The Government has begun to respond to the Independent Cancer Taskforce’s new Five Year Cancer Strategy – Achieving world-class cancer outcomes: a strategy for England 2015-2020.
A recent announcement from the Department of Health makes a commitment to some of the recommendations in the strategy and specifically picks up on a number of issues raised in our recent research study for Cancer Research UK on the capacity of endoscopy services in England - Scoping the Future. (An endoscopy is a procedure where the inside of the body is examined using an endoscope).
Our study carried out by the Health Services Management Centre in conjunction with the Strategy Unit at the Midlands and Lancashire NHS Commissioning Support Unit highlights the pressures facing endoscopy services within the NHS in England. The media have picked up on the concerns regarding the double whammy of increasing activity and struggles to staff services across a range of diagnostic services raised by our study and a second report commissioned by Cancer Research UK on imaging services – Horizon Scanning produced by 2020 Delivery (for example here, here and here).
Our endoscopy study notes that though there has been investment in endoscopy services over recent years - with more physical space provided, staff recruited, and lots of attention given to improving quality and efficiency; this has really only enabled units to keep their heads above water with some fairly frantic paddling. It hasn’t managed to put them in a position to cope with what the future will bring. Units are struggling to recruit and retain trained non-medical endoscopists, and when they are fortunate enough to recruit, training new recruits takes approximately two years, so there is the inevitable boxing and coxing in the meantime to manage demand.
As units juggle the demands of increasing numbers of referrals that must be seen within the current government targets for diagnosis of suspected cancers – spiked by recent media awareness campaigns - and the inevitable increases in surveillance of those people deemed at high risk of developing cancer as more patients enter the system, endoscopy lists intended primarily for training new staff are coming under pressure with extra cases being squeezed in. Respondents to our study talked about a vicious circle, whereby the less training that can be accomplished due to service demands, the longer it takes to train people to manage full lists and increase capacity. And the more that established endoscopists have to shoulder the burden of extra lists while new endoscopists are training, the more these staff are likely to either leave the profession, or experience stress and burn out.
The modelling of future activity - which formed an integral part of the study - forecasts that by 2019/20, the demand for gastrointestinal endoscopy will exceed 2.4 million procedures per annum. This represents an expansion of 44% over the 2013/14 baseline and a growth rate of 6.5% per annum, substantially greater than historical rates of increase in GI endoscopy activity of 2.8% per annum.
Our modelling work from the study suggests that approximately one quarter of the overall forecast growth (c. 1.5% per annum) arises from changes in demography and population health status - factors that might be considered to be outside the immediate control of the health system. However, the remaining growth is driven by deliberate strategies to improve population health or through the roll-out of new technologies. The single largest contributor or growth in endoscopy activity is the roll-out of the bowel scope programme.
It is appropriate therefore that the Government’s announcement includes such measures as providing additional investment in diagnostics over the next five years, and the training of an additional 200 staff to carry out endoscopies by 2018 - in addition to the extra 250 gastroenterologists the NHS have already committed to train in the next five years.
The introduction of a 28 day standard within the new measures, so that patients will be given a definitive cancer diagnosis or the all clear within 28 days of being referred by a GP, is rather less straightforward however and the implications and benefits of this need careful modelling and consideration.
Our study demonstrates that under existing and future predicted pressures the system needs investment irrespective of the speed of diagnosis. We did not consider the implications if this aspect is accelerated – i.e. how one physically ensures there is capacity within exacerbated time constraints when numbers of referrals may fluctuate day to day. To ensure that every endoscopy can be done within an accelerated timescale, some capacity will need to be left available and consequently unused on occasions. The same will no doubt be the case with a whole range of services, including other diagnostics and pathology services.
The case for improving cancer outcomes by investing in a significant expansion in diagnostics has yet to be made. It may be that the provision of more diagnostics will not decrease late diagnosis enough to make a significant difference to outcomes. What is sure is that careful evaluation of the costs and benefits of changes to cancer care across the pathway will be needed if essential improvements in outcomes are to be achieved whilst maximising cost-effectiveness at a time of NHS austerity.