Background: policies and pledges from 1995–2015

1-1 Calman–Hine: 1995–1997

In his foreword to The NHS Cancer Plan, Secretary of State Alan Milburn hailed it as the ‘first ever comprehensive strategy to tackle the disease’. This was mostly true: the NHS Cancer Plan covered everything, from prevention and screening, through to end of life care. But with respect to the services that diagnosed and treated cancer, the plan built on foundations laid under the previous government. In 1995 the Chief Medical Officers of England and Wales, Kenneth Calman and Deirdre Hine, published A policy framework for commissioning cancer services, commonly referred to as the Calman–Hine report. It contained proposals for changes to cancer services that reached deep into the NHS, and particularly into the way doctors and other professionals organised their work.

Driven by the principle that all patients should have access to uniformly high standards of treatment and care, Calman–Hine recommended the creation of cancer units in district general hospitals, with a full range of supportive services coordinated by a lead clinician. More specialised treatment was to be centralised in cancer centres, based in larger hospitals, serving populations of 1 million people or more. The report also recommended that cancer networks be created to link all these services, across hospitals and general practice. Within hospitals, all patients should be managed by MDTs, bringing together surgeons, oncologists, nurses and other professionals, essential to decide on the right course of treatment for each patient. This kind of collaborative approach, according to one of the NHS managers involved in the subsequent NHS Cancer Plan, was rare in the 1990s:

… although it seems almost impossible to think about today, the colorectal surgeon was not talking to the pathologist, even in his own organisation necessarily, and certainly would not automatically have an oncologist involved in cases.

Teresa Moss, former Director, National Cancer Action Team

Calman–Hine was badged as ‘guidance for purchasers and providers of cancer services’. It was pulled together by a small team of clinicians and academics with support from civil servants, but, as one of its authors remembers, it did not have strong backing from ministers, nor did it have much clout from the Department of Health in terms of implementation:

Ken [Calman] wanted to make this initiative (on cancer) but he did not have funding on any scale from the Department of Health or government. They weren’t interested in spending new money at that stage. So the format was advice to commissioners. ‘You’ve been given these pearls of wisdom, please do it without any resource.’

Peter Selby, Professor of Cancer Medicine, University of Leeds

There was, however, some central funding for the development of a series of service guideline documents which followed the report. These summarised what processes of care were most likely to be associated with the best outcomes for individual cancers. They were produced by an expert advisory group, chaired by Professor Bob Haward. The first was on breast cancer (published in July 1996), followed by colorectal cancer (November 1997), lung cancer (June 1998), gynaecological cancers (July 1999) and upper gastrointestinal (GI) cancers (January 2001). These reports became known as ‘Improving Outcomes Guidance’ or ‘IOGs’, a programme initially managed under the auspices of the NHS Executive, but subsequently transferred to the (then) National Institute for Clinical Excellence (NICE). Cancer networks were expected to implement the recommendations from each guidance document, which, from 1997, were accompanied by £10m of recurrent funding for each cancer.

1-2 1997: the arrival of New Labour

Cancer was the only condition singled out in Labour’s 1997 manifesto, with a promise to ‘end waiting’ for surgery for patients with breast cancer. But no timescale was specified, nor funds committed to reduce waiting times. Labour’s initial approach to the NHS was to free up savings by abolishing the internal market, and spend the proceeds on front-line care. Eager to evade their reputation as a tax-and-spend party, they committed to staying within the previous Conservative government’s planned spending allocations for the first 2 years of the administration, which meant only small real terms increases for the NHS. Accordingly, there was little decisive action taken to change the shape of NHS services between 1997 and early 1999, except dismantling some (but not all) elements of the internal market. Other developments did occur that were to prove important in relation to cancer. These included the first-ever tobacco control strategy, Smoking Kills, in 1998, which set a target to reduce the prevalence of smoking from 28% to 24% by 2010.

In May 1999, Tony Blair convened the cancer summit at Number 10 Downing Street and subsequently announced a review of cancer services, plus the creation of a National Cancer Action Team ‘to raise the standard of cancer care in all hospitals’. By October 1999, Professor Mike Richards had been named as the first National Cancer Director.

Pressure on the government to take more decisive action on the NHS increased that winter, driven by media pressure, and the results of the EUROCARE-2 study which showed that cancer outcomes in England were lagging behind other countries. Nick Timmins, then correspondent at the Financial Times, remembers the impact:

… you start getting international comparisons appearing, and we’re not doing so well on some things and we’re particularly not doing so well on cancer. The OECD are suddenly saying, ‘It looks like the NHS isn’t getting terribly good results. It’s not spending very much, but maybe it’s not getting very good results either.’ You get that winter of ’99–2000, where the department’s analysis shows they actually did better than the winter before, but the headlines were just awful, just awful.

