National Assembly for Wales Health and Social Services Committee Inquiry examining the progress made in implementing the Cancer Delivery Plan in Wales including:

Whether Wales is on course to achieve the outcomes and performance measures, as set out in the Cancer Delivery Plan, by 2016;
Progress made in reducing the inequalities gap in cancer incidence and mortality rates;
The effectiveness of cancer screening services and the level of take-up across the population of Wales, particularly the harder to reach groups;
Whether patients across Wales can access the care required (for example, access to diagnostic testing or out-of-hours care) in an appropriate setting and in a timely manner;
The level of collaborative working across sectors, especially between the NHS and third sector, to ensure patients receive effective person-centred care from multi-disciplinary teams.
Whether the current level of funding for cancer services is appropriate, used effectively and provides value for money.

----------------------------------------------------------------------------------------------------------------

The RCN is the world’s largest professional union of nurses, representing over 415,000 nurses, midwives, health visitors, nursing students and health care support workers, including over 24,000 members in Wales. The majority of RCN members work in the NHS with around a quarter working in the independent sector. The RCN works locally, nationally and internationally to promote standards of care and the interests of patients and nurses, and of nursing as a profession. The RCN is a UK-wide organisation, with its own National Boards for Wales, Scotland and Northern Ireland. The RCN is a major contributor to nursing practice, standards of care, and public policy as it affects health and nursing. The RCN represents nurses and nursing, promotes excellence in practice and shapes health policies.

The Cancer Delivery Plan like many of the Welsh Government Delivery Plans has a section on prevention. The RCN has consistently proposed that prevention activity by health professionals needs to be joined up and not disease specific. Despite concerted efforts to prevent ill health in Wales, inequalities in health are widening. The risk factors for many diseases are interlinked and are rooted in poverty and deprivation. This has to be recognised and addressed.

3. The RCN is an active member of the Wales Tobacco Control Alliance. The Welsh Government’s Tobacco Control Action Plan, published in 2012, sets a target of reducing smoking prevalence rates to 16% by 2020, from a current prevalence rate that remains stubbornly high at 23%. This is clearly an ambitious target. As giving up smoking is a key step for individuals taking responsibility for their own health, and reducing their risk of developing cancer, it is essential to recognise that the Tobacco Control Action Plan underpins the preventive element of the Cancer Delivery Plan as well as in a number of other Welsh Government plans.

4. At the last meeting of the Wales Tobacco Control Alliance, members were informed of the concerns that ASH Wales has in terms of the leadership, accountability and monitoring structures for both of these plans. The following issues need to be addressed in order to ensure that the targets set out in both plans are achieved:

· Clear leadership

· Buy-in from key delivery partners and stakeholders

· Consistent strategic representation on delivery boards

· A more formal and robust accountability structure

Nurses are in an ideal position to influence the people they interact with be it in primary prevention, secondary prevention or in teaching the promotion of self care and management. Midwives, health visitors, and school nurses have an obvious role to play in ensure that every child has a healthy start in life. It is vital though that all nurses and midwives promote every encounter with their patients as a public health encounter. If we are to close the gap in health inequalities and the burden of avoidable ill health then we must harness the full potential of the nursing workforce.

The Cancer Delivery Plan makes a commitment to deliver person-centred cancer care in Wales and ‘people are placed at the heart of cancer care with their individual needs identified and met so they feel well supported and informed, able to manage the effects of cancer’. Specifically it calls on LHBs to:

· Assign a key worker to each person with cancer, from the point of diagnosis onwards, to coordinate their care;

The Cancer Patient Experience Survey (CPES) 2013[1] identified that only 66% of patients responding had been given the name and contact details of their key Worker.

7. As highlighted in the report, the most striking finding of the survey relates to the impact of the Clinical Nurse Specialist (CNS). On almost all questions in the survey, patients who have a CNS are significantly more positive than patients who do not have access to a CNS.

“It is clear that the presence of a CNS makes a substantial positive difference to the perceived quality of cancer services seen by patients. On 59 questions in the survey, patients who had a CNS were more likely to be positive about their care and treatment than patients who did not; and the scale of differences on many questions is very substantial. All of these differences are statistically significant.

The most pronounced differences in view between those patients with a CNS and those without one in 2013 were in respect of verbal and written information, involvement, information on financial support, discharge information and post discharge care and emotional support.”

