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Nao report (hc 343 2004-05) the nhs cancer plan: a progress report (full report)


DEPARTMENT OF HEALTH The NHS Cancer Plan: A Progress Report REPORT BY THE COMPTROLLER AND AUDITOR GENERAL HC 343 Session 2004-2005 11 March 2005
The National Audit Office scrutinises public spending on behalf of Parliament. The Comptroller and Auditor General, Sir John Bourn, is an Officer of the House of Commons. He is the head of the National Audit Office, which employs some 800 staff. He, and the National Audit Office, are totally independent of Government. He certifies the accounts of all Government departments and a wide range of other public sector bodies; and he has statutory authority to report to Parliament on the economy, efficiency and effectiveness with which departments and other bodies have used their resources. Our work saves the taxpayer millions of pounds every year. At least £8 for every £1 spent running the Office.
DEPARTMENT OF HEALTH The NHS Cancer Plan: A Progress Report LONDON: The Stationery Office House of Commons to be printed on 7 March 2005 REPORT BY THE COMPTROLLER AND AUDITOR GENERAL HC 343 Session 2004-2005 11 March 2005
This report has been prepared under There have been significant Section 6 of the National Audit Act 1983 improvements in the management and for presentation to the House of Commons in accordance with Section 9 of the Act.
provision of cancer services since the publication of the NHS Cancer Plan, John Bourn
but there is more to be done Comptroller and Auditor General
The NHS Cancer Plan is a ten-year strategy to National Audit Office
improve cancer services 21 February 2005
There has been good progress in improving cancer 10 services during the early years of the Plan but The National Audit Office there is more to be done study team consisted of: Tim Fry, Andrew Anderson, Matt Evans and Mark Vincent, under the direction of James Robertson This report can be found on the National Audit Office web site at www.nao.org.uk For further information about the
National Audit Office please contact:

National Audit Office Press Office 157-197 Buckingham Palace Road Victoria London SW1W 9SP Tel: 020 7798 7400 National Audit Office 2005





The NHS Cancer Plan is well founded 18 1. Progress against the targets and commitments and there is an opportunity now to in the NHS Cancer Plan extend and update the strategy to reinforce partnership working and network structures The Plan is well constructed, well regarded and provides a good foundation for further refinements Cooperation between constituent organisations is 23 key to the effectiveness of cancer networks and the NHS Cancer Plan, but in many cases needs further development Policy and structural changes in the NHS pose challenges for the implementation of the Plan, particularly in terms of cooperation between constituent network organisations Photographs courtesy of Doncaster & Bassetlaw Hospitals NHS Foundation Trust. The Trust's Cancer Unit is committed to providing high quality services by involving patients, carers, and the public in their design and delivery. Justine Desmond Photography www.justinedesmondphotography.co.uk


This is the final report in a series of three National The main participants in the implementation of the Audit Office studies on cancer services in England. The Plan are shown in Figure 1.
first1 examined whether clinical aspects of cancer services are saving more lives across England and in comparison to It will take time for the effects of the Plan to work other countries. The second study2 examines how patients through fully. To evaluate its impact to date we drew on view services, based on the results of a major survey of a survey of all cancer networks, discussions with a wide cancer patients. This report focuses on the NHS Cancer range of health professionals within cancer networks across Plan, reviewing its content, examining its implementation the country, a review of Department of Health papers across the country, and reporting on progress to date and other material, and the advice of a panel of experts against the targets and commitments in the Plan. (Appendix 2) to provide a progress report on the NHS Cancer Plan some four years into its ten-year programme.
The NHS Cancer Plan was published in September 2000 and built on commitments set out in Overall, we found that: the NHS Plan, published two months earlier, which the Plan was generally well conceived and promised more staff and equipment for cancer along with substantial progress has been made to date, with a modernised NHS, with new ways of working to prevent many targets in the Plan met or on course to be and treat cancer. The NHS Cancer Plan is a ten-year met. This should contribute to the downward trend programme of fundamental reform of cancer services in in mortality rates observed for England, which are England. It formally established cancer networks across ahead of the Department's trajectory to achieve the the country, bringing together the organisations and health target of a 20 per cent reduction in mortality from professionals which plan and deliver treatment and care cancer in persons under 75 by 2010; for cancer patients. The aims of the NHS Cancer Plan are: while cancer networks – the vehicle for securing to save more lives; improvements in local cancer services – have made to ensure people with cancer get the right professional progress with some significant successes, they are support and care as well as the best treatment; not always as effective as they could be in terms of staffing, cancer services planning or in receiving the to tackle the inequalities in health that mean full support of other parts of the healthcare system. unskilled workers are twice as likely to die from Networks were established before primary care trusts cancer as professionals; and and other NHS organisational changes, and there is to build for the future through investment in the scope for working arrangements to evolve further.
cancer workforce, through strong research and thorough preparation for the genetics revolution, We make a number of recommendations to consolidate so that the NHS never falls behind in cancer again.
progress to date and to reinforce networks and partnership working.
‘Tackling cancer in England: saving more lives'. (HC 364, 2003-04). Published March 2004.
‘Tackling Cancer: Improving the Patient Journey'. (HC 288, 2004-05). Published February 2005. THE NHS CANCER PLAN: A PROGRESS REPORT
1 Key figures in the implementation of the NHS Cancer Plan
Ministers & Permanent Secretary Cancer Taskforce National Cancer Director (NCD) Advises NCD & Ministers; monitors progress; identifies policy development needs Cancer Policy Team Cancer Action Team (NHS) Cancer Services Collaborative (Department of Health) Supports implementation of Plan and Improvement Partnership Develops/monitors/reviews policy; development of networks; leads on (Modernisation Agency) advises Ministers etc quality assurance of cancer services National programme of service improvement 34 Cancer Networks (NHS trusts, primary care trusts, voluntary sector, clinical groups etc) Source: Department of Health The NHS Cancer Plan is broadly However there are ways in which the strategy for comprehensive but strategy will tackling cancer in England could be improved to cover, for example, strategic issues such as estimates of the need to be kept up to date future cancer burden. Decisions now need to be taken on how to update and bring together all elements of the We found that the NHS Cancer Plan is impressive current cancer strategy in a unified way that ensures that in its coverage of the main elements of World Health it remains the central guiding approach for improving Organisation guidelines3 (especially as they were cancer services and outcomes.
published after the NHS Cancer Plan) for designing strategies against cancer, effectively setting out a series of targets, commitments and milestones for improving The Plan has resulted in cancer services. The Plan compares favourably with other national and state cancer plans published in recent improvements to cancer services years, and is regarded by cancer networks as a useful tool though there is still more to be done outlining strategic direction across the patient pathway. The 34 cancer networks in England are responsible for implementing the NHS Cancer Plan. Almost all cancer network organisations we spoke to were positive about progress against the NHS Cancer Plan, partly because of the initiatives to identify and spread good practice put in place by the Department of Health and the Cancer Action Team, which supports implementation of the Plan within the NHS. National Cancer Control Programmes: Policies and Managerial Guidelines. WHO, 2002.
THE NHS CANCER PLAN: A PROGRESS REPORT
The NHS Cancer Plan contains a very significant 13 The NHS Cancer Plan established cancer networks
number of targets and commitments to be achieved during as the vehicle for the delivery of cancer care. The first its ten-year lifetime. Progress to date in meeting them has wave of cancer networks was established following the been encouraging, including: recommendations of the Calman Hine report, published in 1995. As a result of the NHS Cancer Plan full coverage Boosting the downward trend in smoking; in England was achieved, with a total of 34 networks Extending the breast screening programme; established. The networks are responsible for developing and planning all aspects of cancer services. They are matrix Speeding access to cancer diagnosis and treatment; organisations, combining expertise and input mainly Establishing specialist cancer teams; from acute and primary care trusts, the voluntary sector, numerous generic and tumour-specific working groups, Reducing variation in access to cancer drugs; and a patient and user group, coordinated by a network Boosting specialist palliative care services; management team and headed by a network board.
Getting more cancer specialists in place, and faster than planned; 14 Cancer networks have, in a short time, helped to
improve cancer services in England; though some have
Modernising and expanding cancer diagnostic and achieved more than others reflecting, in part, their current treatment facilities; and state of development. In terms of particular successes, cancer networks have, for example: Increasing the pace of research.
planned for the introduction of new cancer drugs 10 Overall, though there has been some slippage
across the network; in meeting some NHS Cancer Plan target dates, much has been achieved, and major improvements in cancer developed plans for funding specialist services secured. But some targets, such as achieving the palliative care; waiting time targets for 2005, pose significant challenges drawn up action plans for the development of cancer if they are to be fully met. services in line with guidance from the National Institute for Clinical Excellence; and 11 In addition to the NHS Cancer Plan the Department
has launched a number of related initiatives to improve
facilitated development of multidisciplinary cancer services, including a tobacco advertising ban, teams, which are an important element in establishing an integrated cancer care programme to delivering improved patient-centred treatment and improve coordination of care, and strengthening the better outcomes.
partnership between the NHS and the voluntary sector.
Cancer networks have helped drive
forward improvements in cancer
services, but there is more to do if
they are all to become fully effective
12 Most cancer patients require care from many parts of
the NHS at different points in their care journey. Primary,
secondary and tertiary care, as well as the voluntary
sector (such as hospices), need to work closely together
to provide an integrated system of care. Cancer networks
were set up to achieve integrated care as well as improved
clinical outcomes, cost-effective services, improved
patient experience and equity of service provision.