1-3 The NHS Cancer Plan

In the first days of the new millennium, news emerged that Mavis Skeet, a 74-year-old woman with oesophageal cancer, had had surgery postponed four times because of bed shortages, amid a winter NHS crisis exacerbated by flu. By mid-January, her cancer had become inoperable.

The result of this cumulative pressure was a radical shift in Labour’s position on NHS spending. In January 2000, on a breakfast television show, Tony Blair announced that Labour would bring NHS spending up to the EU average within 5 years. In the budget 3 months later Gordon Brown, then Chancellor of the Exchequer, announced that spending on the NHS would rise by 6% on average (double the average growth of the previous 20 years). In return for this increase, the government was determined to reform NHS services in England. The NHS Plan, published in July 2000, promised thousands of new beds, doctors, nurses and hundreds of new hospitals and GP premises. Medical staff would be subject to new contracts, NHS organisations would be accountable for new waiting times targets (a ‘war on waiting’) and expected to deliver care to new national standards. The NHS Plan also contained a promise of a comprehensive national cancer plan and £570m over 3 years for improving cancer services.

The remit of the NHS Cancer Plan, published in September 2000 was broader than Calman–Hine. It set out strategies for prevention, screening, diagnosis, treatment and care, and it also had earmarked funding. Unlike Calman–Hine, it contained detailed plans for implementation over the next 5 years, including milestones and deadlines with dates attached. But it built on its predecessor report in important ways, particularly through the use of cancer networks as the main vehicle for improving services, with MDTs, supported by evidence-based guidance, as the driver of improved care for patients.

Targets were set for speeding up diagnosis and treatment. By 2005, the NHS was to deliver a maximum 1-month wait from diagnosis to treatment for all cancers, beginning with breast cancer in 2001. Childhood cancers, testicular cancer and acute leukaemia, which were already achieving this standard, were set a more exacting challenge: to begin treatment within 2 months of an urgent GP referral. All cancers would be expected to meet this standard by 2005, with breast cancer leading the way by 2002. The overall goal was to have all patients with cancer beginning their treatment within 1 month of urgent GP referral by 2008.

Money was set aside for new equipment (for example 50 new MRI scanners, and 200 CT scanners), staff (1,000 additional cancer specialists by 2006), and for access to 13 new drugs that the recently created NICE was expected to recommend in 2001. Screening programmes were to be expanded: an extra 400,000 women would receive breast screening, pilots launched for bowel cancer screening and prostate-specific antigen (PSA) tests made available to all men who wanted them, subject to informed choice. The NHS Cancer Plan also announced the creation of a National Cancer Research Institute, to have an overview of research and plug any gaps. Progress was to be monitored by the newly formed Commission for Health Improvement, and a process of peer review.

Progress in implementing the NHS Cancer Plan was subject to considerable scrutiny. The Department of Health issued its own updates, in 2001, 2003 and 2004. The first survey of cancer patient experience was published in 2002. The National Audit Office (NAO) also produced a suite of reports in 2004 and 2005: Tackling cancer in England, saving more lives (March 2004), Tackling cancer: improving the patient journey (February 2005) and The NHS Cancer Plan: A progress report (March 2005).,,

By 2006, all cancer waiting time standards were being achieved (including 2 months – or 62 days – from urgent referral to first treatment).

1-4 The next stage: The Cancer Reform Strategy 2007–2010

The NAO’s final report in 2005 noted that there were no plans in place to update the NHS Cancer Plan. That soon changed, as the achievement of many of the targets (and the spending of allocated funding) led many in the cancer world to feel that a new strategy would be needed to maintain momentum. Unlike the NHS Cancer Plan, which had been put together by a small group of clinicians led by the National Clinical Director, the new strategy was developed by a much broader coalition of clinicians, researchers and charities.

The resulting Cancer Reform Strategy, published in 2007, acknowledged progress on many fronts, including a larger workforce and shorter waiting times. But it also flagged the gap in survival between the UK and other countries despite all this activity. Once again, a promise was made to catch up:

By 2012 our cancer services can and should become not only among the best in Europe but among the best in the world. This is the aspiration that drives this Cancer Reform Strategy.

