Comparative data in the 1990s demonstrated that England had higher cancer mortality rates and lower rates of long-term survival than most other European countries. Accordingly in 2000, the Department of Health published the NHS Cancer Plan, setting out a ten year strategy for improving cancer services.
The Cancer Reform Strategy, published on 3 December 2007 and looking ahead to 2012, acknowledged that improvements had been made but noted that the gap in survival rates between England and most of Europe had not been closed. It therefore sought to build on the progress made since 2000 by spreading best practice and recommending what more needed to be done by cancer networks and the NHS to improve clinical outcomes, drive up quality and increase value for money. Amongst the drivers for improved delivery were using better information to enhance quality, inform commissioning and promote choice; strengthening commissioning and making better use of resources. The National Audit Office has now published a report, Delivering the Cancer Reform Strategy, examining how effectively those three drivers have been utilised to improve cancer services.
The report found that:
- although aspects of cancer information have improved substantially since 2007 key deficiencies remain:
- incomplete and inconsistent data limit understanding of variations in outcome and the effective allocation of resources;
- data on radiotherapy activity are not yet publicly available;
- data on chemotherapy activity and outcomes are poor;
- the Department’s planned introduction of a national chemotherapy dataset is two and a half years behind schedule;
- duplication in the publication of cancer data leads to confusion.
- few commissioners make the best use of information when commissioning cancer services and most do not know whether their commissioning is cost effective:
- just 22 per cent of PCTs had attempted to assess the value for money delivered by cancer service providers;
- only around half had identified where expenditure which does not benefit patients could be eliminated;
- a mere 20 per cent had achieved quantified efficiency gains as a result of implementing the strategy;
- delays in the availability of data limit their usefulness in terms of commissioning because of the difficulty of linking costs and activities to outcomes;
- because expenditure on cancer services is structured around payment mechanisms which largely fund hospital activity, commissioners experience difficulties in moving funds to commission services in non-hospital settings;
- chemotherapy and radiotherapy are excluded from the national tariff;
- trusts measure chemotherapy activity in different ways and not all have systems in place to report costs consistently; as a result, reported unit costs varied widely between trusts – from £43 to £4,300;
- although consistently high levels of achievement against cancer waiting time standards were noted and the number of patients diagnosed through urgent referrals increased, the urgent referral rate varied almost fourfold amongst PCTs.
- NHS expenditure on cancer services in 2008/9 was around £6.3 billion; there are opportunities to deliver better outcomes for patients whilst saving money and freeing up resources to meet the increasing demand for services:
- the Department of Health has not monitored the cost of implementing the strategy and the data it collects on expenditure on cancer services include unexplained variations from one year to the next within and between PCTs;
- significant reductions have been made in inpatient hospital bed days for cancer despite an increased incidence of the disease – largely through reduced length of stay and increased use of day treatment;
- poor coding of outpatient activity makes it difficult to measure follow-up activity after treatment;
- the strategy expected emergency admissions for cancer patients to be minimised and, while the rate of increase has been reduced, emergency admissions are still increasing.
The report concludes that progress has been made in improving key aspects of cancer services but there remains substantial scope for making further improvements by tackling variations and raising performance standards. The key driver of further improvements is better quality information. Although there have been improvements in some aspects of cancer information, commissioners’ poor understanding of costs and outcomes means that they do not know whether they are commissioning services which optimise outcomes for patients. Moreover, the Department has limited assurance as to whether implementation of the strategy is achieving value for money.