plan, the NHS wants to use personalised and risk stratified screening and begin to test family members of cancer patients if they have an increased risk of the disease. It is likely that PCNs will be tasked with quizzing patients about their family history in order to gather data that will support this proactive approach.
Gathering and analysing population health data around screening, including factors that deter patients from engaging with it, is invaluable for planning services. For example, most lung cancer diagnoses are made at stage four. However, research by Wilmington Healthcare shows that the chances of a patient being proactive about getting symptoms checked is affected by factors ranging from levels of deprivation in the local community to the quality of screening services.
In the Long Term Plan, the NHS acknowledges that one of the biggest actions it can take to improve cancer survival is to diagnose the disease earlier, and this ambition lies at the heart of its strategy for transforming cancer services.
Local or regional system empowerment is crucial for driving this change and so too is integrated care since the work of Cancer Alliances and RDCs will be entwined within ICSs and PCNs and it will require clinicians from disparate parts of the NHS to work in collaboration.
Pilot schemes, such as ‘MOTs for lungs’, have already demonstrated the value of bringing screening closer to patients’ homes, and this localised, targeted, population health approach will play an important role in delivering key aspirations within the Long Term Plan.
Paul Midgley is director of NHS Insight, Sarah Shield is a consultant, and Oli Hudson is content director at Wilmington Healthcare. For information on Wilmington Healthcare, visit www.wilmingtonhealthcare.com