Improving Outcomes: A Strategy for Cancer — Fourth Annual Report

Objectives

Improving Outcomes: A Strategy for Cancer seeks to improve cancer survival in England through prevention, earlier diagnosis, timely access to high-quality treatment, improved patient experience, survivorship support and better end-of-life care. Its headline ambition was to save an additional 5,000 lives annually by 2015, used as a proxy for narrowing the gap between cancer survival in England and the best-performing European countries.[1][2][3]The strategy recognises persistent inequalities by deprivation, ethnicity and age, and aims to improve both outcomes and equitable access to services.[4][2]

• Reduce preventable cancer risk through tobacco control, smoking cessation, safer alcohol consumption, healthy weight, physical activity, sun protection, occupational-risk reduction and human papillomavirus vaccination.[5][6][7][8]
• Increase earlier diagnosis through public awareness campaigns, evidence-based screening, improved general-practice recognition and referral, direct diagnostic access, greater diagnostic capacity and reductions in emergency presentation.[1][9][10][11]
• Improve treatment quality and access across surgery, radiotherapy, systemic anti-cancer therapy, innovative medicines, molecular diagnostics, genomic services and personalised treatment.[11][12][13][14]
• Strengthen cancer intelligence, registration, data quality, research, clinical audit and comparative analysis to support commissioning, clinical leadership and service improvement.[15][16][17]
• Enhance patient experience, compassionate care, survivorship, management of treatment consequences and choice at the end of life.[18][19][20][21]
• Monitor survival, mortality, stage at diagnosis, screening coverage and patient experience, while interpreting projected survival gains cautiously because the estimates are indicative and cannot attribute all changes to strategy actions.[22][23][24][25]

Implementation

Implementation combines national policy direction with NHS England commissioning, Public Health England-led prevention and intelligence functions, local delivery by clinical commissioning groups, local authorities, general practices and provider trusts, and collaboration with charities, professional bodies, researchers, patients and industry partners.[26][2][27]Annual reporting, national outcomes frameworks, service specifications, datasets, peer review and performance standards provide the principal oversight mechanisms.[26][22][28][29]

• Coordinate national accountability through the Department of Health, Public Health England and NHS England, with the Secretary of State holding NHS England to account for outcomes and national indicator data supporting comparison between areas.[26][22][30]
• Deliver prevention through legislation, regulation, vaccination, public-health campaigns, local authority action, NHS Health Checks and partnerships with schools, businesses, community organisations and voluntary-sector bodies.[31][6][7][32]
• Commission national screening through the Public Health Section 7A agreement, with NHS England commissioning and Public Health England preparing programme specifications; use pilots and formal evaluation before wider rollout of new methods such as human papillomavirus primary screening and faecal immunochemical testing.[28][33][34]
• Run Be Clear on Cancer and related awareness campaigns nationally, regionally and locally, supported by Public Health England, NHS England, the Department of Health, Cancer Research UK and the National Cancer Intelligence Network.[9][35]Evaluate campaigns across awareness, general-practice attendance, urgent referral, diagnosis, stage, emergency presentation and treatment-pathway measures.[35][36][37]
• Support primary care through decision-support software, cancer audits, practice profiles, primary-care facilitators, strategic general-practitioner leads and locally tested accelerated-diagnosis models.[10][38]
• Expand diagnostic and treatment capacity through endoscopy workforce planning and productivity improvement, cancer waiting-time oversight, Enhanced Recovery pathways, radiotherapy service planning and specialised commissioning of chemotherapy and advanced treatments.[11][39][40][41]
• Use evidence-development routes for emerging technologies, including clinical trials, Commissioning through Evaluation and governance review, before determining whether treatments should be routinely commissioned.[13][41]
• Maintain cancer intelligence through the National Cancer Intelligence Network, National Cancer Registration Service, Cancer Outcomes and Services Dataset, Systemic Anti-Cancer Therapy dataset, Radiotherapy Dataset and linked administrative data.[42][16][43][44]Use conformance reporting, monthly data-quality reports, comparative profiles and commissioning tools to identify variation and prompt local action.[15][43][44]
• Assure service quality through a National Peer Review Programme using provider self-assessment, chief-executive endorsement, external verification and risk-based visits, with findings also informing Care Quality Commission inspection activity.[29][45]
• Improve experience and survivorship through the Cancer Patient Experience Survey, trust buddying, specialist cancer-nurse workforce planning, holistic needs assessments, personalised care plans, stratified follow-up and the Living with and Beyond Cancer Programme.[18][46][19][47]
• Strengthen end-of-life care through electronic palliative-care registers, local testing of palliative-care currencies, inspection against priorities of care for dying people and development of funding evidence.[48][3]
• Use investment to underpin selected actions, including £750 million for cancer-service improvement, of which £450 million supported awareness and earlier diagnosis, alongside Cancer Drugs Fund allocations and targeted radiotherapy investment.[1][41][12]The source does not provide a single total strategy budget or comprehensive financing plan.[49][17]

Monitoring & Evaluation

Cancer-strategy monitoring combines annual progress reporting, national outcomes frameworks, cancer registration and intelligence, service-performance statistics, screening measures, patient-reported experience and research evidence. The approach is intended to assess survival, mortality, stage at diagnosis, inequalities, access, treatment quality, survivorship and end-of-life outcomes, although some projections and experimental indicators require cautious interpretation.[26][22][23][42]

