Improving Outcomes: A Strategy for Cancer

Objectives

The strategy seeks to achieve cancer outcomes in England comparable with the best in the world by improving survival, reducing mortality and narrowing inequalities across prevention, diagnosis, treatment, survivorship and end-of-life care. It aims to save an additional 5,000 lives annually by 2014/15, principally through earlier diagnosis.[1][2]

• Prevent avoidable cancers by addressing tobacco use, unhealthy diet, obesity, alcohol misuse, physical inactivity, occupational exposures and other modifiable risks, alongside vaccination and healthier environments.[3][4]
• Improve awareness of cancer symptoms, encourage timely presentation, strengthen primary-care assessment and referral, and expand access to screening and diagnostic services.[5][6][7]
• Extend evidence-based screening, including breast, bowel and cervical programmes, and incorporate flexible sigmoidoscopy into bowel screening subject to United Kingdom National Screening Committee approval.[8][9]
• Provide safe, effective, timely and evidence-based treatment, including surgery, radiotherapy, systemic anti-cancer therapies and multidisciplinary care, while reducing regional variation and avoiding age-based exclusion from appropriate treatment.[10][11][12]
• Deliver personalised care, informed choice, one-to-one support, rehabilitation, risk-stratified follow-up, support for carers and care aligned with patients’ end-of-life preferences.[13][14][15][16]
• Embed equality in cancer policy and services by improving data, targeting interventions and addressing disparities by deprivation, ethnicity, age, disability, sexual orientation, geography and other relevant characteristics.[17][18][19]
• Improve cancer information on incidence, prevalence, stage, survival, service quality, access, patient experience and expenditure to support transparency, informed choice, commissioning and scrutiny.[20][21][22]

Implementation

Implementation combines national leadership, outcomes-based accountability and local clinical and community action. Patients, carers and the public are intended to be central to decisions, while clinicians, commissioners and local organisations are given scope to innovate and improve quality rather than being subject to centralised micro-management.[23][24][25]

• Coordinate delivery across the National Health Service, Public Health England, local authorities and social care, with the NHS Commissioning Board, general practitioner consortia, health and wellbeing boards and HealthWatch holding or supporting distinct commissioning, accountability and participation roles.[2][26][27]
• Use Public Health England for prevention, screening policy and quality assurance, symptom-awareness campaigns, vaccination, public-health intelligence and cancer data recording and analysis; commission agreed screening services through the NHS Commissioning Board.[3]
• Support commissioners through cancer commissioning packs, National Institute for Health and Care Excellence Quality Standards and guidance, tariffs, Commissioning for Quality and Innovation incentives, and specialised commissioning for rare cancers.[28][29][30]
• Mobilise cancer networks, the National Cancer Action Team, NHS Improvement, the National Cancer Intelligence Network, charities, patient groups, professional bodies, researchers, industry and community organisations during transition to new NHS structures and beyond.[31][32][33]
• Strengthen service delivery through direct general-practitioner access to appropriate diagnostic tests, multidisciplinary teams, enhanced recovery and day-case pathways, community-based support, modern radiotherapy and chemotherapy services, and integrated health and social care pathways.[7][34][35][36]
• Monitor outcomes through NHS, public-health and social-care outcomes frameworks, including survival, mortality, stage at diagnosis, emergency presentation, screening participation, patient experience, safety and inequality measures.[25][37][26]
• Publish and use linked data, cancer registries, clinical audits, peer review, Quality Accounts, equality metrics, waiting-time information, patient-reported outcome measures and patient-experience surveys for benchmarking, regulatory oversight and local improvement.[20][21][38][17]
• Review progress through annual reports and implementation oversight from the National Cancer Director and Implementation Advisory Group, supplemented by international benchmarking through the International Cancer Benchmarking Partnership.[32][33][39]

Monitoring & Evaluation

The strategy establishes an outcomes-led accountability model across National Health Service (NHS), public health and social care, using survival, mortality, early diagnosis, quality of life, patient experience, safety and inequalities as central measures of progress.[25][37]It combines national outcomes frameworks, clinical and administrative datasets, audits, public reporting, regulatory oversight and patient participation, although several sections do not specify a single consolidated indicator set or reporting timetable.[1][40][9]

