National Assembly for Wales

Inquiry into the progress made to date on implementing the Welsh Government’s Cancer Delivery Plan

Evidence from Welsh NHS Confederation – CDP 23

Inquiry into progress made to date on implementing the Welsh Government’s Cancer Delivery Plan

Response from the Welsh NHS Confederation

Introduction

The Welsh NHS Confederation, on behalf of its members, welcomes the opportunity to respond to this inquiry into progress made to date on implementing the Welsh Government’s Cancer Delivery Plan.

By representing the seven Health Boards and three NHS Trusts in Wales, the Welsh NHS Confederation brings together the full range of organisations that make up the modern NHS in Wales. Our aim is to reflect the different perspectives as well as the common views of the organisations we represent.

The Welsh NHS Confederation acts as an independent voice in the drive for better health and healthcare through our policy and influencing work and by supporting members with events, information and training.

The Welsh NHS Confederation and its members are committed to working with the Welsh Government and its partners to ensure there is a strong NHS which delivers high quality services to the people of Wales.

Overview

The NHS in Wales continues to work against a backdrop of increasing demand and reducing resources. Our members recognise the importance of change at this key point in the history of the NHS in Wales. In our recent discussion document “From Rhetoric to Reality -NHS Wales in 10 years’ time” we referred to building a new understanding of how the NHS should be used – embodied by an agreement with the public that would represent a shared understanding. Within this document we note the importance that as time progresses we must ensure we work with the public to reduce demand, releasing capacity in the system. This has the potential to result in major gains in how we are able to care for those with life-long conditions.

Is Wales on course to achieve the outcomes and performance measures, as set out in the Cancer Delivery Plan, by 2016?

There has been significant progress made in key areas of service delivery and outcomes in line with the Cancer Delivery Plan. As with cancer services worldwide, challenges remain about earlier diagnosis. These challenges may be greater in the UK due to primary care ‘gate keeping’ systems and in Wales due to its older population and levels of deprivation. However, the NHS welcomes changes to GP contracts in support of oncology services in primary care and view clinical engagement in service quality improvement work on patient pathways as a positive step to address these issues.

It is pleasing to see that there has been a significant improvement in the two key outcome measures of patient survival and patient experience. The reduction in mortality, accompanied by an increase in 1 and 5 year survival rates, since the introduction of the Plan is faster than any of the other UK nations. In addition, the 2013 Patient Experience Survey reported that an overwhelming majority (89%) of patients rated their care as excellent, or very good, with a further 8% rating their care as good. Eighty-eight percent of people were allocated a named specialist nurse and 86% of patients felt they were given the right amount of information. This compares similarly and in some key areas better, to when the same survey was used in England.

There are also some good examples of service development and local practice, including:

- The introduction of peer review by the Cancer Networks, which has succeeded in securing Local Health Board and clinical engagement with significant changes. These changes have led to more consistent delivery of best practice and service improvement to achieve the highest standard of treatment across Wales;

- Improvements in compliance and outcomes in the Cancer Delivery Plan's Performance Measures. These have seen a significant increase in patients recruited to high quality trials, patients giving consent to donate tissue to the Wales Cancer Bank and recording of stage at diagnosis which is a key information requirement for the early diagnosis improvement work; and

- Production of annual Local Health Board cancer services reports and plans, which have introduced transparency into both innovative service developments and responses to variations in patient outcomes and peer review reports.

There are several examples where Welsh Government, NHS Wales and the third sector are working effectively together to improve patient outcomes and experience:

- In improving waiting times from receipt of referral for a suspected cancer to start of definitive treatment. Whilst improvements have been made to compliance with current 31 and 62 day targets, WG has also listened to the clinical voice questioning whether these rather blunt targets are the best way to report the experience for all patient waits. Pilots are underway exploring a new pathway, leading the way in the UK, and also through the Cancer Networks to align pathway processes to ensure more efficient and effective working;

- In early diagnosis a programme of work is being developed focusing initially on lung cancer where patient outcomes and experience are known to be poor. This has involved primary care significant event audits, changes to GP contracts around early diagnosis and referral pathways and will explore the potential of a national awareness campaign in partnership with Cancer Research UK. Macmillan Cancer Support is also proposing to invest significantly in supporting the integration of primary care oncology into cancer service improvement initiatives.

In other areas such as the development of acute oncology services and development and integration of primary care oncology, implementations have been variable. However, through peer review, transparent publication of outcomes and collaborative working with 1000 Lives (and the former NLIAH), we are confident that significant progress will be made by 2016.

We would acknowledge that progress has been poor around, for example, the development of fit for purpose information systems and services, vital for both high quality communication between service providers and also data on outcomes. It is essential that NHS Wales engages more with Public Health Wales and the National Wales Informatics Service to deliver the support needed for service improvement.

One way to address this variation in service would be to have wider clinical engagement and stronger commissioning to enable more ‘joined-up’ delivery and development of services, as well as more robust appraisal of what works well. In addition to this, there are some gaps in policy formation e.g. the lack of clarity on the publication of surgical mortality rates, and around key worker and care planning policies. Closing these gaps will have a beneficial impact on reducing variationsin the quality and effectiveness of care.

What progress has been made in reducing the inequalities gap in cancer incidence and mortality rates?

