P 49
Ymchwiliad i’r Adolygiad Blaenoriaethau ar gyfer y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon
Inquiry into the Priorities for the Health, Social Care and Sport Committee
Ymateb gan: Ymchwil Canser y DU
Response from: Cancer Research UK
Cancer Research UK submission to consultation on priorities for the Health, Social Care and Sport Committee
September 2016
Cancer Research UK (CR-UK) welcomes the opportunity to input on topics that the Health, Social Care and Sport Committee could explore in the new Assembly term. In summary:
- We welcome the proposed inquiries into primary care and waiting times. Both play an important role in cancer care and our previous research suggests the NHS in Wales could make improvements in both.
- Regarding priorities for the next 12 to 18 months, we suggest the Committee undertake inquiries into diagnostic services and prevention. CR-UK believes both areas require attention if Wales is to achieve the best possible cancer outcomes.
- Inquiries into diagnostics and prevention could yield benefits across a number of disease areas. A range of conditions rely on diagnostic capacity and preventable risk factors, such as smoking and obesity, contribute to a number of diseases including heart disease and diabetes.
1. Inquiry topics identified by the Committee
The Committee’s webpage indicates it is considering, among other topics, inquiries into primary care and waiting times. We welcome these proposals for reasons outlined below.
1.1 Primary care
Primary care plays a critical role in effective cancer care: most cancer patients are diagnosed following a referral from their GP.[1] CR-UK’s recent report, Where next for cancer services in Wales?, found primary care could be operating more effectively in two key respects.[2]
Firstly, evidence suggests poor access to primary care is one of the factors contributing to late cancer diagnoses.[3] Some areas of Wales have particular difficulty attracting primary care staff and this adversely affects access in those places. National data also suggests there is an issue: the 2014-15 National Survey for Wales found that 37% of respondents who had used a GP consultation in the previous 12 months found it ‘fairly difficult’ (19%) or ‘very difficult’ (18%) to get a convenient appointment.[4] The figure in the 2013-14 national survey was similar at 38%.[5]
Secondly, how effective GPs in Wales are at identifying cancer symptoms and investigating them needs exploration. GPs have a difficult job in relation to detecting cancer: on average a GP will see only around eight new cancer cases a year.[6] However, there is evidence that GPs in Wales are not consistently adhering to NICE referral guidelines.[7] Findings of the Wales Cancer Patient Experience Survey (WCPES) back this up. Several respondents to the 2013 survey raised concern about the speed at which GPs responded to their symptoms.[8] Relatedly, over one-fifth of respondents indicated that they felt they should have been seen a hospital doctor a ‘bit sooner’ (12%) or a ‘lot sooner’ (10%).[9]
Both of these factors can lead to delays in patients receiving a definitive diagnosis. This in turn can negatively affect patients’ treatment options and prognoses. We are also aware that the Welsh Government introduced a new primary care strategy in 2015.[10] Understanding the impact this initiative is having would be valuable. For these reasons, CR-UK would welcome the Committee conducting an inquiry into primary care.
1.2 Waiting times
Waiting time targets play an important role in cancer care. They exist to ensure that patients progress from diagnosis to treatment as quickly as possible.
The Welsh Government maintains two key waiting time targets relating to cancer care. However, the health service is struggling to meet both.
- First, 95% of newly diagnosed cancer patients, referred via the urgent route, should begin treatment within 62 days of referral. This target has not been met since 2008. In the most recent quarter, April to June 2016, nationally 87.3% of patients began treatment within 62 days.[11]
- Second, 98% of cancer patients referred via the non-urgent route should begin treatment within 31 days of the decision to treat. This target was last met in 2014. Performance between April and June 2016 across Wales was 97.5%.[12]
This is a cause for serious concern because it means cancer patients are being delayed in starting treatment.