• Use the NHS Outcomes Framework’s five domains, covering premature mortality, quality of life, recovery, patient experience and safety, alongside public health and social care outcomes frameworks.[25]Hold the NHS Commissioning Board accountable to the Secretary of State for Health and use commissioning measures to hold general practitioner consortia to account.[25]
• Monitor cancer survival, age-specific mortality, emergency diagnosis, stage 1 and 2 diagnosis, active treatment, inequality gaps, recovery, treatment-related ill health, psychological support, end-of-life care, treatment safety and patient experience.[25][37]Use stage at diagnosis and emergency presentation as proxy measures because survival data have a time lag.[37]
• Retain cancer waiting-time standards and mandatory referral-to-treatment data collection, with commissioners reflecting the standards in provider contracts.[2][41]Continue national and local performance monitoring, maintain shared responsibility for breaches involving inter-provider transfers, and ensure official statistics comply with the UK Statistics Authority’s Code of Practice.[42][41][43]
• Strengthen cancer intelligence through linked national datasets, cancer registries, provider and commissioner-level publication, Quality Accounts, published raw data and tailored analyses.[20][21]Pilot collection of breast-cancer recurrence and metastatic-disease data in 2011/12, with intended full collection from April 2012.[21]
• Apply approval processes for proposed data collections through the Review of Central Returns, Information Standards Board and National Information Governance Board.[28]Improve registry timeliness, completeness and survival-data accuracy, while maintaining evidence that registration deficiencies did not explain international survival differences.[3][44]
• Use international benchmarking through the International Cancer Benchmarking Partnership to compare survival, investigate variation and identify good practice.[32][39]Monitor drug usage, routes to diagnosis, screening trials, cancer-registration quality and emergency-presentation rates as supporting evidence for improvement.[40][45][46]
• Undertake national clinical audits, multidisciplinary team peer review, cancer patient-experience surveys and Patient Reported Outcome Measures to assess quality and guide improvement.[28][17][44][47]Link peer-review findings with Care Quality Commission activity and use proportionate, risk-based regulation where concerns arise.[17][30]
• Publish equality-focused metrics and analyses through the Equalities Portal, covering population characteristics, service access, diagnosis, treatment, outcomes and patient experience by equality group and geography.[22][19]Use HealthWatch and patient, carer and public involvement to strengthen accountability and service responsiveness.[28][48]
• Evaluate screening extensions, awareness campaigns, survivorship pathways, one-to-one support and new service models using participation, outcomes, experience, avoidable appointments, emergency admissions and economic evidence.[8][9][14][15]Publish annual reports on strategy implementation and cancer outcomes, supported by the Implementation Advisory Group during transition to new NHS structures.[32][33]

Costing & Financing

Financing combines protected NHS growth, a system-wide efficiency challenge, targeted cancer investments, tariffs and contributions from statutory and voluntary sources.[24][12][30]The material identifies substantial expenditure and potential savings, but generally does not provide a cancer-specific total budget, allocation methodology, funding-gap estimate or comprehensive economic-assumption framework.[49][40][50]

• Provide NHS cash funding growth of £10.6 billion by 2014/15 and seek up to £20 billion in efficiency savings for reinvestment over the following four years.[24]Align Quality, Innovation, Productivity and Prevention planning with local reform plans and use service redesign to release resources.[51]
• Recognise estimated NHS cancer-service expenditure of more than £5.1 billion in 2008/09, alongside a National Audit Office estimate of around £6.3 billion.[49]Estimate the wider societal cost of cancer at £18.3 billion in 2008/09, with costs expected to rise because of incidence, survival and new treatments.[49]
• Improve value for money by reducing variation in inpatient admissions, bed days, length of stay and radiotherapy productivity.[51][35]Potential annual savings were estimated at approximately £106 million from reducing bed-day use and £113 million from reducing length of stay to best-performing-quartile levels.[51]
• Use tariffs and payment incentives for diagnostics, screening, chemotherapy, radiotherapy, surgery, avoided emergency admissions, survivorship pathways and quality improvement, while improving activity and service-cost information.[7][29][30]
• Fund targeted prevention and early-diagnosis measures, including £60 million over four years for flexible sigmoidoscopy subject to UK National Screening Committee approval and £10.75 million for local and national signs-and-symptoms campaigns begun in 2010.[9][52]
• Develop screening tariffs and pursue specified efficiency opportunities, including average savings of £100,000 per cervical-screening unit annually through a 14-day turnaround and anticipated savings of £12 million annually from breast-screening age-extension randomisation.[8][53]
• Provide £200 million annually for the Cancer Drugs Fund and £50 million of additional in-year funding to strategic health authorities in 2010/11.[12]Support research and development through funding competitions of up to £11 million for tumour profiling and biomarkers.[54]
• Mobilise voluntary-sector investment, including Macmillan Cancer Support’s £300 million commitment over seven to ten years for up to 2,700 additional one-to-one support posts.[14]Continue central funding for advanced communication training in 2011/12, although no amount is specified.[38]
• Maintain ring-fenced public-health budgets for local Directors of Public Health and fund cancer networks during the transition, but without specified allocations in the supplied material.[4][33]Support cancer intelligence through statutory and voluntary funding sources, while the proposed national partnership is not intended to raise cancer funds.[33][31]
• Identify additional but unquantified funding needs for direct diagnostic access, re-ablement, radiotherapy capacity, interim proton-beam therapy abroad, palliative-care funding arrangements and molecular diagnostic centres.[7][15][16][34][54]