Department of Health, Cancer Reform Strategy

There was to be more action on prevention (targets to reduce child obesity as part of a cross-government obesity strategy and public information on the risks of alcohol consumption) and extensions to screening, including more rounds of breast screening and the rollout of bowel screening from 2010. The overall length of targets remained the same, but their scope was broadened. More patients were to be included in the 62-day target from referral to treatment, including those from screening programmes or referred via other consultants. And for women with any breast symptoms, the 2-week wait to be seen by a specialist was to be applied, even if their GP did not suspect cancer. Pledges were also made to improve access to surgery (including training in new forms of surgery), more radiotherapy, and more consistent geographical access to chemotherapy, underpinned by better data.

The Cancer Reform Strategy also contained four major new initiatives on early diagnosis, survivorship, information and equalities. The National Awareness and Early Diagnosis Initiative was designed to boost research into the barriers faced by patients, and stimulate innovation in information campaigns. It represented the first concerted effort to tackle late diagnosis of cancer, which was (and still is) believed to be one of the main causes of the UK’s comparatively poor survival rates. The National Cancer Survivorship Initiative (NCSI) aimed to improve the quality of life for people after cancer treatment, while information and data on cancer were to be improved through the National Cancer Intelligence Network (NCIN). Finally, the persistence of inequalities in access and outcomes was to be tackled by a new National Cancer Equality Initiative.

The actions set out in the Cancer Reform Strategy did not come with any additional funding, and local commissioning bodies were expected to deliver them. Since 2007, much effort had been expended on the development of commissioning skills in PCTs (a programme known as ‘World Class Commissioning’) but, since the late 1990s, the vehicle for local cancer improvement had been the cancer networks (which had reduced in number from 34 to 28). The Cancer Reform Strategy devoted several pages of detail about how cancer networks were to work with PCTs and strategic health authorities (SHAs).

But two events happened in the next two and a half years, which radically altered the structure of the NHS and the environment for all public services. The first was the banking crisis in 2007/08, which led the Labour government to divert public funds to stabilise the financial sector, and tipped the economy into recession. The second was a general election, which brought three terms of Labour government to an end in 2010.

1-5 All change please: 2010 and its aftermath

In the 2010 election campaign, the Conservative party promised to tackle the ballooning public sector debt, and stabilise the economy, which had taken a downturn after the 2008 crisis. Both Labour and the Conservatives pledged to implement flexible sigmoidoscopy for bowel cancer screening, while Labour promised an additional £1bn fund to improve cancer diagnostics. The Conservatives offered a £200m Cancer Drugs Fund, but otherwise reassured the electorate that there would be no ‘top-down’ NHS reform. Comparatively little attention was paid to the elaborate plans developed by the shadow Secretary of State for Health, Andrew Lansley, while in opposition. These included sweeping away many of the existing local and regional commissioning bodies, creating GP-led commissioning groups, setting up an arm’s-length body for health and much greater use of the market, to drive an outcomes-focused, self-improving NHS, free of political ‘meddling’.

The 2010 election produced no overall majority. The Conservatives and the Liberal Democrats formed the first peacetime coalition since 1930, and work began on policies to reduce the ‘record public debt’. One early action taken was the creation of a Cancer Drugs Fund, to fulfil a Conservative manifesto commitment. This fund, which began in 2011 and was worth £200m per year, was designed to give patients access to drugs which were not routinely available on the NHS.

Meanwhile, Andrew Lansley, now Secretary of State for Health, pressed on with his reform plans, publishing a white paper in July 2010, which eventually led to the 2012 Health and Social Care Act, after a great deal of opposition.

This backdrop of radical reform at a time of financial austerity was evident in the next cancer strategy that was produced – the first under the new coalition government – in 2011. Improving outcomes: A strategy for cancer, acknowledged the work of those in the previous cancer initiatives, but once again flagged up the stubborn gap between England and comparable countries, this time quantifying it in terms of lives: 10,000 lives could be saved a year if England’s survival rates were as good as the best in Europe., The 2011 strategy was steeped in the language of Lansley’s reform programme: outcomes were paramount, and patients and front-line clinicians were to be empowered, not to be driven via a ‘top-down hierarchy’.

As in 2007, there was no new investment on offer and a hint of how challenging this period would be was contained in the Secretary of State’s foreword to this report. Although, he wrote, the NHS had done comparatively well in the October 2010 Spending Review (the NHS would get small real terms increases, unlike many other government departments). The uplift represented ‘the toughest settlement the NHS has faced for a long time’. Meanwhile, the ambitious pursuit of better outcomes would be the job of PCTs, ‘until they are abolished, and their functions in the relevant area transferred to consortia, local authorities and the NHS Commissioning Board’.