• Monitor national cancer outcomes through the NHS Outcomes Framework, including under-75 cancer mortality, one- and five-year survival for all cancers, and one-year survival for breast, lung and colorectal cancers.[22]
• Publish national and local indicators through the Health and Social Care Information Centre portal to identify variation and support comparison between local areas.[22][23]
• Track mortality, incidence, routes to diagnosis, emergency presentation, stage completeness, survival, deprivation, ethnicity and age using National Cancer Intelligence Network analyses and cancer-registration data.[42][4]
• Use the Cancer Outcomes and Services Dataset conformance portal, monthly Systemic Anti-Cancer Therapy reports and Radiotherapy Dataset reporting to assess data completeness, treatment patterns, provider variation, mortality after chemotherapy, radiotherapy activity and treatment complexity.[43][44]
• Monitor screening coverage, invitations, uptake, diagnoses, referrals, polyps and implementation of programme extensions, with strengthened governance under the Public Health Section 7A agreement.[50][28][33]
• Assess awareness campaigns throughout the patient pathway through measures of symptom awareness, general-practice attendances, urgent referrals, diagnoses, stage, emergency presentation and conversion rates.[35][36][37]
• Track treatment access through diagnostic activity, cancer waiting-time standards, peer-review compliance, clinical outcomes and national quality measures.[11][39][29]
• Measure patient experience through the Cancer Patient Experience Survey, which in 2014 surveyed more than 110,000 patients and had a 64% response rate; 89% of respondents rated their care as excellent or very good.[18]
• Monitor survivorship implementation through electronic holistic needs assessments, care plans and commissioning-quality reviews; assessments increased by 91% and care plans by 158% in the year to October 2014.[19][47]
• Measure end-of-life care partly through the proportion of deaths in a person’s usual place of residence, recorded at 44.7% in 2013/14, an increase of 0.8 percentage points.[21][48]

Accountability is shared across the Department of Health, Public Health England and NHS England, with the Secretary of State holding NHS England to account for outcomes. NHS England’s cancer waiting-times taskforce supports action where the 62-day referral-to-treatment standard is missed, while peer-review findings can inform Care Quality Commission inspection.[22][2][29][45]

The survival ambition was assessed using projected five-year survival for people diagnosed in 2011 to 2015 compared with the 2006 to 2010 cohort. The estimate of 6,500 to 17,500 additional annual five-year survivors, with a best estimate of 12,000, was explicitly indicative: observed data for the later cohort were unavailable, confidence intervals were substantial, incidence was held constant, and improvement could not be attributed wholly to strategy action or compared reliably with the best European countries.[24][25][51]

Early-diagnosis modelling estimated that a 10 percentage-point shift towards stage 1 or 2 diagnoses could improve five-year survival by approximately 3.3% to 4.4%, equivalent to 7,000 to 9,000 additional people surviving at least five years. However, stage-specific survival indicators depended on more complete and robust national linkage of stage and survival data.[4][23]

Several areas lack a complete national evaluation cycle or formal accountability framework, notably survivorship, consequences-of-treatment services and some local innovation pilots. The available evidence instead emphasises implementation activity, local evaluation, data development and periodic reporting.[19][20][52]

Costing & Financing

Funding combined major cancer-service investment, research funding, drug funding, public-health allocations and targeted technology investment. Reported expenditure rose over the period, but the material does not provide a single consolidated cancer-strategy budget, a quantified overall funding gap, or a comprehensive economic model.[1][49][41]

• Invest £750 million in improving cancer services, including £450 million for cancer awareness and earlier diagnosis.[1]
• Report cancer expenditure rising from £3.19 billion in 2003/04 to £5.68 billion in 2012/13, including a £680 million increase compared with 2011/12; spending per person varied by more than twofold between commissioning organisations.[49]
• Provide Cancer Drugs Fund allocations, including £200 million annually for its initial three-year period, further extension funding and £280 million available in each of 2014/15 and 2015/16.[41]
• Invest £130 million in cancer research through the National Institute for Health Research in 2013/14 and £35 million jointly in 18 Experimental Cancer Medicine Centres for 2012 to 2017.[27]
• Allocate £23 million through the Radiotherapy Innovation Fund to 50 centres in 2012 to develop Intensity Modulated Radiotherapy.[12]
• Provide up to £6 million for Cancer Research UK clinical trials of Stereotactic Ablative Body Radiotherapy.[13]
• Allocate a ring-fenced public-health budget of £8.2 billion over three years to local authorities for issues including obesity, alongside physical-activity and school-sport investments.[7][32]
• Anticipate net annual savings of up to £16 million from human papillomavirus testing for cervical-screening triage and test of cure.[28]

Some funding sources are identified without amounts, including Macmillan Cancer Support support for the Living with and Beyond Cancer Programme, Healthcare Quality Improvement Partnership funding for the National Prostate Cancer Audit, and joint funding for selected trials.[19][53][8][9]

Economic considerations include an explicit cost element in revised Cancer Drugs Fund prioritisation, potential future cost pressure from an ageing population living with cancer, and an average reported financial deterioration of £570 per month among more than four in five people affected by cancer. Palliative-care financing was constrained by inadequate reliable cost data, prompting pilots and development of potential per-patient funding currencies.[41][4][47][48]