THE NHS CANCER PLAN: A PROGRESS REPORT
15 The extent to which networks have been fully
There is scope to improve the commissioning of
established, and the degree therefore to which they are cancer services in some networks. Some primary
fully effective varies, however, and there is more to be care trust commissioners produce plans for cancer done if all 34 networks are to function as effectively as service provision in isolation, when they should possible. Important issues are: be cooperating with other network constituent organisations. The extent to which network Sufficient resources are not always available to
management teams input to the commissioning enable networks to operate effectively. We found
process also varies.
that not all network management teams were fully staffed, with some networks having vacancies for There are concerns regarding the duty of
essential posts. The staffing of additional desirable partnership expected from cancer network
posts was also a challenge, with financial constraints organisations in the context of an evolving NHS.
given as the main explanation. Funding overall was Generally, network management teams reported seen as a problem by some networks.
effective relationships between the networks and their constituent organisations, particularly in the Making the cross-boundary approach work has not
case of acute trusts. However at the more strategic been straightforward. We found that some network
level some strategic health authorities were very boards did not have full representation from acute proactive, whilst others made no reference to the and primary care trusts in their area. Where present, cancer network in their summary local development representation was only at the expected Chief plans. Some networks expressed concerns that, Executive level in around half of cases.
while NHS foundation trusts have the scope to Not all cancer networks plan effectively. Networks
benefit cancer patients, the freedoms that they were required to prepare three-year service delivery have may limit effective partnership working and plans by 2001, underpinned by workforce, and collective efficiency. Similar risks may arise with the education and training strategies. Three of the ten emergence of independent sector treatment centres.
networks we spoke to did not have a current service delivery plan, and although at a national level workforce development was seen as a priority in the NHS Cancer Plan, by late 2003 only a third of networks had produced a workforce strategy; and just over a third had developed an education and training strategy. THE NHS CANCER PLAN: A PROGRESS REPORT


The NHS Cancer Plan is a good model from which Strategic health authorities, working through other countries have taken inspiration. The National primary care trusts, need to ensure that networks Cancer Director should continue to work with his have the resources required for an effective and equivalents overseas to share good practice in drawing sustainable performance. up and implementing blueprints for the development of cancer services, taking account of good practice abroad All networks should have agreed arrangements in that would be applicable in England.
place with local partners for monitoring progress against those targets for which they are responsible, and implement With the approach of the mid-point in the ten-year life them. Where that is deemed not to be the case, the strategic of the Plan, the National Cancer Director should - taking health authority should take corrective action. account of the changed and changing environment of the NHS, subsequent guidance published by the Department The network board should send annually updated to take the Plan forward, and the views of stakeholders information to its constituent bodies and its strategic – consider what changes to the cancer strategy are needed, health authority, to update them on progress against the and how these should most appropriately be brought NHS Cancer Plan. This information should be copied together and published in a unified and accessible form.
for information to the National Cancer Director so that he can have an overview of progress. Any performance As part of its corporate accountability, the Department management response needed would be for the strategic of Health should continue to publish progress against the health authority to take forward. key cancer outcomes in Figure 8 of this report as part of its existing reporting mechanisms.
To make cancer networks work better as cross- boundary organisations the Department of Health, in Cancer networks should ensure that they are able association with strategic health authorities, should to demonstrate to strategic health authorities that they strengthen the functioning of cancer networks by ensuring have appropriate planning arrangements in place locally, that roles and responsibilities of constituent organisations including workforce and education and training strategies, are clearly defined and adhered to. The outputs from this and that these feed into the Local Delivery Plan process.
process should include clear common stated aims, to which all bodies should subscribe, with associated responsibilities and accountabilities.
THE NHS CANCER PLAN: A PROGRESS REPORT


PART ONEThere have been significant improvements in the management and provision of cancer services since the publication of the NHS Cancer Plan, but there is more THE NHS CANCER PLAN: A PROGRESS REPORT
The NHS Cancer Plan is a ten-year 1.3 By 1999 there was general agreement that progress
strategy to improve cancer services was not moving fast enough, and that further action needed to be taken to implement the Calman Hine 1.1 In April 1995 a report (the Calman Hine report)4 was
recommendations and also address other issues such as published by the Expert Advisory Group on Cancer, which prevention and screening. Following a cancer summit was established by the Chief Medical Officers of England convened by the Prime Minister in May 1999, several and Wales to consider the direction in which cancer initiatives were established including the appointment services should be developed. The report was prepared of a National Cancer Director (currently Professor against a backdrop of increasing cancer incidence, Mike Richards) and the announcement of a single cancer variations in treatment outcomes, the major economic target to reduce the death rate from cancer amongst consequences of cancer, and the burden of cancer on the people aged under 75 by at least 20 per cent by 2010 community. It outlined the strategic framework and the from a baseline of 1997. A decision to develop a changes needed in the delivery of cancer services across comprehensive strategy to tackle cancer in England was the country to improve cancer outcomes and survival.
taken by the Prime Minister and the Secretary of State for Health in February 2000. To assist with the development 1.2 The Calman Hine report set out the general
of what was to become the NHS Cancer Plan, a small principles which should govern the provision of cancer advisory group was established and, whilst there was no care (Figure 2), and proposed a new structure for cancer
formal consultation on drafts of the Plan, the National services based on a network of cancer expertise from Cancer Director consulted widely on specific aspects with primary care through to cancer centres. However, various groups of stakeholders. the report set no targets and gave no commitments to additional funding. It was left to local health organisations 1.4 The NHS Cancer Plan, building on a number of
to determine how to implement this overall vision of existing cancer initiatives, was published in September cancer services.
2000. It was designed to be a comprehensive strategy to tackle cancer, covering prevention, screening, diagnosis, treatment and care for cancer, and the investment needed 2 Calman Hine general principles of cancer
to deliver these services in terms of improved staffing, equipment, drugs, treatments and information systems. The Department of Health has responsibility for the NHS  All patients should have access to a uniformly high quality Cancer Plan. Supported by a commitment to increase of care in the community or in hospital.
funding to an extra £570 million a year for cancer services  Public and professional education to help early recognition by 2003-04, the NHS Cancer Plan has four aims: of cancer symptoms, and the availability of national screening programmes are vital.
to save more lives;  Patients, families and carers should get clear information to ensure people with cancer get the right professional and assistance in a form they can understand about support and care as well as the best treatment; treatment options and outcomes available. to tackle the inequalities in health that mean  The development of cancer services should be patient unskilled workers are twice as likely to die from centred and should take account of patients', families', and carers' views and preferences.
cancer as professionals; and  The primary care team is a central and continuing element to build for the future through investment in the in cancer care. Effective communication between sectors is cancer workforce, through strong research and imperative in achieving the best possible care.
through preparation for the genetics revolution, so  Psychosocial aspects of cancer should be considered at that the NHS never falls behind in cancer care again.
 Cancer registration and monitoring of treatment and outcomes are essential.
Source: A Policy Framework for Commissioning Cancer Services (the Calman Hine report) "A Policy Framework for Commissioning Cancer Services" Department of Health/Welsh Office, 1995.
THE NHS CANCER PLAN: A PROGRESS REPORT
1.5 The NHS Cancer Plan is a ten-year programme to
1.6 Figure 4 outlines the content and key elements of the
improve cancer services and outcomes, and contains a NHS Cancer Plan. Part 1 of this Report focuses on progress large number of targets, actions and milestones that are to against the major targets; a full analysis of progress is at be achieved up to 2010. Meanwhile cancer mortality in persons under 75 is falling, and is ahead of the Department's
trajectory to achieve the 2010 cancer target (Figure 3).
Performance against the cancer mortality target for persons under 75 3 year average ratesDeath rate per 100,000 population Required progress towards target.
Assumes reduction spread equally across from 1995-97 baseline rate 1997-99 1999-2001 Source: ONS (ICD9 140-209; ICD10 C00-C97) NOTERates are calculated using population estimates based on 2001 census, subsequent to amendments resulting from the Local Authority Population Study (LAPS). Rates are calculated using the European Standard Population to take account of differences in age structure. ICD9 data for 1993 to 1998 and 2000 have been adjusted to be comparable with ICD10 data for 1999 and 2001 onwards.
THE NHS CANCER PLAN: A PROGRESS REPORT
4 NHS Cancer Plan contents and key elements
Chapter 1: The challenge of cancer Care of all cancer patients to be reviewed by specialist teams Good progress in recent years Monitoring progress to achieve standards Relatively poor survival rates National cancer datasets Inequalities in cancer Strengthening cancer registries A postcode lottery of care Chapter 7: Improving care Poor patient experience New supportive care strategy Meeting the challenge of cancer NICE to develop guidance for supportive care Chapter 2: Improving prevention New training in communication skills New national and local targets to reduce smoking in Improved information for patients disadvantaged groups New Cancer Information Advisory Group New local alliances for action on smoking New internet resources for patients Support in primary care to help people quit smoking £50 million extra for hospices and specialist palliative £2.5 million for research into smoking cessation National five-a-day programme to increase fruit and New Opportunities Fund money for palliative care in vegetable consumption deprived communities National School Fruit Scheme Chapter 8: Investing in staff Raising public awareness Nearly 1000 extra cancer consultants Chapter 3: Improving screening Increases in the number of specialist trainees Routine breast screening to be extended up to age of 70 and More cancer nurses, radiographers and other health professionals available on request to women over 70 More skills and new roles for cancer staff Improved breast screening techniques to increase detection rates Targeted training initiatives New ways of working Better planning for the future Improved cervical screening techniquesColorectal screening pilots Chapter 9: Investing in facilities The NHS Prostate Cancer Programme Substantial investment from New Opportunities Fund Better understanding of screening Additional funding in NHS Plan for 50 MRI scanners, 200 CT Scanners and 45 linear accelerators Chapter 4: Improving cancer services in the community Modernisation of pathology services A central role for primary care in new cancer networks First ever cancer facilities strategy £3 million in partnership with Macmillan Cancer Relief for a lead National audit of major cancer diagnostic facilities cancer clinician in each PCT New partnerships with the private sector £2 million for palliative care training for district nursesNew primary care clinical dataset for cancer patients Chapter10: Investing in the future: research and geneticsNew National Cancer Research Institute Chapter 5: Cutting waiting for diagnosis and treatment Additional investment in research infrastructure Range of waiting time targets, including: maximum two month Additional investment in prostate cancer research wait from urgent GP referral to treatment for all cancers by 2005 Partnership with Macmillan Cancer Relief on genetic counselling Roll out of Cancer Services Collaborative to streamline services in all networks Chapter 11: Implementing the NHS Cancer Plan Cancer the first priority for roll out of booked appointments Additional £570 million by 2003-04 for cancer services By 2004 every patient diagnosed with cancer will benefit from Implementation of cancer service improvements by pre-planned and pre-booked care Chapter 6: Improving treatment Cancer networks develop strategic service delivery plans Extension of guidance programmes to all cancers Network workforce, education and training and facilities strategies to underpin service delivery plans NICE appraisals of cancer to end postcode lottery of care Cancer networks commissioning pilots to be established Establishment of specialist teams Source: The NHS Cancer Plan THE NHS CANCER PLAN: A PROGRESS REPORT
There has been good progress in local authorities and a wide range of working groups improving cancer services during responsible for developing guidelines and implementing good practice, and they include patient and carer the early years of the Plan but there involvement. Networks are accountable to strategic health is more to be done authorities and are responsible for coordinating expert clinical advice, management and local strategy; working Cancer networks have been established across together to improve quality of care and address any inequalities in provision and access.
England to lead improvements in services
1.7 The Calman Hine Report of 1995 recommended the
1.9 Networks are matrix organisations, Figure 5, involving
establishment of cancer networks throughout England, all participants in the range of functions deriving from the each network bringing together all cancer services in a NHS Cancer Plan for which the network has responsibility. locality. The main impetus for their establishment came, The structure of a typical cancer network is shown in however, from the NHS Cancer Plan in 2000, which stated Figure 6, and an example of a particular cancer network
that cancer networks: in Figure 7.
