Improving Outcomes: A Strategy for Cancer

Objectives

The strategy seeks to achieve cancer outcomes in England comparable with the best in the world, improving survival while preventing avoidable cancers, diagnosing disease earlier, improving treatment and quality of life, and reducing inequalities in incidence, access, experience, mortality and survival.[1][2][3][4]It aims to save an additional 5,000 lives each year by 2014/15, principally through earlier diagnosis.[1][3]

• Place patients, carers and the public at the centre of decisions through the principle of “no decision about me without me”, personalised care planning, informed choice and service responsiveness.[5][6][7]
• Prevent cancer by addressing smoking, unhealthy diet, obesity, alcohol misuse, physical inactivity, occupational carcinogens and other modifiable risks.[8][9]
• Increase symptom awareness, support prompt presentation to primary care, strengthen urgent referral and diagnostic access, and expand evidence-based screening.[10][11][12][13]
• Provide timely, safe and effective surgery, radiotherapy, chemotherapy, systemic anti-cancer therapies and molecularly targeted treatment.[14][15][16][17][18]
• Improve survivorship, rehabilitation, self-management, coordinated follow-up, support for carers, and end-of-life care that respects individual preferences.[19][20][21]
• Embed equality throughout the cancer pathway, using tailored information and interventions rather than demographic assumptions, particularly for deprived communities, older people and groups with poorer reported experiences or outcomes.[22][23][24]
• Improve information on incidence, prevalence, treatment, outcomes, inequalities, expenditure and service quality to support patient choice, commissioning and accountability.[25][26][27]

Implementation

Delivery combines outcomes-focused national leadership with locally led commissioning, clinical autonomy, public-health action, patient involvement, data-driven improvement and partnership with voluntary, research, community and commercial organisations.[5][28][29][30]The strategy is implemented alongside NHS and social-care reforms, with transitional support for emerging commissioning arrangements and proposed structures subject to Parliamentary approval.[1][2]

• Assign national leadership to the Department of Health, National Cancer Director and Implementation Advisory Group, with annual reports on implementation progress and cancer outcomes.[31]
• Hold the NHS Commissioning Board accountable to the Secretary of State for Health and use the Commissioning Outcomes Framework to hold general practitioner consortia accountable for improved outcomes.[29]
• Coordinate prevention, vaccination, screening, public-health intelligence and cancer-registry functions through Public Health England, while the NHS Commissioning Board commissions screening services to agreed levels.[8][32]
• Use health and wellbeing boards, joint strategic needs assessments and joint health and wellbeing strategies to align NHS, public health and social-care commissioning with local needs.[33]
• Support commissioners through National Institute for Health and Care Excellence quality standards, cancer commissioning support packs, Improving Outcomes Guidance, tariffs and Commissioning for Quality and Innovation payments.[34][33][35][36]
• Maintain cancer networks during the transition to support consortia, alongside the National Cancer Action Team, NHS Improvement and the National Cancer Intelligence Network.[31][35]
• Engage charities, HealthWatch, patient representatives, community organisations, employers, local authorities, clinicians and academic and industry partners in awareness, prevention, research, support and service improvement.[28][37][38][39]

Operationally, the strategy combines prevention and screening with earlier diagnosis, improved access to diagnostics and treatment, multidisciplinary care, risk-stratified survivorship pathways, service redesign and more productive use of resources.[32][12][20][40]It retains cancer waiting-time standards, including two-week, 31-day and 62-day standards, and requires commissioners to reflect them in provider contracts.[3][27][41]

• Introduce flexible sigmoidoscopy pilots in 2011/12, target 30% coverage by the end of 2013/14 and 60% by the end of 2014/15, with full roll-out intended for 2016 subject to United Kingdom National Screening Committee approval.[10]
• Provide general practitioners with direct access to selected diagnostic tests where urgent referral is inappropriate, supported by referral guidance, decision-support tools, safety-netting, audit and benchmarking.[12][13]
• Expand personalised care through clinical nurse specialists, care co-ordinators, assessment, care planning, self-management support, tailored follow-up, vocational rehabilitation and specialist support where needed.[42][43]
• Reduce avoidable admissions and inpatient stays through day-case or 23-hour care, enhanced recovery, community services and the Transforming Inpatient Care Programme for Cancer.[40]
• Improve treatment access through radiotherapy capacity and quality initiatives, chemotherapy service improvements, the Cancer Drugs Fund, value-based pricing from 2014, molecular diagnostics and proton beam therapy development.[15][16][17][18]

Accountability relies on the NHS, public health and social-care outcomes frameworks, supported by survival and mortality measures, stage at diagnosis, emergency presentation, screening participation, patient-reported outcomes, patient experience, safety measures and inequality metrics.[29][44][30][24]Quality Accounts, clinical audit, cancer peer review, regulatory oversight by the Care Quality Commission, registry data and national surveys provide complementary mechanisms for public reporting, benchmarking and improvement.[25][4][36][45]

Financially, NHS cash funding was protected, with £10.6 billion growth by 2014/15 and an expectation of up to £20 billion in efficiency savings for reinvestment in patient care.[46]Cancer-specific commitments include £60 million over four years for flexible sigmoidoscopy, £10.75 million for local and national signs-and-symptoms campaigns in 2010, £200 million annually for the Cancer Drugs Fund, and £300 million from Macmillan Cancer Support over 7 to 10 years for up to 2,700 additional one-to-one support posts.[10][38][17][42]Savings are expected from reducing inpatient admissions and length of stay, improving radiotherapy productivity and redesigning care pathways.[47][40]

