Improving Outcomes: A Strategy for Cancer — Fourth Annual Report

Objectives

Improving Outcomes: A Strategy for Cancer sets a national framework for England to improve cancer survival, reduce preventable mortality and inequalities, and ensure that people receive timely, high-quality, compassionate care from prevention through diagnosis, treatment, survivorship and end-of-life care.[1][2][3]Its central ambition was to save an additional 5,000 lives annually by 2014/15, as a proxy for halving the cancer-survival gap between England and the best-performing European countries.[2][4]

• Reduce cancer risk through human papillomavirus vaccination, tobacco control, healthier weight, physical activity, alcohol-harm reduction, sun protection and action on occupational exposures.[2][5][6][7][8]
• Increase earlier diagnosis by raising symptom awareness, strengthening primary-care decision-making and referral, expanding diagnostic capacity, improving routes to diagnosis, and increasing the proportion of cancers diagnosed at stages 1 and 2.[2][9][10][11][12]
• Modernise screening by improving breast, cervical and bowel programmes, expanding Bowel Scope Screening, and evaluating human papillomavirus primary screening and faecal immunochemical testing.[8][13][14][15]
• Improve treatment access, quality and value across surgery, radiotherapy, chemotherapy, cancer medicines, molecular diagnostics, genomic testing and specialised therapies.[16][17][18][19]
• Strengthen patient-centred care by improving experience, addressing treatment consequences, supporting recovery and self-management, developing stratified follow-up, and enhancing end-of-life care and choice.[20][21][22][23][24]
• Reduce inequalities in incidence, mortality, diagnosis, access and outcomes related to deprivation, ethnicity, age and other population characteristics, including the needs of older people with cancer.[25][26][27]

The strategy treats intelligence, research and transparent data as cross-cutting enablers, using information on incidence, mortality, survival, stage, routes to diagnosis, treatment, patient experience and survivorship to guide policy, commissioning and service improvement.[28][29][30]Cancer mortality had declined, but substantial socioeconomic inequalities persisted and survival remained poor for several cancer types, reinforcing the focus on early diagnosis and equitable access.[31][26]

Implementation

Delivery combines national leadership by the Department of Health, Public Health England and NHS England with commissioning, provider improvement, clinical leadership, local-authority public-health action, charity partnerships, patient involvement and evidence-led performance management.[1][32][28][7]Annual progress reporting was undertaken jointly by the Department of Health, Public Health England and NHS England, while the NHS Outcomes Framework supported ministerial accountability for NHS England performance and health inequalities.[32][33]

• Coordinate prevention and awareness through Public Health England campaigns, vaccination, screening specifications and Be Clear on Cancer activity, supported by Cancer Research UK and other partners.[5][13][10][34]
• Support primary care through referral guidance, electronic decision support, primary-care facilitators, strategic general-practitioner leads and locally tested rapid-diagnosis models.[11][35]
• Commission and improve services through NHS England, clinical commissioning groups, Strategic Clinical Networks, specialised commissioning, clinical reference groups, peer review and service accreditation.[36][37][38][3]
• Expand diagnostics and treatment capacity through endoscopy productivity work, radiotherapy capacity planning, national treatment datasets, chemotherapy algorithms and integrated pathology, imaging and genomic services.[30][39][12][17][19]
• Embed survivorship in commissioning through recovery packages, holistic needs assessments, personalised care plans, treatment summaries, cancer care reviews, stratified pathways and support for work, finances and physical activity.[21][40][41][23]
• Develop coordinated end-of-life care through electronic palliative-care coordination systems, funding pilots, proposed care currencies, the five priorities of care for dying people, and Care Quality Commission inspection.[24]

Implementation relies on national intelligence infrastructure led substantially by the National Cancer Intelligence Network and Public Health England, alongside the National Cancer Registration Service, the Cancer Outcomes and Services Dataset, the Systemic Anti-Cancer Therapy dataset, the Radiotherapy Dataset and linked research data.[9][42][30][39]These systems support benchmarking of commissioners, trusts, multidisciplinary teams and local areas, while data-conformance reporting identifies deficiencies in recording and submission.[28][30]

Performance is monitored through survival, mortality, stage at diagnosis, screening coverage and uptake, urgent-referral and treatment waiting-time standards, diagnostic activity, radiotherapy delivery, treatment access, equality measures, patient experience and place of death.[25][33][43][16][20][24]The Cancer Patient Experience Survey, patient-reported outcome measures, peer review, service profiles and clinical indicators provide complementary evidence on quality and experience.[38][20][44]Survival projections should be interpreted cautiously because they cannot establish progress against the best European countries or attribute improvements solely to strategy measures.[4][45]

Reported investment included £750 million for improving cancer services, including £450 million for awareness and earlier diagnosis, alongside Cancer Drugs Fund allocations and targeted investments in radiotherapy and research.[2][46][19][47]National cancer expenditure rose from £3.19 billion in 2003/04 to £5.68 billion in 2012/13, although the material does not provide a single fully costed strategy budget or a comprehensive financing plan.[48]

