Cancer summit: 18 September 2024

In March 2021, the Welsh Government published a quality statement for cancer, this describes what good looks like for cancer services across all parts of Wales. This is underpinned by 26 national optimal pathways for each cancer type that provide timed pathways of care describing how organisations can achieve the suspected cancer pathway target.

The Welsh Government published a planned care recovery plan in April 2022, which set out the actions needing to be taken to increase activity to support cancer recovery.

In January 2023, the Minister for Health and Social Services launched the cancer improvement plan for NHS Wales 2023 to 2026. This system wide plan sets out how NHS Wales will enhance cancer care for patients across Wales and aims to improve quality and outcomes and ensure a holistic approach throughout the pathway from prevention to treatment and ongoing care. The plan encourages collaboration across the system, focussing on the attributes outlined in the quality statement for cancer.

Following a ministerial cancer summit held in March 2023, the Welsh Government commissioned the NHS Executive to undertake a national intervention focused upon urological, lower GI and gynaecological cancer to improve service and experience for new patients entering their cancer pathway and support the development of resilient, sustainable and equitable cancer services across Wales. The national support and intervention programme commenced in June 2023, and a national cancer recovery programme has now been established to continue this work.

The ministerial cancer summit held in September 2024 brought together executive officers, operational managers, clinical leads, senior nurses, and stakeholders from across Wales to discuss and agree actions to improve cancer outcomes and performance. The focus of the summit was upon 3 cancer types (breast, lower GI and urological cancer) with a view to agreeing actions, sharing best practice, and addressing any barriers to improvement.

The Cabinet Secretary for Health and Social Care confirmed the commitment to improving access for people with suspected cancer and improving outcomes for people diagnosed with cancer. Expectations for NHS Wales were set out:

• implement the national optimal pathways (NOPs) and reduce the pathway intervals through agreed improvements such as straight to test and same day follow on investigations
• continue to focus on bringing down the volume of people waiting more than 62 days to start their first definite treatment
• continue to improve the waiting time to first outpatient and diagnostic appointment
• continue to improve performance towards the performance target that has been agreed locally

Addressing current waiting times and variation in performance were highlighted as a key priority. Health boards will need to:

• implement the national optimal pathways, ensure that the referral pathway is correct
• focus on improving the time to first contact with patients, improving straight to test provision and access to diagnostics
• invest in workforce capacity

Health boards should ensure that all available capacity is used appropriately and take advantage of any technological and digital innovations such as e-referral to help improve efficiency. These must be supported by changes to service models to create more sustainable services and where necessary should work regionally to address fragile services.

Health boards were asked to take action to reduce and sustain the volume of patients waiting more than 62 days to start their first definitive cancer treatment and implement transformation of pathways, with support from the national cancer recovery programme.

The NHS Executive’s National Director of Performance and Assurance gave an overview of the current position of cancer services. The key points were:

• performance remains below expectations and trajectories are not on track to deliver the required improvement during the current financial year
• the system continues to be unsuccessful in reducing waiting list volumes at all stages of the pathway for the most challenged cancer sites
• the number of patients waiting more than 62 days to start their first definitive treatment is too high and a sustainable position cannot be achieved based on current levels of demand and capacity
• the number of patients entering the pathway continues to increase, whilst the number of confirmed cancers remains consistent
• health boards supported by the NHS Executive should undertake analysis and pathway reviews to understand the current referral pathways and what work is required with primary care to understand referral behaviour
• demand has increased by 20% since 2022 and there is variation in local referral numbers across cancer types, especially in skin, urological and breast cancer
• activity levels for patients with cancer have historically not kept pace with demand
• the 28 day diagnostic waypoint in the national optima pathways is not being achieved
• implementation of the national optimal pathways is key to driving improvements in service delivery and reducing variation across health boards
• NHS Wales organisations must deliver improvement and where appropriate embrace the opportunities to work on a regional basis

The National Director for the Strategic Programme for Planned Care highlighted progress made since the cancer summit held in March 2023:

• a series of national workshops have been held to discuss how productivity can be improved for urological, lower GI and gynaecological cancer pathways
• a cancer recovery programme has been established and a detailed workplan developed to support NHS Wales organisations in implementing the national optimal pathways across 5 cancer types (breast, gynaecological, lower GI, skin, urological)
• there are increasing degrees of regional working where fragility has been identified across services and diagnostics
• improved data capturing and recording is in place to help NHS Wales organisations with demand and capacity planning through the development of cancer business intelligence tools
• rapid diagnostic clinics have been established and NHS Wales organisations are now working towards enhancing acute oncology services in line with the service specification
• a diagnostic workforce plan has been approved which will focus on imaging, endoscopy and pathology, ensuring they align with the national diagnostic programme
• improvements have been made in the HRT post-menopausal bleeding and gynaecological pathways through closer working with the:
  • national strategic clinical network for women’s health
  • national strategic clinical network for cancer
  • gynaecology clinical implementation network (CIN)

Brief presentations were given which focused upon 3 pathways.

Urology

The clinical lead for the urology cancer site group (CSG) highlighted that urology performance at an all-Wales level had been around 40% before the pandemic and although some health boards have seen some improvements, the overall performance levels remain considerably below the target level. It was suggested that the reasons for this are due to increased referrals, variable capacity due to workforce and estates issues, variation in practice and waiting times across Wales. Staff shortages impact on services which impacts on the ability to upskill existing staff.