Monitoring & Evaluation

The strategy establishes an outcomes-led accountability model for cancer services, combining national outcomes frameworks, commissioning oversight, public reporting and data-driven quality improvement. The NHS Commissioning Board is accountable to the Secretary of State for Health and uses the Commissioning Outcomes Framework to hold general practitioner consortia accountable for improved outcomes.[29]NHS, public health and social care outcomes frameworks are intended to align responsibility across services.[1][30]

• Measure cancer outcomes through one-year and five-year survival, age-specific mortality, stage 1 and 2 diagnosis, emergency presentation, inequality gaps, treatment outcomes, patient-reported outcomes and patient experience.[44]
• Use proxy measures for survival, including early-stage diagnosis, emergency-route diagnosis and general practitioner use of diagnostic tests, because survival data are subject to time lags.[29][44]
• Retain and performance-manage cancer waiting-time standards, including two-week, 31-day and 62-day standards, supported by mandatory referral-to-treatment data collection.[3][48][49]

Information infrastructure is central to monitoring. The National Cancer Intelligence Network links datasets and provides analytical support to commissioners and providers, while the Health and Social Care Information Centre publishes raw data for wider use.[25]Cancer registries are expected to improve completeness and timely production of data, including staging information submitted through National Health Service information requirements.[44][8]New data collections require approval through the Review of Central Returns and the Information Standards Board.[25]

• Publish information on incidence, prevalence, survival, services, expenditure, inequalities, treatment, waiting times, clinical outcomes and patient experience.[26][6]
• Use Quality Accounts to report organisational quality priorities, engage boards and explain improvements to commissioners, patients and the public.[25]
• Apply equality metrics, the Equalities Portal and health equity audits to identify and address differences in access, treatment, outcomes and experience.[6][24]
• Undertake national clinical audits and peer review of multidisciplinary teams, with peer-review findings linked to Care Quality Commission risk-based regulation.[4][36]

Patient experience and public accountability are reinforced through national surveys, provider-level benchmarking and HealthWatch. The 2010 National Cancer Patient Experience Survey invited more than 100,000 adult patients across 158 eligible Trusts and received nearly 70,000 responses.[45]Results cover communication, involvement in decisions, confidence in clinicians, access to clinical nurse specialists, information, dignity and respect.[45]Survey findings are intended to support commissioners, providers and local improvement, including action on inequalities.[50][23]

Evaluation also draws on international benchmarking, research and service-specific datasets. The International Cancer Benchmarking Partnership compares survival and investigates factors underlying international differences.[31][51]Screening programmes are piloted and evaluated nationally, with quality assurance overseen by Public Health England.[8]The Radiotherapy Dataset and chemotherapy dataset support comparative analysis of access, activity, outcomes and costs.[15][16]Annual reports are to measure strategy implementation progress and cancer-outcome improvements, supported by an Implementation Advisory Group.[31]

Several sections do not specify a single consolidated indicator set, universal reporting timetable or defined accountability sanctions beyond the outcomes frameworks, audits, surveys, regulatory processes and published data.[52][24][33]

Costing & Financing

Financing combines protected National Health Service funding, efficiency expectations, targeted investments and tariff-based incentives, but no single fully costed cancer-plan budget or quantified overall funding gap is provided.[46][35][36]National Health Service cash funding was protected through the Spending Review, with growth of £10.6 billion by 2014/15, alongside an expectation of up to £20 billion in efficiency savings over four years for reinvestment in patient care.[46]

• Invest in earlier diagnosis, screening and diagnostic capacity, including £60 million over four years for flexible sigmoidoscopy within bowel screening and £10.75 million for local and national signs-and-symptoms campaigns in 2010.[10][38]
• Fund access to cancer medicines through the Cancer Drugs Fund at £200 million annually, supplemented by £50 million of in-year funding for strategic health authorities in 2010/11.[17]
• Support targeted-medicine research through funding competitions of up to £11 million in early 2011.[18]
• Mobilise £300 million from Macmillan Cancer Support over 7 to 10 years to help create up to 2,700 additional one-to-one support posts.[42]

Cancer care imposes substantial direct and societal costs. Estimated National Health Service expenditure on cancer services exceeded £5.1 billion in 2008/09, while the National Audit Office estimated £6.3 billion.[2]The wider societal cost of cancer was estimated at £18.3 billion in 2008/09.[2]The £6.3 billion estimate included £1.2 billion for pre-treatment activity, screening, diagnostic investigations and primary care that had previously not been classified as cancer-related.[27]

The financial strategy emphasises productivity and service redesign. Matching the best-performing quartile for inpatient admissions per new cancer diagnosis could save around £106 million and 532,000 bed days annually, while matching the best quartile for average length of stay could save around £113 million and 566,000 bed days annually.[40]More productive radiotherapy use, day-case and 23-hour pathways, enhanced recovery, reduced emergency admissions and reduced unnecessary follow-up are identified as mechanisms for releasing resources while maintaining or improving quality.[46][47][40]

• Use tariffs and Commissioning for Quality and Innovation payments to reward quality, productivity, rapid diagnostic access, reduced emergency admissions and cost-effective chemotherapy, radiotherapy and screening services.[13][35][36]
• Fund local screening elements annually through the NHS Commissioning Board, with Public Health England retaining specified national screening responsibilities.[32]
• Maintain mixed statutory and voluntary funding for the National Cancer Intelligence Network and transitional funding for cancer networks.[31]
• Develop a dedicated palliative-care funding system, with recommendations planned for summer 2011.[21]

Some commitments have no stated monetary value, including additional funding for earlier diagnosis, direct-access diagnostics, radiotherapy capacity, re-ablement, cancer-network support, equality pilots and policy research.[3][13][20][23]Costs are expected to rise as cancer incidence increases, survival improves and new treatments become available.[2]