Monitoring & Evaluation

Cancer strategy monitoring combines national outcomes measures, service-performance standards, patient-reported evidence, cancer intelligence and programme-specific evaluations. Accountability is shared principally across the Department of Health, Public Health England and NHS England, with the NHS Outcomes Framework supporting the Secretary of State for Health and Social Care in holding NHS England to account.[32][33]

• Monitor cancer survival, under-75 mortality, incidence, stage at diagnosis, screening activity, waiting times, treatment access, radiotherapy, patient experience, survivorship and inequalities by deprivation, ethnicity and age.[25][49][27]
• Publish annual implementation progress reports through the joint Department of Health, Public Health England and NHS England arrangement, supported by indicator-portal data, National Cancer Intelligence Network analyses and local benchmarking tools.[32][43][9]
• Use cancer registration, mortality and survival statistics, including five-year net survival, age-standardised mortality and deprivation comparisons; the under-75 mortality rate was 141.5 deaths per 100,000 population in 2013.[31]
• Strengthen data quality through mandatory Cancer Outcomes and Services Dataset submissions, conformance reporting, monthly Systemic Anti-Cancer Therapy dataset reports and radiotherapy reporting.[30][39]
• Track screening coverage and delivery, including breast and cervical screening coverage, Bowel Scope Screening uptake, invitations, procedures, referrals and polyp retrieval.[36][15]
• Assess early-diagnosis and awareness initiatives using surveys, general-practice attendances, urgent referrals, diagnoses, stage, emergency presentations, conversion rates and detection rates.[34][50]
• Monitor cancer waiting-time standards through quarterly NHS England statistics; in July to September 2014, 83.5% of patients began first treatment within 62 days of urgent referral, below the 85% operational standard.[16]
• Use peer review, clinical indicators, service profiles, accreditation and Care Quality Commission inspection information to assure service quality; 2,153 cancer services and teams were reviewed in 2013/14.[38]
• Measure patient experience through the Cancer Patient Experience Survey and patient-reported outcome measures; in 2014, 89% of surveyed patients rated their care excellent or very good.[20]
• Monitor survivorship implementation through Clinical Quality Review Groups, electronic holistic needs assessments, care plans and evaluations of stratified follow-up models.[40][41]

Progress towards the ambition to save an additional 5,000 lives annually was estimated by comparing 2006–2010 diagnoses with projected 2011–2015 cohorts, using linear five-year survival projections by cancer and age group while holding incidence constant.[4]The resulting estimate of 6,500 to 17,500 additional annual five-year survivors, with a best estimate of 12,000, is indicative and cannot establish progress against the best-performing European countries or attribute improvements solely to strategy actions.[4][45]

Several monitoring arrangements remain developmental: the early-stage diagnosis indicator was experimental because of inconsistent staging data, proposed stage-specific survival indicators required more robust national data, and some campaign and service-model evaluations were still ongoing.[43][51][23]

Costing & Financing

Financing combines major national cancer-service investment, targeted treatment funding, research investment and selected public-health allocations. However, the material does not provide a single consolidated strategy budget, a costed implementation plan, quantified funding gap or comprehensive economic assumptions.[2][48][19]

• Invest £750 million in cancer-service improvement, including £450 million for cancer awareness and earlier diagnosis.[2]
• Report national cancer expenditure rising from £3.19 billion in 2003/04 to £5.68 billion in 2012/13, including a £680 million increase from 2011/12.[48]
• Fund the Cancer Drugs Fund at £200 million annually for its initial three years, supplemented by £50 million in 2010/11, £400 million to extend the Fund to March 2016, and £280 million available in each of 2014/15 and 2015/16.[19]
• Invest £130 million in National Institute for Health Research cancer research in 2013/14 and £35 million jointly in 18 Experimental Cancer Medicine Centres for 2012 to 2017.[47]
• Provide £23 million through the Radiotherapy Innovation Fund in 2012 and make up to £6 million available for Stereotactic Ablative Body Radiotherapy clinical trials.[46]
• Allocate £8.2 billion over three years as a ring-fenced local-authority public-health budget, alongside physical-activity and school-sport investments.[7][52]
• Anticipate net savings of up to £16 million annually from human papillomavirus testing for triage and test of cure.[13]

Other reported economic considerations include substantial variation in commissioner cancer spending, with the highest-spending organisation spending more than twice as much per person as the lowest; the reasons, including the effects of incidence and prevalence, remain unclear.[48]The palliative-care funding review identified a substantial lack of reliable cost data, while the Department of Health was developing cost-benefit analysis of possible free social care at the end of life.[24]People affected by cancer were reported to be an average of £570 per month worse off in more than four out of five cases.[40]

Many delivery areas, including data systems, screening expansion, awareness campaigns, diagnostic capacity, survivorship, end-of-life care and molecular diagnostics, identify funding bodies or resource needs but do not specify monetary budgets or total costs.[42][53][11][21][24]