At the Cross Party Group on Nursing and Midwifery in October 2013, Macmillan Cancer Support identified that there is a mismatch between the distribution of Clinical Nurse Specialists in Wales and the distribution of cancer incidents. The group also heard from a Clinical Nurse Specialist for Breast Cancer who was concerned that some patients with certain types of cancer still don’t have access to a CNS. At the meeting of the Cross Party Group in February 2013, Assembly Members were told of circumstances where men in Wales were personally paying to receive specialist robotic surgery for prostate cancer in England as the surgery was not available in Wales. The RCN was pleased to see the Welsh Government decision to fund robotic surgery system for Wales capable of minimally invasive treatment of prostate cancer at Cardiff and Vale University Health Board in August 2013. It is important that patients in Wales have an equity

Nurse specialists provide direct patient care, play a vital role in educating patients about how to manage their condition and importantly, provide emotional support. They take a leading role in ensuring that patients get the best care possible. A number of independent studies have shown that specialist nurses are both clinically and cost effective. [2]

The cost benefits generated by specialist nurses include:

· reduced waiting times,

· avoidance of unnecessary hospital admission/ readmission (through reduced complications,

· post-surgery/enhanced symptom control/ improved patient self-management),

· reduced post-operative hospital stay times,

· the freeing up of consultant appointments for other patients,

· services delivered in the community/at point of need,

· reduced patient treatment drop-out rates,

· the education of health and social care professionals,

· the introduction of innovative service delivery frameworks,

· direct specialist advice given to patients and families.[3]

Whilst the development of the role of the specialist nurse has been one of the most exciting innovations in nursing practice in recent times it is also one of the least understood and valued and as such are vulnerable in times of constrained public spending. An RCN (2008) highlighted that;

· more than one third of specialist nurses reported that they had a vacancy freeze in place.

· 47% reported that they were at risk of being downgraded and

· 68% reported having to see more patients.

11. The RCN has recently published ‘More than just a Number[4]’ showing that in England, hidden within wider nursing workforce cuts is a significant loss and devaluation of skills and experience in the NHS with 3,994 fewer full time equivalent (FTE) nursing staff working in senior positions (bands 7 and 8). The staff affected by this includes ward sisters, community matrons, clinical nurse specialists and advanced nurse practitioners. A similar study has not yet been undertaken in Wales but we have evidence from our members that specialist posts have been under threat.

12. The RCN recommends that every patient with cancer should have the right to specialist nursing care, and ask that the Welsh Government undertake an audit of the number and type of cancer specialist nurses in Wales. Specialist nurse posts should also be supported through robust long term funding and time should be given to specialist nurses to ensure that they can fulfill the core elements of their role, namely providing clinical expertise, leadership and education and training.

At the Cross Party Group on Nursing and Midwifery in October 2013 we also discussed how we currently don’t have the right follow up care in Wales. The system that we have in place currently is based on people’s experience of cancer many years ago, not on how people experience cancer today. At least one in four people living with and beyond cancer – over 30,000 in Wales[5] - experience a wide range of long-term debilitating health conditions caused by their cancer or its treatment. This growing population of individuals with chronic health conditions will challenge existing care models and will need the ongoing support of practice and community nurses.

Nurses in the community are committed to meet the coming challenges but, historically, they have simply not benefited from the national vision and investment needed to provide us with the workforce we need today. Across the UK 27 per cent of NHS community nurses are over 50 and will have retired within the next 10 years. We are simply not educating enough new staff to fill these posts, let alone increase services. The RCN believes strongly that a renewed investment in the community nursing workforce is essential to support the changing nature on the way in which we provide health services in Wales.

[1] http://wales.gov.uk/docs/dhss/publications/140117canceren.pdf

[2] Epilepsy Action (2010) Best care: the value of epilepsy specialist nurse. http://www.sudep.org/wp-content/uploads/2010/07/EpilepsySpecialistNurse-Report-2010.pdf

[2] Parkinson’s UK (2011) Parkinson’s nurses- affordable, local, accessible and expert care: a guide for commissioners

in England. http://www.parkinsons.org.uk/PDF/Englandnursereport.pdf

16 Parkinson’s UK (2011) Parkinson’s nurses in Scotland- providing safe, effective and patient-centred care.

http://www.parkinsons.org.uk/PDF/Scotlandnursereport.pdf

[2] Mynors G, Perman S and Morse M (2012) Defining the value of MS specialist nurses. Multiple Sclerosis Trust. http://www.mstrust.org.uk/downloads/defining-the-value-of-ms-specialist-nurses-2012.pdf

[5] Macmillan estimate based on known cancer prevalence (Maddams J, Utley M, Møller H. Projections of cancer prevalence in the United Kingdom, 2010-2040. Br J Cancer 2012; 107: 1195-1202) and expert consensus, see Macmillan Cancer Support (2013) Throwing light on the consequences of cancer and its treatment.