There is variation in performance against waiting time targets between local health boards (LHBs). For example, in the second quarter of 2016, at Cardiff and Vale LHB 82.4% of patients began treatment within 62 days; at Cwm Taf LHB alternatively over 92% of patients began treatment within 62 days.[13] Similarly, the performance across different cancer types varies. For example, in the second quarter of 2016, 100% of patients with cancer of the brain or central nervous system began treatment within 62 days; alternatively, during the same period only 72.5% of patients with cancer of the lower gastrointestinal area began treatment within the target time.[14]
CR-UK would therefore welcome the Committee exploring waiting time performance. In particular, we would encourage the Committee to investigate the factors that are contributing to performance being below target and why some health boards and cancer specialisms are able to meet performance targets and others are struggling.
In addition, we would welcome the Committee investigating the Welsh Government’s intention to introduce a ‘single pathway’ for cancer patients. We understand this will mean recording waiting times from the point at which cancer is suspected, an aspiration CR-UK welcomes. However, our recent research found progress implementing the single pathway has been slow.[15] We would welcome evidence on what has delayed progress and proposals for how it could be accelerated.
2. Additional themes for inquiry by the Committee
We believe there are two areas which it would be valuable for the Health, Social Care and Sport Committee to investigate in the next 12 to 18 months: diagnostic capacity and prevention. Both are vital if Wales is to achieve world-class cancer outcomes, and could also deliver benefits across a range of disease areas. We consider each in turn below.
2.1 Diagnostic capacity
Early diagnosis has the potential to transform cancer outcomes over the coming years. For example, when bowel cancer is diagnosed at stage one, around 95% of patients survive for at least five years. In contrast, fewer than 10% of those diagnosed at stage four do likewise.[16]
In Wales, early diagnosis was a focus of the Cancer Delivery Plan and some progress has been made in recent years.[17] But there is still further to go: in 2014 around 35% of cancer patients were diagnosed at stage three or four.[18] Achieving consistent early diagnosis relies on patients being able to access diagnostic services so that symptoms can be investigated promptly. Today, however, we believe that diagnostic capacity in Wales is struggling to keep up with demand and thereby contributing to late diagnoses.[19]
We base this analysis on several factors. Firstly, comparing waiting time performance suggests diagnostic delays are a problem. National performance against the 31-day target, which measures from after the point of diagnosis, is below target by a relatively small margin. Alternatively, performance against the 62-day target, which includes the diagnostic phase, is significantly lower. Secondly, expert stakeholders interviewed for our project on cancer services repeatedly identified limited diagnostic capacity – workforce and equipment – as an issue.[20] Thirdly, NICE recommends that GPs should, in certain circumstances, be able to directly refer patients with suspected cancer for investigative tests rather than first referring to a hospital physician.[21] Yet, our project found that GPs’ direct access to investigative test was variable across Wales.
Looking ahead, demand for diagnostic services is likely to increase for two key reasons. Firstly, NICE, in a decision CR-UK supports, recently lowered the threshold at which GPs should refer people for investigation in cases of suspected cancer.[22] Secondly, CR-UK projects that the number of cancer cases diagnosed each year in Wales will grow over the coming decade, driven by an ageing population and preventable risk factors.[23] This reinforces the case to think carefully about diagnostic services.
Improving diagnostic capacity would not only benefit cancer patients. A range of conditions rely on investigative tests to achieve a definitive diagnosis. We therefore believe it would be very useful for the Health Committee to explore diagnostic capacity, including workforce and equipment. In particular, we suggest the Committee investigate existing capacity in Wales, the likely trajectory of future demand based on GPs consistently implementing best practice, and the resource needed to meet this demand.
2.2 Prevention
As mentioned above, CR-UK’s recent report on cancer services in Wales showed that the number of cases diagnosed each year in Wales is likely to grow over the next decade.[24] This is being driven in part by an ageing population; but preventable risk factors are also playing a role.
Research suggests around four in ten cancer cases are attributable to preventable risk factors.[25] Among a range of factors, smoking and obesity are the most significant. However, rising cancer incidence associated with preventable risk factors is not inevitable: governments are able to influence public behaviour and reduce the prevalence of key risk behaviours.[26] Doing this will require the Welsh Government to consider the full range of policy levers available to it – and smoking and obesity should be a particular focus.