"would be the organisational model for cancer services to implement the Plan, bringing together health Getting money through to front line service commissioners and providers, the voluntary sector and local authorities to work together to improve 1.10 In the NHS Cancer Plan the Government promised
cancer services." an extra £280 million in 2001-02, rising to £407 million by 2002-03 and £570 million by 2003-04. An investment 1.8 By early 2001 there were 34 established cancer
tracking exercise was undertaken by the Department in networks covering the whole of England, each serving early 2003 which showed that investment in the first year a population of between 700,000 and 3 million based had been below target (£199 million) followed by a period around geographical health communities. Headed by of catching up in 2002-03. A second investment tracking a network board, and with a core management team, exercise is currently in progress. Preliminary results for networks comprise acute trusts, primary care trusts the 34 cancer networks show that the £570 million target (responsible for commissioning and, in some cases should be met.
providing, cancer services), voluntary sector organisations, 5 Cancer networks are complex organisations which cross normal organisational boundaries
Cancer Network Functions Patients & Carer Groups Local Authorities Source: National Audit Office THE NHS CANCER PLAN: A PROGRESS REPORT
6 Typical Cancer Network Structure
Strategic Health Authority (Chief execs of network organisations including PCTs, acute trusts and voluntary sector organisations) Commissioning Group (PCTs) Network Executive Team (e.g. Medical Director; Director; Nurse Director; Service Improvement lead; admin staff, etc) Partnership Group (e.g. breast, colorectal, lung, etc) (Patient and Carer Forum) (e.g. radiotherapy, chemotherapy) There has been good progress against most of the major targets in the NHS Cancer Plan 7 An example of a cancer network
1.11 We visited a sample of cancer networks which
The 3 Counties cancer network is a relatively small cancer was agreed with the Department of Health as being network covering a population of 1.02 million in representative of networks across England. Cancer Gloucestershire, Herefordshire and South Worcestershire. networks have, in a short time, helped to improve cancer The network includes: thousands of nurses and allied health services in England; though some have achieved more professionals, hundreds of GPs, hospital consultants and than others reflecting, in part, their current state of other doctors, scores of GP surgeries, 16 community hospitals, seven voluntary sector organisations providing hospice care, development. In terms of particular successes, cancer and many other charitable organisations working within its networks have, for example: boundaries. The network covers five primary care trusts, two strategic health authorities, four district general hospitals, planned for the introduction of new cancer drugs one oncology centre, two cancer intelligence units, three across the network; hospital trusts and two breast screening services.
developed plans for funding specialist Source: Department of Health, "The NHS Cancer Plan: Three year palliative care; progress report - Maintaining the momentum", 2003 developed action plans for the development of cancer services in line with guidance from the National Institute for Clinical Excellence; and facilitated development of multidisciplinary teams, which are an important element in delivering improved patient centred treatment and better outcomes.
THE NHS CANCER PLAN: A PROGRESS REPORT
1.12 We used our visits to cancer networks (Appendix 2)
1.16 In addition to meeting many targets and
to look in more detail at specific progress against the NHS commitments in the NHS Cancer Plan, the Department Cancer Plan. In each of the cancer networks that we visited and others have taken a number of other initiatives to we asked the network management team, the SHA and a improve cancer services across the whole cancer care PCT to assess the progress of the cancer networks against pathway. These include: the NHS Cancer Plan. Four (of eight) SHAs rated progress as good or very good, and four rated it as acceptable. Of eight on prevention. Introduction of a tobacco advertising
ban in 2003 and restrictions on point-of-sale
PCTs, five rated progress as good, one as acceptable, one advertising (2004), the availability of nicotine as acceptable/good and one as acceptable/poor. Of nine replacement therapy and the stop-smoking aid network management teams five rated progress as good or Bupropion (Zyban) on prescription, and further very good, and four as acceptable or acceptable/good.
measures on smoking prevalence in a Department of Health Public Health White Paper in November The NHS Cancer Plan contains a very significant 2004. The White Paper also included a commitment number of targets and commitments for achievement to fund community food initiatives in more PCTs during the ten-year lifetime of the Plan. In 2001, 2003 from 2006, following and building on lessons and 2004 the Department of Health reported on progress learned from the 5-A-Day evaluation; in implementing the NHS Cancer Plan, taking stock and considering the challenges ahead. These reports showed on improving cancer services in the community.
that significant progress has been made in implementing Publication of good practice, commissioning the NHS Cancer Plan and improving cancer services in relevant research projects, establishing a dedicated England, whilst recognising that there are challenges to programme within the Cancer Services Collaborative be met and more to be done if all the Plan's targets and Improvement Partnership, and establishing an commitments are to be fully met. In addition to setting out integrated cancer care programme to improve progress, the 2004 report took account of changes since coordination of care across the whole care pathway the NHS Cancer Plan was published, such as Shifting the and between primary and secondary care; Balance of Power and the NHS Improvement Plan, and demonstrated how cancer services fit in the "new" NHS. on improving care. Actions include strengthening
the partnership between the NHS and the voluntary
1.14 Figure 8 on pages 14 to 17
sector at a national level through the National shows progress against Partnership Group for Palliative Care, the Coalition the major targets of the NHS Cancer Plan. A detailed for Cancer Information which oversees the progress report is at Appendix 1.
development, delivery and dissemination of patient information, and providing funding for an End of Life Within overall progress there have been a number of major achievements on investing in staff. In addition to the NHS
1.15 Key successes to date include:
Cancer Plan commitments, the Cancer Care Group Workforce Team has commissioned Skills boosting the downward trend in smoking; for Health (the sector skills council for health) to extending the breast screening programme; develop a range of competency frameworks to support the development of new and evolving roles speeding access to cancer diagnosis and treatment; within cancer care, including for chemotherapy establishing specialist cancer teams; services, supportive and palliative care, endoscopy services and cystoscopy, and for MDT coordinators. reducing variation in access to cancer drugs; Additional national training programmes for boosting specialist palliative care services; colorectal and breast cancer teams, and getting more cancer specialists in place and faster on investing in research. Actions include doubling
modernising and expanding cancer diagnostic and the number of patients volunteering in cancer trials treatment facilities; and a year ahead of schedule; and new initiatives on prevention, and supportive and palliative care.
increasing the pace of research. THE NHS CANCER PLAN: A PROGRESS REPORT
Some targets require more work to ensure Progress is being made in spreading good practice, facilitated by the 1.17 Some targets for 2001 to 2004 in Figure 8 and
Department of Health and the Appendix 1 were not fully met or were met later than Modernisation Agency planned. In these former cases, there is on-going work 1.19 A number of initiatives have been put in place
to ensure that slippage is minimised. For example, on to identify and implement good practice since the raising public awareness of cancer, the NHS Cancer Plan establishment of cancer networks. The Cancer Services contained a target for the development of a programme Collaborative Improvement Partnership, founded in 1999 to promote public awareness of the symptoms and signs as part of the NHS Modernisation Agency, is a national of cancer and benefits of early diagnosis by 2001. Whilst initiative to improve experience and outcomes of care for this target was not met, the Department has provided patients with suspected or diagnosed cancer by optimising funding to the voluntary sector to raise public awareness, systems of care delivery. It provides specific funding for and has undertaken research projects, the results of dedicated staff resources and project management support which are under consideration. It is currently planned for clinical teams in cancer networks. All but one of the that a pilot programme of raising public awareness of the cancer networks in our survey told us that Cancer Service symptoms of cancer will be set up in 2005, which will Collaborative Improvement Partnership projects had been include an assessment of the impact of the programme useful in improving patient-centred care. on symptomatic patients and whether they are presenting earlier for diagnosis and treatment. 1.20 The Cancer Action Team (CAT) funded by the
Department of Health has a key role to play in sharing
1.18 Other challenges remain. For example considerable
information and spreading good practice. It runs the effort will be required to meet the waiting times targets for Network Development Programme (NDP), which hosts all cancers by 2005; and further service expansion will be meetings of all 34 cancer networks and issues regular needed if the target for the number of smokers quitting is newsletters. Networks told us that the NDP was the main way in which they learned of, and shared, good practice. The programme is designed to support cancer networks in their development as well as the delivery of the NHS Cancer Plan.
1.21 All network management teams that we visited
thought the CAT were very helpful and supportive, and
were unanimous in their praise for the National Cancer
Director and his team.
THE NHS CANCER PLAN: A PROGRESS REPORT
8 Progress against major targets in the NHS Cancer Plan
Improving Prevention  Reduce smoking among manual groups from 32% in 1998 to  Smoking among manual groups has reduced from 33% in 1998 26% by 2010.
to 31% in 2003. (Note – the method of calculation has changed for smoking prevalence in manual groups).1 Establish comprehensive smoking cessation services in  Stop smoking services were established in al PCTs by 2001. PCTs by 2002.
 800,000 smokers successfully quitting2 at 4-week stage  204,151 4-week quitters reported in 2003-04. between 2003-04 and 2005-06.  £2.5m for research into reduced smoking prevalence.  Funding for a range of projects, including evaluation of ‘stop smoking' initiatives. £2.2m spend to date.
 5-A-Day programme to increase fruit & vegetable  National awareness campaign on-going. 5-A-Day community consumption. Roll-out 2002 onwards. initiatives targeting deprived areas (66 PCTs) being undertaken - to be evaluated late 2005.  National School Fruit Scheme - to make a free piece of fruit  Scheme extended to include vegetables. Nearly 2 mil ion school available to children aged 4-6 each school day. children now participating – a 94.7% take up amongst eligible schools. Rol -out achieved in al English regions.
 Public awareness smoking campaigns.  Large scale media campaigns funded by Department of Health. Evidence suggests increased awareness of key messages.
 Development of programme to promote public awareness of  Funding provided for research into programme to raise public awareness. Five research projects commissioned in 2001. A pilot programme to raise public awareness of cancer symptoms will be set up in 2005.
Improving Screening All women will have two views of the breast taken at every 81 out of 85 breast screening units met target. All will achieve screening by 2003.
target by August 2005.
Routine breast screening to be extended up to age 70 by Al 85 units are expected to extend screening by April 2005. December 2004.
Cervical Screening Liquid based cytology pilots to be reviewed by NICE in 2002. Pilot studies completed. In 2003 NICE recommended national If successful, introduced across the NHS. roll-out, and cervical screening modernisation programme Health authorities to achieve 80% cervical screening coverage Considered an unfair expectation for all PCTs, because of their smaller size. Target dropped.
