Rationale for change

Improving the quality of cancer care in the UK has been a key health policy objective since the publication of the Calman-Hine report (Department of Health, 1995). This report highlighted that outcomes for UK cancer patients were worse than in most other European countries. The NHS Cancer Plan (Department of Health, 2000) and the Cancer Reform Strategy (Department of Health, 2007) maintained this focus and considerable achievements have been made. Overall mortality has fallen, survival rates are improving for many cancers and patients' experience has improved (Cancer Reform Strategy, 2007).

Despite these successes, there remains a case for doing more to improve cancer care.

  • The Office for National Statistics, in 2005, estimated that one in three people will be diagnosed with cancer at some point in their life, with incidence projected to increase by around a third overall, between 2001 and 2020.

  • The UK has relatively high mortality rates compared with other countries, according to findings published by the World Health Organization in 2009. Evidence from Cancer Research UK, published in 2008, supports these findings, suggesting that if survival rates equalled the best in Europe, this would equate to around 11,000 fewer deaths per year. The Cancer Reform Strategy (Department of Health, 2007) also identified that England uses more hospital beds for cancer than other countries, which accounted for a large proportion of total cancer expenditure.

  • An estimated £3.6bn is spent on cancer care in secondary and tertiary care across England. A key message from the Cancer Reform Strategy is to achieve world class commissioning by setting the role of network teams as a commissioning resource to PCTs. This needs to be collaborative and based on patient care pathways with input from cancer clinicians.

  • Improving Outcomes: A Strategy for Cancer (Department of Health, 2011) highlights the need to move away from process measures and towards outcome measures for key areas such as prevention and early diagnosis, quality of life and patient experience, and better treatment.

  • The results of the national Cancer Patient Experience Survey 2011/12(Department of Health, 2012) provided much positive feedback. Again however, the results highlighted the need to improve patient experience in key areas such as the need for more coordination and integration between professionals and care providers.

London cancer services

In June 2009, NHS London and PCTs in London agreed that cancer services in London should be reviewed. While good progress has been made to improve cancer care in the capital over the last decade, and many areas of excellence exist within the NHS in London, survival rates still lag behind much of the UK and other European capitals.

As part of the London cancer review, an expert group of 45 clinicians, drawn from a range of clinical specialties, hospitals, and cancer networks, helped define the case for change. Cancer Services, Case for Change, (NHS London, 2009), set out a clear case for the need to improve the commissioning and provision of cancer services for Londoners.

This work identified some key challenges for London.

  • Around 13,600 people die from cancer in London each year, with more than half of them under 75.

  • The number of new cancer cases in London is predicted to increase from around 27,000 in 2002, to 28,500 in 2022.

  • The variance in mortality in the Case for Change (NHS London, 2009) shows that not only is there significant variation between London boroughs, but also that nine London boroughs have mortality rates higher than the UK average.

  • One factor for this variation in mortality is poorer recognition of early signs and symptoms of cancer, and low uptake of invitation to screening in some areas, leading in turn to late presentation of cancer. Londoners have historically reported a poorer experience of cancer care when compared with other regions of England.

  • London has a young and often transient population, with a potential impact on the ongoing management of cancer.

  • There are high rates of chronic illness among Londoners, leading to many more cancer patients having co-morbidities affecting their outcomes and experience of the health system.

  • There is a high proportion of single person households compared with the rest of the UK, with negative implications for inpatient discharge and aftercare.

  • A lack of progress in implementing coordinated cancer services across London has also led to service provision that often provides patients with fragmented care. Numerous geographic and organisational boundaries between providers have hampered service development.

  • Finally, demand for cancer services in London is likely to come from a wider base than the population of 8 million. Due to patients from outside of London receiving treatment in London, the demand increases to an estimated 12 million.

Model of Care for Cancer Services

A Model of Care for Cancer Services was published in August 2010, which highlighted four key areas for improvement.

  • Improving early diagnosis - Late diagnosis of cancer is a major factor in causing poorer relative survival rates for cancer. Improved public awareness of symptoms, increased uptake of screening, earlier diagnosis and increased GP access to diagnostic services is needed to improve the chances of surviving cancer.

  • Extending local service provision - There are inequalities in access and outcomes across London, and care and treatment should be standardised. For the more common cancer services, such as chemotherapy, non-complex surgery and acute oncology, there should be a focus on increasing the availability of these services to the populations served.

  • Consolidating specialist services - Specialist surgery takes place on too many sites. For rarer cancers and more complex interventions, there should be a drive to consolidate these specialist services into centres of excellence, ensuring the right teams and facilities are available.

  • Creating integrated systems - Organisational boundaries must not be a barrier to treatment. Providers and commissioners should work together to specify and deliver integrated care pathways to consistent practice pathways, using the best practice, evidence and clinical guidance available.

Integrated Cancer Systems

In order to implement the recommendations in the model of care, a specification for integrated cancer systems (ICS) was developed. The London Cancer Alliance was formed by a group of providers coming together in a formal, governed way with the aim of providing comprehensive, integrated cancer patient pathways and services. Our ICS is clinically-led, has responsibility for delivering the specified care pathways for different tumour sites, and has responsibility for governing and delivering services across the system.

Multi-disciplinary teams (MDT) underpin the management and delivery of patient care by bringing together all of the relevant experts to plan coordinated treatment.

The Case for Change highlights variability across London in structure, function, roles and compliance with Improving Outcomes Guidance requirements of multi-disciplinary teams. The LCA has worked with clinicians, managers and MDT coordinators to ensure that multi-disciplinary teams are standardised across provider networks, and that patient access to a key worker is available consistently throughout the networks.

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