There is an appetite for change and there are a number of improvements now starting to have an impact including the implementation and embedding of the TULA service across all health boards and the increase in robotic capacity at Swansea Bay and Aneurin Bevan university health boards. There are opportunities for more regional working and improvements are needed for reporting of diagnostics tests.

The following actions were agreed:

• develop real-time data per cancer site or pathway point to enable sight of where capacity is available, and support access and regional working
• upskilling of nursing workforce, including clinical nurse specialist (CNS)-led prostate biopsy and flexible cystoscopy, as well as a formalised accredited training programme
• improve pathology capacity and reporting
• work with HEIW to develop a workforce strategy focused on attracting trainees and retaining high quality candidates

Lower GI

The clinical lead for the colorectal CSG highlighted that performance across all health boards for lower GI cancer remains difficult, the numbers of patients waiting has more than doubled compared to pre-pandemic levels. In order to support pathway improvements, health boards are seeking to implement component waits in the pathway with a view to completing the diagnostic stage by day 28 and the treatment stage within 21 days. This is challenging for diagnostics with the current infrastructure, the number of trained endoscopists and current levels of endoscopy capacity. For treatment, more than 60% of patients require surgery as their first definitive treatment and there is variation in pre-operative assessment and pre-habilitation services, theatre access, and use of robotic surgery.

Breast

The clinical lead for the breast CSG highlighted that there has been considerable progress across the breast pathway and services are reporting they are more sustainable which will lead to increased performance and better patient outcomes. Improvements include:

• implementation of the national optimal pathway for breast cancer
• development of the UK’s first national optimal pathway for metastatic breast cancer
• pathway for use of PARP inhibitors in patients with hereditary breast cancer (BRCA gene carriers)
• pathway for chemoprevention for women with high risk of developing breast cancer
• establishment of purpose-build breast centre units providing services from one site at Swansea, Cardiff, Llantrisant and Ystrad Mynach
• reduction of waiting time for first appointment from 14 to 16 weeks to 2 to 3 weeks
• proof of concept of collaborative working, post-pandemic CSG initiative reduced waiting times from 16 to 4 weeks

Challenges to the service included:

• Current cancer targets relate to the start of the first definitive treatment and does not include the adjuvant therapy, which impacts cancer outcomes, or immediate breast reconstruction for patients undergoing mastectomy, which impacts patient experience.
• Variation in clinical practice in treatment of node positive breast cancer. Axillary radiotherapy is currently available in west and north Wales, but not available in southeast Wales where axillary node clearance is the standard treatment.
• Delayed breast reconstruction for patients undergoing mastectomy is impacting physical, psychological, emotional and sexual outcomes.
• The statement of intent for diagnostic imaging services published in March 2018 concluded that Wales has seven radiologists per 100,000 population in comparison to a European average of 12 and the paper on breast imaging by NHS Wales health collaborative concluded that the situation for breast radiologists was worse. The projected increasing demand, difficulty in recruitment and forthcoming retirements, would make the situation more difficult.
• Symptomatic and screening services are run independently but use the same capacity. The need for collaborative working was highlighted and consideration was given to co-locating screening and symptomatic services to provide a collaborative approach for the same pool of highly skilled clinicians. An integrated model would concentrate the highly skilled staff, who can work flexibly and provide cross cover when needed and deliver a high-quality service.

Core themes

There were several common themes that are applicable to all tumour sites as follows:

• implementation of the national optimal pathways
• work with HEIW on longer term workforce retention and recruitment strategies
• regional working and effective collaboration

The NHS Executive highlighted the support available to NHS Wales organisations to improve cancer services:

• development and implementation of the national optimal pathways
• sharing learning and good practice
• quality improvement support to multi-disciplinary teams
• management information systems to map demand across modalities
• reducing variance across NHS Wales organisations
• undertaking gap analysis
• supporting collaborative or regional working

The demand on cancer services, as measured by the volume of pathways opened on the suspected cancer pathway, has increased since the introduction of the planned care recovery plan in April 2022.

Waits are driven primarily by delays in the early stages of the pathway at first outpatient appointment and diagnostics stage. These are often services that have to balance wider planned care demand and clinical urgency with suspected cancer. Wider capacity challenges in pathology, imaging and endoscopy therefore significantly impact the cancer pathway.

A diagnostic strategy has been developed to support the development of more sustainable diagnostic services and the implementation plan will be published following consultation.

It is important for health boards to maintain focus on cancer service recovery, maintaining a balance of treating clinically urgent patients and reducing the backlog of people waiting more than 62 days to start treatment. Addressing the backlog impacts the capacity to treat those still waiting within the target timeframe.

The following commitments and actions were agreed and progress against these will be monitored:

• health boards to implement the national optimal pathways and reduce the variance in pathways through one-stop models, where appropriate
• health boards to agree with the NHS Executive a target for sustainable reduction in the number of patients experiencing long waits, based on the levels required to achieve target compliance, and take urgent and immediate action to reduce the volume of patients waiting more than 62 days to start their first definite treatment
• health boards, with support from the NHS Executive, to focus on reducing the time to first outpatient, increase straight to test, and ensure all diagnostic activity is completed within 28 days
• NHS Executive to discuss with HEIW options to support workforce retention, recruitment and upskilling of the cancer workforce
• NHS Executive to facilitate collaborative and regional working for specialist and fragile services