By 2001 all PCTs to review cervical screening coverage in DH does not monitor this target because of ‘Shifting the Balance deprived and minority ethnic groups. of Power'. However it remains good practice and there is some good activity in some areas. THE NHS CANCER PLAN: A PROGRESS REPORT
 Bowel screening introduced in 2003 if pilot studies  Insufficient evidence by 2003 to take a decision. Roll-out will support this.
commence in April 2006.
 Targeted training initiatives in endoscopy in 2001.  National training initiatives for endoscopy were established from 2001. 3 national and 7 regional training centres began training programmes in 2004.
NHS Prostate Cancer Programme  Prostate cancer programme3 to improve early detection,  Prostate Cancer Risk Management Programme launched in treatment, care and research.
July 2001. Good progress made in all areas.
Improving Cancer Services in the Community  £3m p.a. in partnership with Macmillan Cancer Relief for a  By April 2004, 279 out of 303 PCTs had lead cancer clinicians lead cancer clinician in each PCT.
in post. But questions over continued funding.
 £2m for training in palliative care for district and  Training programmes for palliative care delivered in all community nurses. 34 cancer networks. Funding extended to £2m p.a. for 3 years. 10,000 nurses participated to date.
Cutting Waits for Diagnosis and Treatment  2 week wait for an outpatient appointment after urgent GP  Now 99.2% within 2 weeks. 93.5% of people with suspected referral by Dec 2000.
cancer seen by a specialist within target by 2001.  Max 1 month from urgent GP referral to treatment for  Between 95% and 100% now achieved. (91.5% - 100% leukaemia, testicular and children's cancers by 2001.
 Max 1 month from diagnosis to treatment for breast cancer by  97% of both targets for patients now achieved. 94.2% 2001 and max 2 months from urgent GP referral to treatment by 2002 for 1 month target, and 96.5% by 2003 for  Max 1 month wait from diagnosis to treatment for all cancers  89.9% of patients diagnosed with cancer treated within by end of 2005.
31 days. Target date 31 December 2005.
 Max 2 month wait from urgent GP referral to treatment for all  78% of all urgently referred patients with cancer treated within cancers by end of 2005.
62 days. Target date 31 December 2005.
 By 2004 all cancer patients will have pre-planned and pre-  Draft template issued to NHS in early 2004 to enable data collection to begin. Progress against target will be assessed  Roll-out to cancer networks of Cancer Services Collaborative  Service Improvement Leads in every cancer network and service programme of service improvement by 2003-04.
THE NHS CANCER PLAN: A PROGRESS REPORT
8 Progress against major targets in the NHS Cancer Plan (continued)
Improving Treatment  National Institute for Clinical Excellence (NICE) to commission  4 new reports and 2 updates since 2000. Programme to Improving Outcomes guidance on all cancers by 2003 for be completed in 2005-06. During 2004 cancer networks health authorities (now PCTs) and trusts to implement. developed action plans for implementing guidance setting firm milestones for delivery.
 NICE appraisals of cancer drugs to end the  16 drugs appraised and 11 appraisals in progress. National postcode lottery. Cancer Director in 2004 reported increasing drug use, but unacceptable variations between networks remain. New measures being introduced to address this.
 Care of cancer patients to be reviewed by a specialist  More than 95% of trusts report providing care within teams for lung, breast, upper gastro-intestinal and bowel cancers.
 National Cancer Standards published in 2000. Peer Review  Standards published in 2000; revised and extended in 2004. visits to begin in 2001. All cancer networks reviewed in 2001. Second review began in November 2004 to assess progress.
 National cancer datasets developed by 2002.  Largely complete. Datasets for some rarer cancers will not be completed until 2005.
 The government will set out plans to strengthen cancer  Action plan for cancer registries published in 2001. Cancer registries in 2000.
registration improved and links to cancer networks established.  Health authorities to agree palliative care investment with  Cancer network investment strategies for palliative care in place networks in 2001.
for 3 year period 2003-2006.
 £50 million for hospices and specialist palliative care services  £50m has been allocated to cancer networks.  Supportive care strategy to be developed, including standards  Draft strategy published as cancer standards in 2002. Due to be for supportive and palliative care in 2001.
completed in 2005.
 NICE to develop guidance on supportive care in 2001.
 Guidance published March 2004.
 New training in communication skills.  Advanced communication skills training programmes developed. Pilots successful; roll-out started.
 Cancer Information Advisory Group will identify gaps and  Remit changed to focus on dissemination and delivery. develop guidance on patient information in 2001. Accreditation processes for information providers being developed, and cancer information leaflets are now available centrally for local use.
 Cancer networks to take account of views of patients/carers  Partnership Groups established in 30 out of 34 networks in planning services in 2001.
THE NHS CANCER PLAN: A PROGRESS REPORT
Investing in Staff  By 2006 there will be nearly 1000 extra cancer specialists.  Met ahead of schedule. 975 extra consultants in post by  Increase specialist trainee places by 2008.  No specific target in plan, but 36% increase in training places between 1999 and 2003.  Scheme to increase SHOs in histopathology.  £1.3m invested to fund 3 training centres. An Intensive Training and Assessment Centre for histopathologists from overseas was set up in 2003-04. In 2004-05, 3 new training centres have been set up and 6 additional centres will come on stream in  Training places for radiographers to be increased; attrition  Training places have more than doubled. Average attrition rates reduced significantly between 2001 and 2002 in diagnostics and radiotherapy.
 New skills and new roles for cancer staff.
 New roles introduced for diagnostic and other staff. New skill mix models are being implemented for breast and cervical screening and radiotherapy. Investing in Facilities  New MRI scanners, linear accelerators and other cancer  Over £400m invested in new facilities so far. All plans achieved equipment to be delivered. by end of 2004. By end of 2004 the NHS had received 68 MRI scanners, 177 CT scanners, 83 Linear accelerators and over 700 items of breast screening equipment since April 2000.  Additional funding to support modernisation of  £28m invested to support upgrades and reconfigurations in 23 pathology services.
39 pathology sites.
 National Cancer Facilities Strategy based on an audit by  Audits undertaken. Single facilities strategy document not cancer networks by 2001. produced. New facilities strategy in development incorporating, for example, radiotherapy stocktake and PET-CT framework. Investing in the Future: Research and Genetics  National Cancer Research Institute, including National Cancer  NCRI established 2001, and NCRN fully established in Research Network, to be fully established in 2003.
October 2002.
 Form partnership with Macmillan Cancer Relief on genetic  Pilot work underway. counselling in 2001 to develop new services.
Implementing the NHS Plan  Additional £570m for cancer services by 2003-04.  Preliminary results of current tracking exercise show  Networks to develop service delivery plans, underpinned  Strategic plans produced, but variable quality. By late 2003 by workforce, education and training and facilities strategies a third of networks had a workforce and/or education and training strategy. Improving Outcomes guidance action plans and other initiatives are seeking to address this.
NOTES1 General Household Survey data is now weighted. This roughly increases prevalence by one percentage point.
2 New commitment in Priorities & Planning Framework 2003-063 Published September 2000 in advance of NHS Cancer Plan THE NHS CANCER PLAN: A PROGRESS REPORT
PART TWOThe NHS Cancer Plan is well founded and there is an opportunity now to extend and update the strategy to reinforce partnership working and network structures THE NHS CANCER PLAN: A PROGRESS REPORT
The Plan is well constructed, well from prevention through to terminal care. We consider regarded and provides a good that the coverage of the Plan is impressive; and it sets out, for each of the areas where action is proposed, foundation for further refinements indicators of what should be achieved by specific dates. The Plan also provides the basis for the improvement of The NHS Cancer Plan is broadly cancer services through new equipment, extra and more specialised staff, better access to drugs and a redesigned care pathway, focussed in particular on delays in access.
2.1 In 2002 (after publication of the NHS Cancer
Plan) the World Health Organisation (WHO) published
guidelines setting out good practice for the content and
The NHS Cancer Plan has been a model for implementation of national cancer control programmes. cancer plans in other countries In the WHO's view, such programmes should evaluate 2.4 A number of overseas national or state cancer plans
ways to control cancer and implement those that are the have been published in recent years, some of which most cost-effective and beneficial for the largest part of have been modelled on the NHS Cancer Plan. Inevitably, the population. A national cancer control programme because they start from different baselines, it is not should promote the development of treatment guidelines, straightforward to compare the NHS Cancer Plan with emphasise prevention and early detection, and provide those of other countries. Nonetheless, in key aspects such support to patients with advanced disease. The WHO as coverage and comprehensiveness, use of evidence guidelines, Figure 9 overleaf, are intended to provide
and the setting of explicit goals for the implementation the information needed for the development of feasible, process, the NHS Cancer Plan compares favourably with equitable, sustainable and effective national cancer other national or state plans.5 control programmes, setting out ways to approach cancer control, and how to plan, implement, monitor and evaluate a cancer control programme.
Cancer planning in Scotland and Wales follows broadly similar lines to England 2.2 We commissioned an independent consultant
2.5 In recent years, major steps have been taken in both
– Anthony J Harrison, Senior Fellow, King's Fund Scotland and Wales to improve the provision of cancer – to compare the NHS Cancer Plan against the WHO services. Scotland has its own national Cancer Plan, guidelines, looking in particular at whether the Plan is published in 2001, and has three cancer networks which comprehensive, covering all the areas identified by the receive ring-fenced funding (Figure 10 on page 21).
WHO; and whether the NHS Cancer Plan is consistent with the guidelines in terms of devising, implementing 2.6 In Wales (Figure 11 on page 21) three cancer
and monitoring a national cancer control programme.
networks were established in 2002. A Welsh Strategic Service Development Plan was published at the end of 2.3 He concluded that the NHS Cancer Plan broadly
2002 by the Cancer Services Co-ordinating group (CSCG). covers all of the main elements which the WHO considers This Plan was further developed by Cancer Networks in appropriate to an effective cancer control programme, their Service Development Plans.
"Cancer control policies in eleven OECD countries", JA Bennett et al, University of Ottawa, 1999. This covers Australia, Belgium, France, Germany, Ireland, Italy, Japan, New Zealand, Sweden, US and UK. Anthony J Harrison also considered the following in greater depth: France: "Cancer: Une mobilisation nationale tous ensemble"; New Zealand: "Towards a cancer control strategy for New Zealand"; American States: "New Jersey Comprehensive Cancer Control Plan". THE NHS CANCER PLAN: A PROGRESS REPORT
9 Priority actions for National Cancer Control Programmes
Guidelines for all countries Additional guidelines for countries with a high level of resources 1 Develop a national cancer control programme to ensure a Full, nationwide implementation of control programme effective, efficient and equitable use of existing resources.
evidence-based strategies guaranteeing effectiveness, efficiency and accessibility.
