COMMENTARY

Will the NHS England Long Term Plan Help Cancer Survival?

Karol Sikora, PhD, FRCR, FRCP, FFPM.

Disclosures

January 23, 2019

Hello, this is Professor Karol Sikora talking about the NHS Long Term Plan.

It's a document 134 pages long, and came out a couple of weeks ago.

And I'm going to talk specifically about cancer. But just some general points. The first point is clearly what's wrong with the NHS is the silos of community care, primary care, and secondary care. And a lot of it is addressing those, and quite rightly, that is something that needs to change. The second feature of the NHS that's really poor is its information technology. And again, this addresses that. So those two points, fantastic.

The third point is much more challenging and much more inexplicable. In deprived areas men live to the age of 73 years, in well-to-do areas they live to 83 years. Now, we all know that that's a mix of factors involved - smoking, diet, exercise, occupational history, and so on. How you get that back to normal is a huge challenge.

And then the fourth thing is, it does talk about the [budget] settlement of 3.4% per year for the next 5 years but that's not going to meet medical inflation. And the idea we're going to squeeze 1% out of efficiency savings, I've been clinical director doing that for a period of 15 years in West London. There's no more money to be saved without reducing the quality of the service.

So, very challenging.

Constructive Criticism

The problem with the report – it's easy to knock it. It's much more difficult to come up with something constructive.

The things it doesn't mention; it doesn't mention the private sector at all in any way. And yet, a lot of what we do in the NHS is done by the private sector, whether it's hospital cleaning, or whether it's actually clinical services, routine surgery, for example, in private hospitals around the country.

But let's look at cancer. So it's a short section on cancer and a lot of it comes from Mike Richards' excellent report that I talked about a month or so ago. And basically, the long-term plan has an ambition that by 2028, 10 years' time, we will reduce the number of patients with stage 3 and 4 cancer significantly. In fact, the figure is that stage 1 and 2 patients with cancer will become three quarters of all cancer presentations. Is this achievable? So how are we going to do it?

First of all, we'll deal with the screening programs - bowel screening, HPV screening - get Mike Richards to come back and do a report on the current cancer screening programmes.

Realistically, this isn't going to make a huge difference. Screening, however well implemented, misses a lot of non-compliant patients that don't actually come forward when they have symptoms. So it's not as easy as that, and the numbers that it's going to contribute to is relatively small.

Then we're going to look at lung cancer, specifically in deprived areas, and put CT scanners in car parks. This doesn't seem to me to actually be very productive. There's not much good data to suggest that routine CT scanning for patients that have got a smoking history actually saves lives. And what there is, is pretty controversial. And it's a pretty expensive way to do it.

And again, you've got the selected bias, the people that turn up for CT scanning are the very people that would turn up to their GP if they have a cough.

Rapid Diagnosis

But the best idea here, and it is really a good one, is rapid diagnostic services. The idea that you go to a single stop shop where you can have your symptoms, if you've had them for a lengthy period of time, completely examined, examined not by a doctor, but actually get investigations. You can have endoscopy, you can have imaging, MRI, CT scan, maybe even PET-CT scan. And the idea is that the waiting time to rule out cancer will be 28 days. That's the only weakness in it all. In America, you'd sue if you had to wait 28 days to sort out if your symptoms are due to cancer.

We've got to speed this up. There's no reason it can't be done within 1 working day. It's actually cheaper. Patient comes to a place, brings a book, and by the end of 3 hours he's out on the street again, with a report suggesting he has or has not got cancer. So tremendous. The concept's great. What's light in this report is how you're going to implement it. Are you going to use hospital facilities? The 10 pilots do indeed use hospital facilities. That means you've got to compete for car parking space with hospital visitors, you've got to compete for it with emergencies for CT scans, and so on. It'd be much better to put them in non-traditional locations. Not car parks, not vans in car parks. Build it for everybody. Put the lung cancer patients, not in the car park, but into the rapid diagnostic centre. Get everything streamlined.

The real thing that it just doesn't address is who's going to make the referral? How's it going to be done? And it's going to be rolled out in 2019, that's this year. And there's no detail whatsoever about who's going to refer. Can I walk in and get a CT scan tomorrow if I've got a cough? Who's going to screen me out not to waste NHS resources?

We all know the 'worried well'. When I was clinical director at Hammersmith, we covered some very disparate areas. You had the worried well of Windsor who would be the first to come forward with any problems they had, and then the much less well-heeled people in Harlesden, Central Middlesex Hospital, that would just go for months with a cough or other symptom and not trouble the NHS.

It's getting round that diversity of customer that we need to do.

So can we actually get a rapid diagnostic system? We do need to have the criteria, we do have to avoid people with headache going backwards and forwards for more and more CT scans consuming resources. We need to have a mechanism to make it work and that’s very light in this.

OK, give it a chance. That's the plan -  rapid diagnostic services. Let's do it. The real weakness is going right back to the beginning of what I said - the whole tenor of the report is trying to break down the community, primary and secondary care barriers to try and have a smooth, streamlined service through it. If you've got a rapid diagnostic service, then how is the primary and community system going to interact with it? Because that's where it has to come. People can be educated, people can be told, if you have certain symptoms for more than 2 weeks, you should do something about it. But now it can take you a month to get a GP appointment. And we all know reading the papers, the number of GP’s over 50 retiring has never been higher. So we're going to have a crisis in general practice. So we're going to have to come to another mechanism for the gatekeeper role for the rapid diagnostic service.

These are all problems that are not addressed here. But it's a great start. And I think given the right people behind it, and given funding, which is absolutely vital to make this work, we can create a diagnostic service. In Europe, France, Germany, Italy, you wouldn't wait more than a week to get the diagnosis of cancer. You'd have your endoscopy, you'd have all your imaging done, and the biopsy report on the table. Here, it can sadly take several months to get there. And that almost certainly, as the report says, is the reason for the lower cancer survival rates here in Britain compared to the rest of Europe.

It's not that we don't have access to high cost drugs, CAR-T cell therapy, proton therapy, it's not that at all. It's simply late diagnosis, stage 3, 4 diagnoses. So this report states the problem, it states a solution, but not the mechanism of getting to the solution.

Us oncologists I guess are going to have to help to try and put the plan into function.

If you have any comments about what I’ve just said. Please let me know. I'd be very interested to see what you think about the rapid diagnostic services that are outlined in the plan.

Thank you.

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