In 2013-14, 21% of adults in Wales were recorded as smokers – down from 27% around a decade earlier.[27] This is positive, but there is more progress to be made. If current trends are continued, tobacco could lead to over 1.3 million new cases of disease in the UK over the next 20 years. [28] Instead, CR-UK believes a tobacco-free future, where adult smoking prevalence is 5% or less, is the right aspiration.[29]
Obesity, which is the single largest preventable cause of cancer after smoking, is on the rise in Wales.[30] In 2003/04 around 18% of adults were reported to be obese; by 2015 this had reached 24%.[31] CR-UK has shown that current obesity trends could lead to an additional £2.5 billion in direct health and social care costs across the UK by 2035.[32] For this reason, we welcome the Committee identifying sport and public health as a possible topic for inquiry. However, while physical activity has an important role to play in tackling obesity, we think an inquiry into prevention could add value by exploring a wider range of options, such as regulation and product reformulation.
Reducing the prevalence of smoking and obesity would deliver benefits across a number of disease categories. Smoking is associated with heart disease, stroke and chronic obstructive pulmonary disease;[33] obesity is linked to heart disease, diabetes and respiratory problems.[34]
As an ageing population drives demand for healthcare, it is likely that the financial pressure on healthcare services will grow. This reinforces the case for preventative interventions to reduce the prevalence of risk factors likely to cause ill health and incur additional cost. We therefore think the Committee on Health, Social Care and Sport could play a valuable role by exploring and outlining options for ambitious preventative action in Wales.
3. About Cancer Research UK
Cancer Research UK is the world’s largest independent cancer charity dedicated to saving lives through research. We support research into all aspects of cancer and this is achieved through the work of 4,000 scientists, doctors and nurses. In 2014/15, we invested £434 million in research, including our £41 million contribution to the Francis Crick Institute. We receive no funding from the Government for our research.
4. Contact details
For more information please contact:
Anneka Hughes, Public Affairs Officer – Wales, on XXXXXXXXXXX or XXXXXXXXXXXXXXXXXXXXXXXX.
Or, Leo Ewbank, Policy Adviser, on XXXXXXXXXXXX or XXXXXXXXXXXXXXXX.
5. References
[1] National Cancer Intelligence Network (2012) Routes to diagnosis 2006 – 2010 workbook (a): version 3.2a, March 2014. http://bit.ly/1OelnIH, Last accessed 25/08/2018.
[2] Morrison et al (2016) Where next for cancer services in Wales? Cancer Research UK. http://bit.ly/1UWMq9D, Last accessed 25/08/2016.
[3] Ibid.
[4] Welsh Government (2015) National Survey for Wales: Headline results, April 2014 – March 2015 (revised). http://bit.ly/1FKI3bd, Last accessed 25/08/2016.
[5] Welsh Government (2014) National Survey for Wales: Headline results, 2013-14 – Revised. http://bit.ly/2bYgQhn, Last accessed 28/08/2016.
[6] National Institute of Health and Care Excellence (2015) NICE’s new symptom-based approach will help save thousands of lives from cancer. http://bit.ly/1ddAlOI, Last accessed 25/08/2016.
[7] Morrison et al (2016) Where next for cancer services in Wales? Cancer Research UK. http://bit.ly/1UWMq9D, Last accessed 25/08/2016.
[8] Bracher M. et al (2014) exploration and analysis of free-text comments from the 2013 Wales Cancer Patient Experience Survey (WCPES), University of Southampton. http://bit.ly/2bqeqp1, Last accessed 25.08.2016.
[9] Welsh Government (2014) Wales Cancer Patient Experience Survey: National Report. http://bit.ly/1Nt97Qu, Last accessed 26/08/2016.
[10] Welsh Government (2015) Our plan for a primary care service up to March 2018. http://bit.ly/1FntBGe, Last accessed 26/08/2016.
[11] Stats Wales (n.d.) Patients newly diagnosed via the urgent suspected cancer route starting treatment by local health board and quarter. http://bit.ly/2biE8wG, Last accessed 25.08.2016.