2 Establish a core surveillance mechanism to monitor and evaluate outcomes as well as processes.
b Implement a comprehensive surveillance system, tracking all components 3 Develop education and continuous training for health and results.
c Provide support for less affluent countries. 1 Implement integrated health promotion and a Strengthen comprehensive evidence- based health promotion and prevention 2 Control tobacco use, and address alcohol use, unhealthy programmes and ensure nationwide diet, physical activity and sexual and reproductive factors.
implementation in collaboration with other sectors.
3 Promote policy to minimize occupational related cancers and known environmental carcinogens.
b Establish routine monitoring of ultraviolet radiation levels if the risk of skin cancer 4 Promote avoidance of unnecessary exposure to sunlight in high risk populations. 1 Promote early diagnosis through awareness of symptoms a Use comprehensive nationwide promotion of prevalent cancers.
strategies for early diagnosis of all highly prevalent detectable tumours. 2 Ensure proper diagnostic and treatment services are available for the detected cases.
3 Provide education and continuous training to target population and healthcare workers. 1 Implement screening for cancers of the breast and cervix a Effective and efficient national screening for cervical cancer (cytology) for women where incidence justifies such action and the necessary over 30 and breast cancer screening resources are available. (mammography) of women over 50. Curative therapy 1 Ensure accessibility of effective diagnostic and a Reinforce the network of comprehensive treatment services.
cancer treatment centres that are active for clinical training and research, and 2 Promote national minimum essential standards for disease give special support to the ones acting as staging and treatment.
national and international reference centres.
3 Establish management guidelines for treatment services, essential drugs list, and continuous training.
4 Avoid performing curative therapy when cancer is incurable and offer palliative care instead. Pain relief and 1 Implement comprehensive palliative care that provides a Ensure that national pain relief and pain relief, other symptom control, and psychosocial and palliative care guidelines are adopted spiritual support.
by all levels of care; and nationwide there is high coverage of patients through 2 Promote national minimum standards for management of a wide variety of options, including pain and palliative care.
home-based care.
3 Ensure availability and accessibility of opioids, especially oral morphine.
4 Provide education and training for carers and public.
Source: WHO: "National Cancer Control Programmes: Policies and managerial guidelines." 2002 THE NHS CANCER PLAN: A PROGRESS REPORT
10 Cancer planning in Scotland
11 Cancer planning in Wales
In May 2001 scenarios published by the Scottish Executive After Calman Hine, the Cameron Report (1996) reviewed Health Department set out forecast cancer incidence and cancer services in Wales, concluding that multi-disciplinary mortality, providing a forward look to enable the NHS in team working was essential, with service development based Scotland to plan future cancer services. These scenarios are on implementation of standards for cancer services. The currently being updated.
CSCG was established to implement the recommendations of the Cameron Report. The CSCG advises the Welsh Assembly In July 2001 the Cancer Plan – ‘Cancer in Scotland: action Government on the development of cancer policy.
for change' – was published, expected to run for at least 10 years, and covering prevention, screening, access, Cancer is a stated top priority for the Welsh Assembly improving treatment and care, palliative care, resources and Government and work is in hand to develop a national policy research and development. for tackling this disease. Targets for cancer services are published in the annual Welsh Assembly Government's Services The Plan established three regional cancer network areas, in & Financial Framework planning guidance. There are the north, west and south east of Scotland. Each was given 12 acute trusts in Wales, with (since April 2003) 22 local flexibility as regards structure, and additional ring-fenced health boards who commission health services. Health investment totalling £25 million a year until at least 2005-6 Commission Wales commissions specialised cancer services was provided for all three networks to use to improve access, at a national level. The Assembly Government's Health and availability and quality of cancer services. The regional Social Care Department's three regional offices performance networks' structures, including governance and accountability manage the NHS against the SaFF targets. To assist efforts issues and how they work with the NHS Scotland, the voluntary to improve cancer services additional funding in support of sector and patients, is currently being restructured to keep pace cancer services has been made available at various times since with organisational developments, and remain at the forefront 1999 by the Welsh Assembly Government.
of cancer services planning and delivery. From 1997 minimum standards were set for specific cancer Each cancer network is required to produce an annual plan types and revised versions of these standards are to be and 6-monthly feedback reports based on a Scottish Executive published in 2005. Three cancer networks, funded by the Health Department template. The Health Department produces Welsh Assembly Government, were set up in 2002. These an annual report on progress, and has recently published a networks are seen by the Assembly Government as the driving three-year review of progress against all actions set out in force in implementing the standards and improving the quality the Cancer Plan. This report concluded that there have been of care for patients with cancer.
significant improvements to date, though more remains to be done. The Health Department is likely to review progress again In December 2002 a Welsh Strategic Service Development in 2 years time.
Plan (SSDP) looked at the requirements for cancer services over 5 years (10 for radiotherapy). The three cancer networks Source: Scottish Executive Health Department have now further developed the all Wales SSDP with their own detailed network five-year SSDP. Implementing the new 2005 Cancer Standards through the SDPs and meeting the SaFF Cancer networks have very positive views of targets will lead to improved patient outcomes.
the NHS Cancer Plan Source: Welsh Assembly Government, Cancer Services Co-ordinating Group, Wales 2.7 Cancer leads or managers from each cancer network
management team, primary care trust and strategic health
authority we spoke to (Appendix 2), were very positive
2.8 Cancer network management teams also felt that
about the NHS Cancer Plan. They described it as a useful the NHS Cancer Plan had been a welcome and useful tool which outlined strategic direction across the patient document, though there was some concern that the focus pathway. Other positive comments included that it was on waiting times had made it difficult to sell the Plan to evidence based, provided real targets and milestones, clinicians. Some cancer network management teams felt and had succeeded in driving improvements in cancer that a review of the NHS Cancer Plan would be timely, services for patients. Limited criticisms raised were mainly building on the excellent work that had already been on the Plan being focussed on secondary care at some achieved, and focusing on the future of cancer services expense of primary care and prevention. The Department in England, though these comments were made prior to told us that the focus at the time of publication of the the 2004 progress report on the NHS Cancer Plan by the NHS Cancer Plan was addressing secondary care and Department of Health.
that further research had been needed to establish what was needed in primary care. This has been addressed and the Department is now putting greater focus on primary care. A White Paper on Public Health which includes prevention of cancer has recently been published.
THE NHS CANCER PLAN: A PROGRESS REPORT
There is scope to extend and update the regimes on survival chances, the costs of achieving these strategy to tackle cancer in England reductions and the alternative uses of the resources involved. It would also include, given the objectives of 2.9 Since the NHS Cancer Plan was published in
the NHS Cancer Plan, estimating the most cost-effective 2000 things have moved on within the NHS. There are ways of reducing disparities in access and incidence and new organisational structures within the NHS and new improving patient experience.
developments within cancer. In the light of these and planned and future changes there is scope to extend and iii) Costing the objectives of the Plan
update the cancer strategy, and ensure that it is available and published in a useful and unified way: 2.12 Although the Plan makes specific commitments on
additional funding for cancer (£570 million over three
i) Estimates of the future cancer burden
years), the costs of individual components of the Plan are not all made explicit. While early reports on specific 2.10 The WHO guidelines state that "as an initial step, a
cancers published by the Department were supported national cancer control programme requires an analysis by specific funding for restructuring cancer services to of the cancer burden and risk factors….as well as a improve outcomes6, the Plan itself does not provide a capacity assessment". Though some aspects are covered financial envelope within which strategic decisions could in other guidance, such as that produced by NICE, the be made. However the Department told us that, in line Plan contains no estimates of the numbers expected to be with devolving responsibilities to the front line, NHS diagnosed with cancer over the medium to long term (as organisations have maximum flexibility to use allocated has been done in Scotland), nor of changes in the relevant resources to meet local circumstances and priorities risk factors. Such estimates have three key functions: within the context of national frameworks.
at a tactical level they are needed as the basis for estimating the scale of the capacity required to treat iv) Updating the cancer strategy
the estimated numbers requiring treatment, and of 2.13 There are no plans in place to formally revise or
the care facilities for those for whom treatment is update the NHS Cancer Plan itself, though the Department (including organisations such as the National Institute for Clinical Excellence) has published, and will continue to at a strategic level they are a key element in determining the appropriate balance between publish, guidance to take the Plan forward. This includes prevention and treatment; and the Department's four-year review in October 2004 which aims to show how cancer fits into the evolving NHS, and they provide the baseline for determining what the a rolling publication and revision programme of clinical impact of the NHS Cancer Plan is expected to be, guidelines (by NICE).
and therefore its expected effectiveness. 2.14 The NHS has undergone structural and other major
ii) Efficiency of NHS cancer services
changes since the publication of the NHS Cancer Plan, 2.11 The WHO guidelines comment that "an efficient
including the creation of strategic health authorities in programme is one that achieves the best possible results 2002. Current and future changes include the creation of using the available resources". Although this is complex, NHS foundation trusts and independent sector treatment and has not been done comprehensively in any country, centres. These changes mean that cancer networks are this requires the identification of alternative spending increasingly operating in a new environment. However, plans – different mixes of policies and resources and the Department currently has no plans to bring together different spending levels - and measures of what they will and publish in a unified form a revised and updated cancer achieve. At the strategic level, for example, this involves strategy, which could also include clarification of the role estimating the impact of preventive measures on the of network management teams, and broad descriptions of numbers developing cancer and of different treatment key players' roles within the wider cancer network.
Improving Outcomes Guidance on breast cancer (1996), colorectal cancer (1997), and lung cancer (1998). Later IOG reports set out costings for implementation but had no ear-marked funding. IOG implementation was considered as part of the spending review, and appropriate funding included in NHS allocations but not separately identified.
THE NHS CANCER PLAN: A PROGRESS REPORT
Cooperation between constituent 2.18 From our discussions with cancer network
organisations is key to the management teams and others, it is apparent that relationships with PCTs were particularly challenging, effectiveness of cancer networks and though good relationships had been built up in many cases. the NHS Cancer Plan, but in many This is partly explained by the fact that most PCTs were in general set up after cancer networks had formed, PCTs cases needs further development thus finding their own feet at a time when cancer networks had only just begun to establish themselves. Department of 2.15 Most cancer patients require care from many parts
Health guidance8 issued in 2002 recommended that cancer of the NHS – primary, secondary and tertiary care as networks should develop formal agreements between well as the voluntary sector. As noted by the All Party constituent organisations about their authority and how they Parliamentary Group on Cancer7, cancer networks have work together, but there has been little progress made in shown that they are capable of delivering change, by implementing this recommendation.
working across the traditional primary – secondary care divide and across different professional disciplines.
