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Ein cyf / Our ref: GL/DH/1311/915 |
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Dyddiad / Date: 4 April 2014 |
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Dear Sir/Madam
Inquiry into the Implementation of the Welsh Government’s Cancer Delivery Plan
Thank you for the invitation to provide feedback on the Welsh Government’s Cancer Delivery Plan I hope the following information will be of use to the Health and Social Care Committee.
This response reflects the views of the Health Board and the North Wales Cancer Network. In doing so it reflects comments that are drawn from the perspectives of an NHS provider, commissioner and patients advocate.
Overview
Whilst it is the case that much of the Cancer Delivery Plan will be delivered by 2016 it is also likely that aspects of the plan will remain challenging and might not be delivered. Not only does the plan state that the incidence rate of cancer is increasing, it also makes reference to the challenging economic climate that not only existed at the time of publication but continues to exist at the time of this response. There must therefore be a concern that certain aspects of the plan cannot be delivered when set against a context of multiple priorities and diminished funding.
It is our view that access to evidenced based cancer treatment is consistently available to the people of Wales and as the evidence accumulates to support new therapies, these are adopted as soon as practicable in Wales. The key challenges for Wales and the Delivery Plan are early referral/diagnosis, end of life care and equity. Early diagnosis is the key to good outcomes in cancer and at this time rapid access to diagnostics provides perhaps the greatest challenge.
The plan has delivered much around end of life care, however it should be noted that ‘end of life’ features within a cancer plan, whilst our concern remains that end of life needs to feature in all plans related to chronic disease.
Equity across Wales continues to be a challenge, and whilst the plan makes attempts to address this, it remains an area which could be difficult to deliver by 2016. An example here would be the number of approved Individual Patient Funding Requests (IPFR) for cancer drugs where there exists variation between different areas of Wales.
Specific Outcome Indicators and Performance Measures – Annex 3- Cancer Delivery Plan
It is unclear as to whether the plan can within the stated timeframe influence a reduction in the rate of increase in cancer incidence. A reduction in incidence will in the main depend on lifestyle changes eg smoking ban and it is unlikely that the benefits from such developments will be seen immediately. This said it is noted that more emphasis has been placed on the prevention agenda following publication of the plan and this is to be welcomed.
It is pleasing to see that a significant reduction in mortality accompanied by an increase in 1 and 5 year survival has been evidenced in the time of the plan and it is believed that this improvement can continue. This is particularly felt in North Wales where the cancer burden is the greatest in Wales but is matched by 1 and 5 year survival that is the best in Wales. This improvement in survival is however not matched by compliance with the cancer treatment waiting times which have proved difficult to attain in a sustained manner since the publication of the Delivery Plan – this said in most cases 9 patients in 10 are still treated within the target parameters. Failure to attain these targets consistently across Wales is, in our view, related in significant part to achieving an early diagnosis and the inequity mentioned earlier.
The last points above also reflect the stage of cancer when diagnosed and of course this influences the performance measure that, increasingly, patients are diagnosed with lower stage disease. This may be an issue that is difficult to improve significantly within the timescale of the plan as it will depend on early presentation to primary care from the public and prompt referral to cancer services as well as improved access to diagnostics.
Finally the plan has succeeded in ensuring that clinical trial activity is maintained, 30 day post treatment mortality data is collected and that all patients will have a key worker. Regarding the last two items we believe it reasonable to expect that by 2016 all 30 day post treatment mortality will not only be collated but interrogated. In terms of a Key Worker, all patients will not only have a key worker but one that provides greater impact on their care.
Summary of Outcomes- Annex1- Cancer Delivery Plan
Outcome 1- People are aware of and are supported in minimizing their risk of cancer through healthy lifestyle choices
The data suggests that since publication of the Delivery Plan there has been limited impact on the behaviour of the public in terms of lifestyle adjustment. This said it is also the case that at a local level there has been a significant increase in efforts within the NHS to address these issues. It is therefore possible that a more significant change may be apparent as the result of this plan. In North Wales this is reflected by new public awareness campaigns using public transport and cancer prevention talks in state schools.
Outcome 2- Cancer is detected quickly where it does occur or recur.
As previously mentioned it is this aspect where the plan at this time has its greatest challenge. Access to primary care is becoming more challenging as is direct access to diagnostics from primary care. In addition availability of more services 24 hours a day all year round is challenging and again availability of services more locally is difficult to achieve.
It is felt that this vital aspect of the plan has perhaps not been given the emphasis it should have been and the impact has been underestimated. It is these aspects of the cancer pathway that are subject more than any other to competing priorities and funding pressures and this needs to be addressed in the second half of the intended duration of the plan.
Outcome 3- People receive fast, effective treatment and care so they have the best possible chance of cure
In 2014 the Cancer Delivery plan has maintained momentum of speed of treatment and access to evidence based effective treatment. Whilst the issue of cancer waiting times has already been addressed it is worth noting that new emphasis is being placed on Peer Review – a process that features directly within the plan. This process is now addressing its fourth major cancer type and by 2016 all main cancer types will have been subject to the process with the first cohort of cancer types getting their first re-assessment.
Peer review alongside further developments within the cancer performance framework should ensure that the Delivery Plan ensures ongoing and improved quality assessment of cancer services.
Outcome 4- People are placed at the heart of cancer care with their individual needs identified and met so they feel well supported and informed, able to manage the effects of cancer
The Cancer Delivery Plan has been successful in providing greater emphasis on the holistic nature of cancer care and certainly at a local level significant efforts are being made with the third sector to address this person-centred issues. Whilst the various pieces of work are not yet complete there is a focus and momentum to have established and sustainable models of care by 2016.
In North Wales this is evidenced by projects regarding delivery of Key Worker, holistic care planning and rehabilitation.
Outcome 5- People approaching the end of life feel well cared for and pain and symptom free
Considerable progress has been made to date regarding the provision of palliative care including aspects of care involving the third sector and 7 day week working. The emphasis on seamless working across all sectors of the NHS and the 3rd sector is welcome and certainly evidenced in the day to day practice in North Wales.
Conclusion
It is noted that this inquiry takes place half way through the lifecycle of the Welsh Government’s Cancer Delivery Plan and as such certain aspects of the plan remain work in progress.
The themes within the plan remain valid as do many of the outcomes identified in the various annexes and to this extent the plan provides an important contextual framework for improving the delivery of cancer care.
Progress against the plan is evident especially in terms of ensuring the safety and quality of cancer treatment and end of life care. Progress is also evident in terms of holistic person centred care and many developments will be implemented in full by 2016.
The principal challenges for delivery of the plan remain at the front end of the cancer pathway – prevention and early diagnosis. The objectives for prevention though laudable may be slower to deliver outcomes and real improvement in the burden of disease may not be seen for many years rather than by 2016. The immediate concern however is achieving a rapid cancer diagnosis – this is the limiting factor that needs to considered further if the plan is going to achieve its wider objectives. In North Wales this is reflected by new public awareness campaigns using public transport and cancer prevention talks in state schools.
Yours sincerely
GEOFF LANG
ACTING CHIEF EXECUTIVE