[12] Stats Wales (n.d.) Patients newly diagnosed not via the urgent cancer route starting treatment by local health board and quarter. http://bit.ly/2bPHtSB, Last accessed 25.08.2016.
[13] Stats Wales (n.d.) Patients newly diagnosed via the urgent suspected cancer route starting treatment by local health board and quarter. http://bit.ly/2biE8wG, Last accessed 25.08.2016.
[14] Stats Wales (n.d.) Patients newly diagnosed via the urgent suspected cancer route starting treatment by tumour site and quarter. http://bit.ly/2bMwj2l, Last accessed 26.08.2016.
[15] Morrison et al (2016) Where next for cancer services in Wales? Cancer Research UK. http://bit.ly/1UWMq9D, Last accessed 25/08/2016.
[16] Cancer Research UK (n.d.) Bowel cancer survival by stage at diagnosis. http://bit.ly/1UxCFTn, Last accessed 25/08/2016.
[17] Welsh Government (2012) Together for Health – Cancer Delivery Plan. http://bit.ly/2b5MDNC, Last accessed 31/08/2016.
[18] Welsh Government (2016) Together for Health – Cancer Annual Report 2015. http://bit.ly/25wX1A3, Last accessed 01/06/2016.
[19] Ewbank, L. (2016) Four key ways to improve cancer patient care in Wales. Cancer Research UK science blog. http://bit.ly/2byGynL, Last accessed 30/08/2016.
[20] Morrison et al (2016) Where next for cancer services in Wales? Cancer Research UK. http://bit.ly/1UWMq9D, Last accessed 25/08/2016.
[21] National Institute of Health and Care Excellence (2015) Suspected cancer: recognition and referral, NICE guidelines [NG12]. http://bit.ly/1sIJK99, Last accessed 25/08/2016.
[22] National Institute of Health and Care Excellence (2015) Suspected cancer: recognition and referral, NICE guidelines [NG12]. http://bit.ly/1sIJK99, Last accessed 25/08/2016.
[23] Morrison et al (2016) Where next for cancer services in Wales? Cancer Research UK. http://bit.ly/1UWMq9D, Last accessed 25/08/2016.
[24] Morrison et al (2016) Where next for cancer services in Wales? Cancer Research UK. http://bit.ly/1UWMq9D, Last accessed 25/08/2016.
[25] Parkin D. et al (2011) The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. British Journal of Cancer 105: s77-s81. http://bit.ly/2bUlbia, Last accessed 26/08/2016.
[26] Pierce J (2012) What public health strategies are needed to reduce smoking initiation? Tobacco Control. 21: 258-264. http://bit.ly/2bx8X3z, Last accessed 30/08/2016.
[27] Public Health Wales Observatory (2015) Welsh Health Survey lifestyle trends 2015. http://bit.ly/2bCAnmt, Last accessed 26/08/2016.
[28] Bhimjiyani A et al (2016) Aiming high: Why the UK should aim to be tobacco-free. Cancer Research UK. http://bit.ly/299m6w0, Last accessed 26/08/2016.
[29] Cancer Research UK (n.d.) Our policy on a Tobacco-Free UK. http://bit.ly/2bBzR4o, Last accessed 31/08/2016.
[30] Cancer Research UK (n.d.) Bodyweight facts and evidence. http://bit.ly/2btVEgv, Last accessed 26/08/2016.
[31] Welsh Government (2016) Welsh Health Survey 2015: Initial headline results. http://bit.ly/2c4KdLL, Last accessed 30/08/2016.
[32] Bhimjiyani A et al (2016) Tipping the scales: Why preventing obesity makes economic sense. Cancer Research UK. http://bit.ly/29XWPEc, Last accessed 26/08/2016.
[33] Action on Smoking and Health (2016) Smoking statistics: fact sheet. http://bit.ly/2bPlUBZ, Last accessed 02/09/2016.
[34] Public Health England (n.d.) Health risks of adult obesity. http://bit.ly/2cvpUvs, Last accessed 02/09/2016.