Involvement of acute and primary care trusts in cancer
networks can be a very positive factor but does not

2.16 Cancer networks are a partnership of constituent
organisations, at the centre of which is the network management team. They were set up to ensure integrated 2.19 Network management teams told us that senior
care across geographical localities. They were new managers in most acute trusts were actively or very actively to the NHS, but since their creation there have been involved in the cancer network. There was less participation various structural changes to the NHS, including new from PCTs, with half of all network management teams organisations and new roles for strategic health authorities reporting that some or all the PCTs had little or no senior and primary care trusts. These changes require strong and management involvement with the network.
committed partnership working among the networks' constituent organisations, and appropriate resourcing 2.20 There was a strong correlation between networks
of, and effective planning and monitoring by, network with effective relationships and those in which constituent management teams. organisations were actively involved. For example, networks reported that where involvement is high, relationships 2.17 Our survey asked network management teams to
helped to push forward the NHS Cancer Plan, with assess the effectiveness of relationships between the effective joint working at a strategic and clinical level. network and its constituent organisations. The results However, where networks reported low involvement, they are shown in Figure 12. With the exception of local
commented that a lack of enthusiasm by trusts and rivalries authorities, relationships were generally regarded as at between trusts had hindered progress, particularly in least adequate.
planning and adopting network wide approaches to service reconfiguration and in addressing specific problems such as a shortage of radiologists.
12 Network management teams' assessment of the effectiveness of relationships with constituent organisations
Constituent Organisation Very Good Voluntary Sector Local Authorities Source: NAO survey "Meeting national targets, setting local priorities: the future of cancer services in England". All-Party Parliamentary Group on Cancer, 2004.
‘Shifting the Balance of Power: Next Steps', Department of Health, 2002. THE NHS CANCER PLAN: A PROGRESS REPORT
Some strategic health authorities are proactive and
2.24 An independent evaluation in May 2004 by Professor
support cancer networks, but not all
Alison Richardson from the Florence Nightingale School of 2.21 In January 2003, the Chief Executives of SHAs and
Nursing and Midwifery, and John Sitzia and Phil Cotterell the National Cancer Director agreed that further work was from the Patient and Public Involvement Research Unit at needed to clarify the accountabilities of cancer networks, Worthing and Southlands Hospitals NHS Trust, concluded their role in clinical governance, and help define what that 30 of the 34 cancer networks had established a makes a cancer network. They acknowledged also that partnership group and that the range and depth of activities there needs to be clarity within and across SHAs about accomplished by them was impressive, both in terms how networks are integrated into whole systems. The of projects completed and their visibility in the cancer National Cancer Director and SHA Chief Executives are network. Cancer networks confirmed, in our survey, that currently reviewing the functioning of cancer networks in the majority (16 out of 27 networks who responded) of the light of changes within the NHS.
partnership groups had been effective or very effective. However, the May 2004 evaluation found that over half of 2.22 SHAs are responsible for ensuring cancer networks
groups expressed concerns over future funding, and that are in place and operating effectively, and for supporting around half of the groups had no representation from black their development. Whilst most SHAs that we visited and ethnic minority ethnic communities.
acknowledged that providing support to facilitate the development of cancer networks was a key role, it was Network boards can have problems settling clear that some adopt a much more hands-on approach their purpose and getting representation from than others. At one end of the spectrum some SHAs took participant bodies very much a strategic overview; at the other they were very proactive, for example publishing a detailed strategic 2.25 Cancer networks are headed by a network board.
framework for cancer services development in their Key responsibilities of the board include strategic locality. Summary local development plans produced planning, clinical governance development, strategic by SHAs in 2003 varied in the extent to which they monitoring, and ensuring support strategies are in place addressed cancer issues, with some making no reference for workforce and facilities planning. Discussions with the to cancer network involvement. The NAO believes good Cancer Action Team indicated that by 2004 a considerable practice by SHAs in supporting cancer networks includes number of cancer network boards were still struggling establishing accountability agreements with networks to with issues such as clarity of purpose, authority and ensure a common understanding of strategic direction consistent senior membership 2.26 The NHS Cancer Plan notes that close involvement
Good initial progress has been made in securing
of Chief Executives of provider trusts and PCTs in network patient involvement, and networks now need to build
boards is essential. However, our survey of cancer networks on this and develop partnership groups into fully
found that complete representation of acute trusts applied in representative, effective network participants
three quarters of the networks which provided information (18 out of 23 respondents). For the other five networks, 2.23 As noted by the National Institute for Clinical
between half and three quarters of trusts were represented Excellence in their guidance on supportive and palliative on the network board. Our survey showed that about half care, patient involvement in decisions about health care of the acute trust representatives were at Chief Executive can bring about changes in the provision of services. level. For PCTs, 11 of the 23 network boards had full The NHS Cancer Plan confirmed that NHS decision representation; and a quarter of the PCTs represented makers at all levels should take account of the views were represented at below their board level.
and preferences of patients, and included a commitment for 2001 that cancer networks should take account of the views of patients/carers in planning services. Consequently a 3-year Cancer Partnership Project, jointly funded by the Department and Macmillan Cancer Relief aimed to establish partnership groups (patients, carers and professionals) on each cancer network.
THE NHS CANCER PLAN: A PROGRESS REPORT
Networks face challenges in their staffing being kept afloat by keeping staffing vacancies open, one was seeking funding from the voluntary sector for a lead pharmacist post which the PCTs would not finance, and Not all network management teams are fully staffed
others were required to pay for accommodation without 2.27 Each network should have an effective management
this being adequately funded.
team, and network-wide working groups to plan services and map patient pathways. As a minimum, the network Improvements are possible in the ways in team should include a lead clinician, lead nurse, lead which cancer networks plan, commission manager and a service improvement lead. Increasingly cancer services and monitor performance cancer networks also have leads for pharmacy, information, audit, palliative care, user involvement and Not all cancer networks are planning effectively
public health. We regard this as good practice. 2.30 The NHS Cancer Plan requires cancer network
constituent organisations to work together to develop
2.28 Our survey returns revealed that these complements
strategic service delivery plans to develop all aspects were not always complete. At the time of our survey all of cancer services – prevention, screening, diagnosis, networks had a lead clinician in place, but five networks treatment, supportive care and specialist palliative care. had no lead nurse. One network had no lead manager The target set was for each network to draw up a three- and one had no service improvement lead. With other year service delivery plan in line with the NHS Cancer positions in the network management team, whilst it is Plan and other cancer guidance by 2001. By the same left to the networks themselves to decide upon whether or date, all cancer networks were expected to draw up not such posts are required, the staffing of these positions, workforce, and education & training strategies to underpin once created, is also a challenge (Figure 13). Networks
the cancer network service delivery plan. told us that financial constraints were the main reason why vacancies were not filled.
2.31 In December 2001 NHS regional offices (as they
then were) provided the National Cancer Director with
Cancer network funding and resourcing remains
a challenge

an appraisal of service delivery plans that were to be produced by their cancer networks by 31 October 2001. 2.29 From 2001, cancer network management teams
Inevitably, with networks and PCTs in the early stages of have received central funding from the Department of development, the appraisal showed that not all networks Health of £40,000 a year for initial set-up/support costs, had produced fully comprehensive service delivery plans. irrespective of the size of the network or the community Regional offices had varied opinions on the quality of served. Any other resources were expected to be obtained the service delivery plans. Typical comments stated that from the network's PCTs responsible for commissioning some plans were comprehensive and well-focussed, well- cancer services. Six of the ten network management teams structured with a sound appreciation of problems within that we spoke to told us that they thought the level of the health community, whilst other plans lacked strategic resources they had was acceptable (four) or good (two). grasp, contained a great many omissions and outstanding Four teams told us the level of resources was poor. One questions, and varied in content and structure. network management team told us that the network was 13 Created positions within cancer networks are not all filled
% Created and Not Staffed User Liaison Lead Public Health Lead Palliative Care Lead Source: NAO Survey THE NHS CANCER PLAN: A PROGRESS REPORT
2.32 Of the ten cancer networks that we spoke to in
2004, six had a three-year service delivery plan drawn
14 Example of collective commissioning
up in 2001 or 2002 and which was still a live planning document. Of these three had been or were currently the The North Derbyshire, South Yorkshire and Bassetlaw PCT subject of review. A seventh cancer network had drawn Consortium (NORCOM) provides an example of collective up an interim service delivery plan in 2001 and produced commissioning. NORCOM is a formal joint sub-committee of the 13 PCTs in the cancer network, that allows the PCTs to a revised document in 2004. Three of the ten cancer make collective decisions on the planning, procurement and networks told us they had no current planning document review of cancer services in their area.
to plan for and monitor the implementation of the NHS Benefits of NORCOM are that it has enabled the PCTs to Cancer Plan.
prioritise the development of cancer services across the network, including addressing variations in prescribing 2.33 Although at a national level workforce development
practices within the community, ensuring NICE guidance was seen as a priority in the NHS Cancer Plan, only is implemented, and planning tertiary services in the area 12 of the 34 cancer networks had developed a workforce effectively. NORCOM has also facilitated the making of difficult decisions on a collective basis, for example on the strategy by 2003, and only 13 of the 34 had developed an reconfiguration of cancer services.
education and training strategy. A network of workforce development cancer leads is now in place to assist cancer networks with workforce planning and related education 2.36 The extent to which cancer network management
and training. In addition, Improving Outcomes guidance teams provide input to the local delivery planning process action plans are now starting to address workforce issues.
varies. Some network management teams (six of the ten we spoke to) are closely involved in providing information to Most commissioning of cancer services is joined up
enable PCTs to prepare local development plans, resulting but there are nevertheless problems
in well-defined plans based on a firm assessment of current service provision. But some have limited input into the 2.34 PCTs, as budget holders, are responsible for
process (three of the ten) and in one case virtually no input.
commissioning cancer services. They are expected to use cancer network plans and advice to contract for cancer 2.37 Many individuals we spoke to in PCTs told us that
services across the network.
they were finding the planning process for commissioning cancer services difficult. In particular, the variable quality, 2.35 Generally, the cancer networks that we visited had
completeness, and consistency of local data led to adopted (or were planning to adopt) a network-wide difficulties at the planning stage. This was attributed partly to approach to commissioning cancer services, with the a lack of resources and structure devoted to data collection designation of a lead commissioning PCT, allowing all and analysis locally. SHAs are responsible for amalgamating PCTs within a network to agree on funding a common PCT local plans. Individual comments from SHAs that cancer strategy across the network. In practice, however, we spoke to included that the quality of PCT planning there are variations and the Cancer Action Team noted documents varied considerably, that the local planning that some PCTs were producing their commissioning process was an ongoing learning process, and that the plans in isolation from other PCTs in the network, and process was disjointed and unsatisfactory.
continuing to contract cancer services in the traditional way with their local acute trust. The All Party Parliamentary Key performance targets are generally monitored at
Group on Cancer noted that in some parts of the country all levels within the cancer network but monitoring of
joint commissioning is not sufficiently in place and other targets and commitments is variable
they recommended that the PCTs should be required to collaborate in commissioning cancer services. The 2.38 Cancer networks have an important role in monitoring
inherent risk in individual commissioning by PCTs is that progress against the Plan. We found variation in the extent the priorities identified by the network are not addressed, to which this was being done, and confusion as to whose to the detriment of patient outcomes.
responsibility within the network it was to do this.