The strategy maintained the focus on national leadership (by retaining the National Cancer Director) and the role of the Implementation Advisory Group to help monitor its delivery. The strategy was not clear about where the National Cancer Action Team would sit under the reformed NHS, and suggested both it and (former) NHS Improvement might become social enterprises. Funding was continued for cancer networks, but the paper hinted that these would also need a ‘new style’ once GP consortia – clinical commissioning groups (CCGs) – were up and running.

Better data were promised, including new data to be collected on stage of disease. Screening was again extended, including a wider age range for breast cancer (as part of a large clinical trial) and early implementation of flexible sigmoidoscopy for bowel cancer, with full rollout by 2016. Screening was now to be run by the new Public Health England, which would also take the lead on raising patient awareness on early diagnosis.

The strategy listed a range of desired improvements in treatments, including more use of radiotherapy and the most up-to-date surgical techniques. Some of the core principles of Calman–Hine remained in place, for example the continued use of the Improving Outcomes Guidance, MDTs and peer review (albeit the latter subject to being ‘streamlined’). But networks received very limited attention: instead the driver of improved cancer services was to lie with the new GP consortia which, the report noted, were too small individually for optimal commissioning of a complex service such as cancer, and were likely to have to collaborate. It was up to the new consortia in the future to determine whether ‘to continue getting advice and support from networks or to seek such support elsewhere’.

In 2015, the NAO published its appraisal of progress on the 2011 Strategy. It said that survival was improving, but survival rates remained about 10% lower than the European average. There were still persistent variations in access and treatment around the country, and between groups of patients, for example between older and younger patients.

Although staging data had improved in its completeness, the NAO was unhappy that data on cost and efficiency had not improved, and data more generally were not flowing as quickly as it should, hampering commissioning and evaluation. The report noted ‘It is also unclear whether any one organisation, at a national level, has oversight of cancer commissioning across a range of complex treatment pathways’.

The NAO also warned that there was a risk that progress in improving cancer services and cancer information could stall as a result of the 2012 reorganisation, pointing to the downgrading of the National Clinical Director from a full-time to a part-time post, the disbanding, in 2013, of the National Cancer Action Team and the major reduction in funding and staff for the 28 cancer networks.

The mood music at the time was around not having a disease-specific focus, which was seen as a good thing in terms of benefitting cross-disease working etc. I do buy into that rationale to some extent, but essentially it meant that you had a cancer strategy with no real sense of where initiatives in it sat in relation to the wider system, uncertainty over who was really driving it, who was really responsible.

Emma Greenwood, Director of Policy and Public Affairs, Cancer Research UK

1-6 The Five year forward view and beyond

The first substantive vision for the re-engineered English NHS came in the form of the Five year forward view, published in 2014 by NHS England. There was a heavy emphasis on new models of care as a route out of the intense financial and demographic pressures facing the service, but cancer featured, along with mental health, as a priority area.

In the absence of a central cancer team, and a lack of capacity at the Department of Health and NHS England, development of the next (and current) 5-year strategy was handed to an independent cancer task force led by Sir Harpal Kumar, then Chief Executive Officer of Cancer Research UK. The task force published its report Achieving world-class cancer outcomes – A strategy for England 2015–2020 in July 2015. The 96 recommendations were accepted in full. The 2015 strategy called for more progress on prevention, including reducing smoking prevalence to 13% (21% for routine and manual groups) by 2020 and to 5% by 2035. It also recommended a big push towards more rapid diagnosis, aiming for 95% of patients referred by a GP to wait less than 4 weeks for a cancer diagnosis or for cancer to be excluded (and 50% within 2 weeks) by 2020. This would mean a big expansion in diagnostic capacity, and improving the availability of some diagnostic tests to GPs.

Better patient experience would come from all patients having access to test results online, and clinical nurse specialists (CNS) available to all patients to coordinate care. In addition, the quality of life for cancer survivors merited considerable attention, including the development of a quality-of-life measure by 2017. Progress would depend on investment in new infrastructure – replacement and upgrades for all linear accelerators (linacs) and molecular diagnostics, and plugging workforce gaps, especially in diagnostics, oncology and CNS. Finally, the report also recommended creating cancer alliances – a revived form of cancer network – to bring commissioners, providers and patients together, to ‘drive and support improvement’.

These changes were estimated to cost £400m per annum. Once again, a closing of the gap between England and the best of Europe was the prize, with an additional 30,000 patients a year surviving 10 years or more. Progress reports against delivery of the strategy are released yearly by NHS England, while its board also actively monitors elements of the strategy which were priorities in the Five year forward view, namely faster diagnosis and replacing radiotherapy equipment, in addition to existing cancer waiting times targets.

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