It should be acknowledged that closing the inequalities gap is challenging, and requires modification of public behaviours which even if achievable will only cause a fall in mortality in the long term.

Equity across Wales continues to be very testing, although the plan makes concerted attempts to address this. An example of inequity would be the number of approved Individual Patient Funding Requests (IPFR) for cancer drugs – where there is a significant discrepancy between both the number of applications and the responses given in the different regions of Wales. This process is currently under review and it is hoped this will make strong recommendations to reduce these inequities.

In those areas with the greatest challenges around equalities, it is worth noting that Local Health Boards are engaging across public and third sector services to improve population health and patient outcomes. They are running a number of innovative schemes, including Smoke Free Homes, Alcohol Brief Intervention Training, and partnerships such as the Macmillan Libraries Project.

How effective are cancer screening services and the level of take-up across the population of Wales, particularly the harder to reach groups?

Some of the greatest challenges the NHS faces in the Cancer Delivery Plan centre on Outcome 2 – Cancer is detected quickly where it does occur and recur. Anecdotally, direct access to diagnostics from primary care is not always straightforward.

Where screening uptake is poor, there are good examples of Local Health Boards working with their public health teams to increase engagement, and target specific areas and populations. For example, Cwm Taf University Local Health Board has highlighted a tripartite campaign planned for 2014 to raise awareness of screening campaigns, as well as symptoms and signs of specific cancers - the campaign will also include information on how people can reduce their risk of cancer. Nationally, Public Health Wales is also delivering a campaign to target those parts of the population, e.g. the more deprived communities through innovative ‘making every contact count’ initiatives.

Can patients across Wales access the care required (for example, access to diagnostic testing or out-of-hours care) in an appropriate setting and in a timely manner?

As referenced in our answer to the previous question, there is some anecdotal evidence that direct access to diagnostics from primary care can be difficult. We also recognise current issues around the high levels of demand generally for unscheduled care (including out-of-hours) and diagnostic services.

In addition, the availability of more services 24 hours a day, all year round, is not always evident, and the availability of services more locally is proving difficult to achieve. Some clinicians have expressed the view that this vital aspect of the Plan has perhaps not been given the emphasis it should have been, and impact has been underestimated. It is these aspects of the cancer pathway that are subject more than any other to competing priorities and funding pressures, and we believe this should be addressed in the second half of the duration of the Plan.

What level of collaborative working exists across sectors, especially between the NHS and third sector, to ensure patients receive effective person-centred care from multi-disciplinary teams?

There is evidence of strong collaborative working across sectors from Local Health Boards and Trusts. In areas including palliative care, funding for cancer services, and reducing health inequalities, the NHS in Wales shows evidence of strong partnership working and engagement with the third sector and other partners.

Is the current level of funding for cancer services appropriate, used effectively and providing value for money?

It is acknowledged that during these unprecedented challenging financial times, cancer services, like others, are struggling to meet growing patient demands. An aging population and better treatments means that more patients are suitable for treatment and more treatments are suitable for patients.

A greater focus on ‘Prudent Healthcare’ in the second half of the Plan is required to reduce ineffective treatment interventions:

- There is strong correlation between patient support by specialist nurses and improved outcomes - whereas the correlation with the spend on expensive end of life drugs is less clear. Reporting of 30 day mortality will highlight variations in the use of treatments;

- There is significant variation in hospital based follow up of uncertain benefits whereas patients aren’t consistently receiving the holistic needs support they do require for successful rehabilitation;

- Acute oncology can reduce admissions and length of stay for unscheduled care associated with cancer and its treatment by approximately 30%.

Peer review by clinical experts and publication of findings and Local Health Board action plans to address concerns found will drive up standards of service delivery.

A strategy to commission the infrastructure for stratified medicine or personalised oncology needs to be developed to select patients most likely to benefit from expensive treatment interventions.

Conclusion

It is important to note that this inquiry takes place halfway through the life cycle of the Welsh Government’s Cancer Delivery Plan and, as such, aspects of the work will naturally remain in progress. Progress against the Plan has been significant, especially in terms of key outcomes of patient survival and patient experience, ensuring the safety and quality of cancer treatment and end of life care. Progress is also evident in terms of holistic person centred care, and many developments will be implemented in full by 2016.

However, as highlighted in our response, the aging population and levels of deprivation mean there are significant challenges for the planning of safe, effective and sustainable cancer services in the future. While the objectives for prevention are important, it should be recognised that significant improvement in the burden of the disease may not be seen for many years beyond 2016. The immediate concern must be achieving rapid cancer diagnosis and rapid access to effective treatment.

Consideration should be given to the establishment of a strategic planning and delivery group which is clinically led and made up of Health Board Directors of Finance and Planning with good engagement from appraisal and commissioning bodies in Wales. This needs to be cancer-focused, proactive, robust, decisive and collaborative. It should also have the ability to access quality information on performance and outcomes, advice regarding best practice as required and strong links with specialist commissioning groups.

There is no doubt that Wales has the skills, the capacity and the ability to meet the demanding targets in the Welsh Government’s Cancer Delivery Plan. In the second half of the Delivery Plan period, the Welsh NHS will continue to work together with partners in government and the third sector, and demonstrate success in positive outcomes for patients and reduced health inequalities.