THE NHS CANCER PLAN: A PROGRESS REPORT
2.39 Cancer network management teams monitored
2.43 In April 2002 the Secretary of State for Health
progress against the Plan through reports to their network announced the establishment of NHS foundation Board, but there was inconsistency in how frequently trusts. Twenty NHS foundation trusts were approved by this was done. We found that that four networks out 1 July 2004. Whilst they are bound by a duty of of 34 monitored progress at least monthly, around half partnership under the Health and Social Care Act 2003 monitored quarterly, seven monitored less frequently than to cooperate with other NHS bodies, it is unclear what this once a quarter, and five did not monitor progress at all.
means in practice. On the positive side the core freedoms of NHS foundation trusts will give them greater flexibility 2.40 Most network management teams we visited
and speed in developing services, and this could well be monitored key targets on a regular basis (other than that on of benefit to patients. smoking cessation, which is largely left to PCTs), and there is regular reporting to the network board on other issues, 2.44 However, PCTs and cancer network management
usually annually or on an ad hoc basis. For some issues, teams that we interviewed expressed concerns as to the such as patient communication and communication skills extent to which NHS foundation trusts will continue to of health professionals, networks generally had no formal cooperate with the rest of the cancer network, and the process for monitoring or reviewing progress. These are extent to which they remain accountable to other network now starting to be addressed.
members. A workshop of key stakeholders, convened by the Cancer Action Team in January 2004, identified 2.41 Most SHAs that we visited monitored key targets
NHS foundation trusts as one of the high risk areas in in the NHS Cancer Plan on a monthly basis, though terms of implementing the NHS Cancer Plan, as they two regarded it as the responsibility of the network may limit effective partnership working and collective management team to do so. All of the PCTs that we visited decision making, and the effective implementation of – as part of their remit to hold provider trusts to account NICE Improving Outcomes Guidance. On the other hand for the delivery of the services they commissioned - were the Department has stressed that there is no evidence monitoring key targets on a regular basis.
that NHS foundation trusts are having a destabilising effect on cancer services. They also pointed to several NHS foundation trusts that have publicly affirmed their Policy and structural changes commitment to cancer networks.
in the NHS pose challenges for 2.45 Similar concerns may apply to other developments
the implementation of the Plan, such as the introduction of independent sector treatment particularly in terms of cooperation centres, although the Department has confirmed that there between constituent network is a clear national understanding that independent sector treatment centres should be active participants in cancer networks if they undertake cancer care.
2.42 Since the NHS Cancer Plan was published in
September 2000 the NHS has seen a number of structural
changes, including the abolition of health authorities
and the establishment of SHAs. There are further policy
and structural changes that are already known about
and which will take place over the next few years. Some
of these will provide a significant challenge to cancer
networks (and the wider NHS) and the way in which
they operate. For example, giving patients more choice
about where they receive treatment and care, and the
establishment of NHS foundation trusts, are likely to
provide challenges for at least some cancer networks.
THE NHS CANCER PLAN: A PROGRESS REPORT
APPENDIX 1Progress against the targets and commitments in the NHS Cancer Plan Improving Prevention Reduce smoking among manual groups from 32% in Smoking among manual groups has reduced from 33% in 1998 to 1998 to 26% by 2010. 31% in 2003 (Note - the method of calculation has changed for smoking prevalence in manual groups).1 Establish comprehensive smoking cessation services in Stop smoking services were established in all PCTs by 2001.
PCTs by 2002.
Set local targets to reduce smoking in the 20 health £50k allocated to the 20 most deprived HAs for projects (with agreed local authorities with highest rates.
targets) to help smokers from manual groups to quit.
800,000 smokers successfully quitting2 at 4-week stage 204,151 quitters reported in 2003-04.
between 2003-04 and 2005-06. Establish local alliances for action on smoking.
42 alliances established across England. £2.5m for research into reduced smoking prevalence.
Funding for a range of projects, including evaluation of ‘stop smoking' initiatives. £2.2m spend to date.
Pilots in prisons and hospitals to reduce smoking Pilot projects in prisons and hospitals by 2001. Also in the army, factories prevalence in 2001.
and working men's clubs. Good practice guides for each setting produced. Diet and Nutrition 5-A-Day programme to increase fruit and vegetable National awareness campaign on-going. 5-A-Day community initiatives consumption. Roll-out 2002. targeting deprived areas (66 PCTs) being undertaken - to be evaluated in late 2005. ‘Choosing health' commitment to fund community food initiatives in more PCTs from 2006 following and building on lessons learned from the 5-A-Day evaluation.
Raising awareness of the 5-A-Day message.
Awareness increased from 52% in 2002 to 59% in 2003. Consumption of fresh fruit rose by 5.8% between 2001-02 and 2002-03. Over 450 organisations have been licensed to use the 5-A-Day logo. ‘Choosing Health' commitment to extend the criteria for using the 5-A-Day logo to processed foods and foods targeted at children (mid 2005).
National School Fruit Scheme - to make a free piece of Scheme extended to include vegetables. Nearly 2 million school children are fruit available to children aged 4 - 6 each school day.
now participating in the scheme - a 94.7% take up amongst eligible schools. National roll-out completed November 2004. ‘Choosing Health' commitment to consider extending schemes to all LEA maintained nurseries.
THE NHS CANCER PLAN: A PROGRESS REPORT
Improving Prevention continued.
Public awareness smoking campaigns.
Large scale media campaigns funded by Department of Health. Evidence suggests increased awareness of key messages and campaigns now the single biggest reason for quit attempts.
Development of programme to promote public Funding provided for research into programmes to raise public awareness. awareness of cancer in 2001. Five research projects commissioned in 2001. A pilot programme to raise public awareness of cancer symptoms will be set up in 2005.
Assessment of research evidence related to approaches Application of research findings under consideration. to raise awareness.
Levels of public awareness and understanding will The pilot programme to raise public awareness of cancer symptoms will be assessed.
include assessment of the programme's impact.
Improving Screening All women will have two views of the breast taken at 81 out of 85 breast screening units met target. All will achieve target by every screening by 2003.
Routine breast screening to be extended up to age All 85 units are expected to extend screening by April 2005. of 70 by Dec 2004.
Introduce new 4-tier working for breast screening. Major on-going progress. Posts established in all four tiers, with 53 Asst. Practitioners and 158 Advanced Practitioners in post at March 2003.
Cervical Screening Liquid based cytology pilots to be reviewed by NICE in Pilot studies completed. In 2003 NICE recommended national roll-out, and 2002. If successful, introduced across the NHS.
cervical screening modernisation programme announced.
A 4- tier skill mix model for cervical screening staff is 30 Advanced Practitioners currently in post. Problems identified are under development.
being addressed.
Health authorities to achieve 80% cervical screening Considered an unrealistic expectation for all PCTs, because of their smaller coverage by 2002.
size. Target dropped. By 2001 all PCTs to review cervical screening DH does not monitor this target because of Shifting the Balance of Power. coverage in deprived and minority ethnic groups. However, it remains good practice and there is some good activity in some areas.
THE NHS CANCER PLAN: A PROGRESS REPORT
Improving Screening continued.
Bowel Cancer Screening Bowel screening introduced in 2003 if pilot study Insufficient evidence by 2003 to take a decision. Roll-out will commence supports this.
Research is continuing to evaluate approaches to Pilots will commence in 2005, with further expansion in 2006. Major trial will report in 2007. Targeted training initiatives in endoscopy in 2001. National training initiatives for endoscopy were established from 2001. 3 national and 7 regional training centres began training programmes in 2004.
NHS Prostate Cancer Programme Prostate cancer programme3 to improve early Prostate Cancer Risk Management programme launched in July 2001. detection, treatment, care and research. Risk Good progress in all areas.
management programme to be launched in 2001.
£4.2 million on prostate cancer research.
Funding provided.
Evidence to support a screening programme will be On-going review. kept under review.
Understanding Screening New national information sources to be developed.
New information leaflets introduced in Oct 2001, translated into 18 languages, and sent out with all screening invitations. Good practice guidance and materials for women with Guidance, leaflets and picture books developed with women with learning disabilities have been published.
Improving Cancer Services in the Community £3m p.a. in partnership with Macmillan Cancer Relief By April 2004, 279 out of 303 PCTs had lead cancer clinicians in post. for a lead cancer clinician in each PCT.
But questions over continued funding.
Development of primary care cancer datasets in 2003.
Dataset developed and piloted in 2004. £2m for training in palliative care for district and Training programmes for palliative care delivered in all 34 cancer networks. community nurses. Funding increased to £2m p.a. for three years. 10,000 nurses participated to date.
A central role for primary care in cancer networks.
All 34 cancer networks have PCT representation. Most network boards are chaired by a PCT Chief Exec.
DH will develop good practice guidelines in out of Superceded by NICE guidance on supportive and palliative care. Tools are hours palliative care. being implemented in each cancer network to support out of hours care.
THE NHS CANCER PLAN: A PROGRESS REPORT
Cutting Waits for Diagnosis and Treatment 2 week wait for an outpatient appointment after urgent Now 99.2% of people with suspected cancer seen by a specialist within GP referral by Dec 2000. two weeks. 93.5% of people with suspected cancer seen by a specialist within target by 2001.
Max 1 month from urgent GP referral to treatment for Between 95% and 100% now achieved. (91.5% - 100% by 2002).
leukaemia, testicular and children's cancers by 2001.
Max 1 month from diagnosis to treatment for breast 97% of both targets for patients achieved. 94.2% by 2002 for 1 month cancer by 2001, and max 2 months from urgent GP target, and 96.5% by 2003 for 2 month target.
referral to treatment by 2002.
Max 1 month wait from diagnosis to treatment for all 89.9% of patients diagnosed with cancer treated within 31 days by cancers by end of 2005.
June 2004. Target date 31 December 2005.
Max 2 month wait from urgent GP referral to treatment 78% of all urgently referred patients with cancer treated within 62 days by for all cancers by end of 2005.
June 2004. Target date 31 December 2005.
By 2004 all cancer patients will have pre-planned and Draft template issued to NHS in early 2004 to enable data col ection to begin. pre-booked care.
Progress against target wil be assessed by 2005.
Roll-out to cancer networks of Cancer Services Service Improvement Leads in every cancer network, and service Collaborative programme of service improvement Improving Treatment NICE to commission Improving Outcomes guidance on 4 new reports and 2 updates since 2000. Programme to be completed all cancers by 2003 for health authorities (now PCTs) during 2005-06. During 2004 cancer networks developed action plans for to implement.
implementing guidance set ing firm milestones for delivery.
NICE appraisals of cancer drugs to end the 16 cancer drugs appraised and 11 appraisals in progress. National Cancer postcode lottery.
Director in 2004 reported increasing drug use, but unacceptable variations between networks remain. New measures being introduced to address this. Care of cancer patients to be reviewed by a specialist More than 95% of trusts report providing care within teams for lung, breast upper GI and bowel cancers.
National Cancer Standards published in Autumn 2000. Standards published in 2000; revised and extended in 2004. Al cancer Peer review visits to begin in 2001.
networks reviewed in 2001. Second review began in November 2004 to assess progress. National cancer datasets developed by 2002. Largely complete. Datasets for some rarer cancers wil not be completed until 2005.
Local health communities to provide sufficient support Some progress made on certain cancers (lung, head and neck, colorectal), such that complete and accurate cancer data can but complete data not yet available.
be collected.
The government will set out plans to strengthen cancer Action Plan for cancer registries published in 2001. Cancer registration registries in 2000.
improved and links to cancer networks established.
THE NHS CANCER PLAN: A PROGRESS REPORT
Health authorities to agree palliative care investment Cancer network investment strategies for palliative care in place for 3 year with networks in 2001.
period 2003-2006.
£50 million for hospices and specialist palliative care £50m was allocated in 2003-4, with £38.5m being spent to date. services by 2004. Supportive care strategy to be developed, including Draft strategy published as cancer standards in 2002. Due to be completed standards for supportive and palliative care in 2001.
NICE to develop guidance on supportive care in 2001. Guidance published March 2004. Cancer networks are developing action plans for implementation of NICE guidance.
New training in communication skills.
Advanced communication skills training programmes developed. Pilots successful; roll-out started. Cancer Information Advisory Group will identify gaps Remit changed to focus on dissemination and delivery. Accreditation and develop guidance on patient information in 2001. processes for information providers being developed, and cancer information leaflets are now available centrally for local use. Trusts and networks to make high quality, culturally Included as a recommendation in the NICE guidance on supportive and sensitive information available to cancer patients. palliative care. Patchy progress to date. Networks have completed action plans to implement the NICE guidance. DH to commission development of audit tools to NICE guidance on supportive and palliative care recommends that networks measure patient care experience. should ensure audits of patients' experience are undertaken. NHS R&D has commissioned an audit tool focusing initially on prostate cancer. New internet resources for patients. DH provided £440k for development of prostate and breast cancer internet sites.
Cancer library to be launched in October 2000.
Now due to be launched 2005.
Cancer networks to take account of views of patients/ Partnership Groups established in 30 out of 34 networks by 2004. carers in planning services by 2001.
New Opportunities Funding for palliative care in Community Palliative Care programme is funding 55 projects between 2003 deprived communities. and 2007. The Living with Cancer Programme, 2001-2005, funds projects for disadvantaged groups, including black and minority ethnic groups.
DH to agree with the voluntary sector the core elements Included in NICE supportive and palliative care guidance. Aimed at ensuring of specialist palliative care to be available to patients services are planned, commissioned, organised and provided to the highest possible quality across the NHS and voluntary sectors. THE NHS CANCER PLAN: A PROGRESS REPORT
Investing in Staff By 2006 there will be nearly 1000 extra Met ahead of schedule. 975 extra consultants in post by June 2004. cancer specialists.
National Cancer Director to set long term targets for National Cancer Director works closely with the Workforce Review Team numbers of cancer specialists by 2001. to project future workforce requirements for cancer, though no specific long term targets have been set.
Increase specialist trainee places by 2008. No specific target in Plan but 36% increase in training places between 1999 and 2003. Scheme to increase SHOs in histopathology. £1.3m invested to fund 3 training centres. An Intensive Training and Assessment Centre for histopathologists from overseas was set up in 2003-04. In 2004-05 3 new training centres have been set up and 6 additional centres will come on stream in 2005-06. More cancer nurses.
The number of cancer nurses has increased, but figures are not held central y. Training places for radiographers to be increased; Training places have been more than doubled. Average attrition attrition rates reduced. rates reduced significantly between 2001 and 2002 in diagnostics and radiotherapy. New skills and new roles for cancer staff. New roles introduced for diagnostic and other staff. New skill mix models are being implemented for breast and cervical screening and radiotherapy. All cancer service providers to have a written training No cohesive training strategies have been drawn up at network level. strategy for cancer clinicians. Partly addressed through improving outcomes guidance action plans.
Investing in Facilities New MRI scanners, linear accelerators and other Over £400m invested in new facilities so far. By the end of 2004 the NHS cancer equipment to be delivered. had received 68 MRI scanners, 177 CT scanners, 83 linear accelerators and over 700 items of breast screening equipment since April 2000. All plans achieved by the end of 2004.
Additional funding to support modernisation of £28m invested to support upgrades and reconfigurations in 39 pathology sites. 23 pathology services.
National Cancer Facilities Strategy based on an audit Audits undertaken. Single facilities strategy document not produced. New by cancer networks by 2001.
facilities strategy in development incorporating, for example, radiotherapy stocktake and PET-CT framework. DH will explore the scope for private partnerships in On imaging, strategic health authorities have identified potential gaps in relation to pathology and imaging.
capacity. Part of the strategy for imaging is to meet these gaps through more partnerships with the private sector. On Pathology DH is considering the potential for independent sector involvement, in line with the NHS Improvement Plan approach to diagnostic services.
THE NHS CANCER PLAN: A PROGRESS REPORT
Investing in the Future: Research and Genetics National Cancer Research Institute, including National NCRI established 2001, and NCRN fully established in October 2002. Cancer Research Network, to be established in 2003.
Research into cancer genetics.
This is part of the ongoing NCRI Strategic Analysis. The National Cancer Tissues Resource being established under NCRI is expected to provide a world-class resource for genetic research.
Form partnership with Macmillan Cancer Relief on Pilot work underway.
genetic counselling in 2001 to develop new services.
DH will commission evidence based reviews relating The Department continues to commission evidence reviews to support the work of NICE.
Implementing the NHS Plan Additional £570m for cancer services by 2003-04.
Preliminary results of current tracking exercise show target met.
Cancer networks will be the organisational model to 34 cancer networks were established by 2001, covering the whole of implement the NHS Cancer Plan.
England. Development programmes for network boards and network teams have been commissioned from the Clinical Governance Support Team and the NHS Leadership Centre. Networks to develop service delivery plans, Strategic plans produced but of variable quality. By late 2003 a third of underpinned by workforce, education and training and networks had a workforce and/or education & training strategy. Improving facilities strategies in 2001. Outcomes guidance and other initiatives are seeking to address this. Cancer Network Commissioning Pilots to be established. 8 pilots were established during 2001. The move to PCT-led commissioning in 2002 affected the impact of these pilots, though good practice was shared through the Network Development Programme.
Cancer Taskforce to be established.
Cancer Taskforce established in 2000 chaired by the National Cancer Director and involving patient representatives, clinicians and managers.
NOTES1 General Household Survey data is now weighted. This roughly increases prevalence by one percentage point.
2 New commitment in Priorities & Planning Framework 2003-063 Published September 2000 in advance of NHS Cancer Plan THE NHS CANCER PLAN: A PROGRESS REPORT
APPENDIX 2Methodology We used a variety of methods to obtain evidence to produce a progress report on the NHS Cancer Plan. These are summarised below.
We formed a joint reference panel for all three cancer studies to provide feedback on our proposed approach and initial findings. The members are: Survey of cancer networks Mary Barnes, Avon, Somerset and Wiltshire We surveyed the 34 cancer networks in late 2003 on behalf of all three cancer studies to establish their views on the NHS Cancer Plan, their role in implementing Mitzi Blennerhassett, former cancer patient and the Plan, and progress in meeting the targets, milestones participant in a number of patient advocacy and and commitments within it. We received responses from all 34 networks.
Derryn Borley, CancerBACUP; Dr Peter Clark, Clatterbridge Centre for Oncology Interviews with NHS organisations and Association of Medical Oncologists; We undertook a series of interviews with constituent Stephen Dunmore, Big Lottery Fund; organisations of a sample of cancer networks, agreed with the Department of Health as being representative Dr John Ellershaw, Marie Curie Hospice Liverpool of cancer networks across England. In each network we and Royal Liverpool University Hospitals; spoke to representatives from at least one primary care Professor David Forman, Northern & Yorkshire trust and strategic health authority, and from the network Cancer registry and Information Service ; management team. In some localities we spoke to more than one network, at their request. The agreed sample of Martin Ledwick, CancerBACUP; networks that we visited was: Dr Fergus Macbeth, Velindre NHS Trust, Cardiff and the National Collaborating Centre for Cancer; Dame Gill Oliver, Macmillan Cancer Relief; Greater Manchester and Cheshire Professor Mike Richards, National Cancer Director; Humber and Yorkshire Coast Professor Alison Richardson, Florence Nightingale School of Nursing and Midwifery; Mr Zen Rayter, Association of Breast Surgery at BASO; Surrey, Sussex and West Hampshire Peter Tebbit, National Council for Palliative Care; South West London Jill Turner, Cancer Services Collaborative Dr John Wiles, Harris Hospiscare, Orpington, Kent; Literature reviews and existing research We reviewed and analysed existing literature Julie Wood, South Leicestershire PCT.
and research from a variety of sources, including academic journals, official Department of Health We are grateful to all members of the reference panel for and other publications.
their help and advice.
THE NHS CANCER PLAN: A PROGRESS REPORT

Source: https://www.nao.org.uk/wp-content/uploads/2005/03/0405343.pdf

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Undergraduate Research Symposium The Auburn Montgomery School of Sciences Table of Contents Schedule of Events . 5 Poster Session I . 6 Oral Session I . 7 Poster Session II. 8 Abstracts . 9-28 Phagocytic Activity in Bufo marinus . 10 Antibiogram of Coliform Bacteria Isolated from River Water . 11 Anuran Immunology and the Effect of Corticosterone on Basophil Proliferation . 12

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Part 17: First Aid 2010 American Heart Association and American Red Cross Guidelines for First Aid David Markenson, Co-Chair*; Jeffrey D. Ferguson, Co-Chair*; Leon Chameides; Pascal Cassan; Kin-Lai Chung; Jonathan Epstein; Louis Gonzales; Rita Ann Herrington; Jeffrey L. Pellegrino; Norda Ratcliff; Adam Singer Modern, organized first aid evolved from military experi-