– In partnership with Royal Marsden Partners

Finding cancer early is the single biggest step we can make to improving patient outcomes and saving lives. In 2023 just 57.6% of staged cancers[1] were diagnosed at an early stage[2]. This is well below the NHS Long Term Plan ambition of 75% by 2028.

With just 1 in 15 cancers diagnosed via screening, improving early diagnosis is heavily reliant on symptomatic pathways. In practice, this means supporting patients to present early in primary care and supporting primary care to make appropriate referrals through Urgent Suspected Cancer (USC) pathways.

We have partnered with RM Partners, the Cancer Alliance serving North and South West London, to identify practical steps which can be taken in primary care to improve rates of diagnosis. The research is based on analysis of 46 interviews with GPs across West London alongside data including referral behaviour, workforce and population demographics.

The research identified six actions for general practice to increase early diagnosis:

1. Reviewing practice performance and operation: Understanding and reviewing cancer performance data, participating in cancer audits, internal case review and knowledge sharing.
2. Adopting quality systems: Use of best practice decision support and safety netting tools, underpinned by a culture of quality improvement.
3. Addressing systemic inequity: Increasing awareness of systemic inequity and the impact on cancer through training and actively implementing best-practice process.
4. Workforce stability: Retaining staff without high reliance on locums, whilst ensuring clear orientation of locums when required.
5. System awareness and participation: Awareness and use of direct access and Vague Symptom pathways, building relationships within PCNs and with secondary care
6. Training and clinical improvement: Accessing cancer-specific training to support the appropriate use of cancer pathways.

These findings are underpinning the support being provided to primary care teams within RMP. More detail on the research findings and recommendations as well as the methodology can be found below, and both reports are available to download.

[1] From CancerData. This excludes the 20% of cancers which are unstaged in the Rapid Cancer Registrations Dataset.

[2] Early stage is defined as a cancer diagnosed at Stage I/II

Since the pandemic, SACT activity has grown rapidly

The number of patients receiving Systemic Anti-Cancer Therapy (SACT) in Thames Valley grew by 7% between 2021 and 2022. This rise in activity, combined with increasing treatment complexity, length, and national shortages in SACT staff, has put pressure on departments and workforce.

Thames Valley Cancer Alliance serves a population of 2.3 million people, spanning two ICSs, four Acute Trusts and nine Hospitals. SACT is delivered within the Alliance by Oxford University Hospitals (OUH), Buckinghamshire Healthcare (BHT), Royal Berkshire (RBH) and Great Western Hospitals (GWH).

Starting in September 2023, Edge Health worked closely with TVCA and its constituent trusts to provide demand and capacity analysis, identify system pressures and develop innovative solutions to meet this need over the next five years.

As an Alliance, we were aware of the national and regional SACT pressures and wanted to review our demand, capacity and workforce to support service development and raise the awareness of the significant increase in activity we will expect in the coming years. Edge Health worked closely with our clinical teams to understand the pressures and activity in SACT services and to provide recommendations to be delivered across the system including a demand and capacity tool for our biannual SACT assessments.

Edge Health are knowledgeable, professional and a very approachable team supporting the requirements of our service.

Lyndel Moore – TVCA Cancer Clinical Lead for Nursing and AHPs

Our approach involved working closely with key stakeholders across the Alliance to draw out insights from provider data and workforce interviews

After gathering data on patient volumes, complexity and treatment types and combining this with workforce data from all four acute trusts, we interviewed key clinicians and stakeholders to understand and articulate the pressures and problems that they were facing on a day-to-day basis.

From data and interview insights, we developed a set of scenarios for the future growth of SACT treatment within the alliance. These were:

• Population growth scenario: demographics-driven model
• Core growth scenario: based on growth trends observed locally and nationally
• High growth scenario: accounting for additional pressure exerted by factors such as high growth in demand for oral SACT treatments

Note: Chart figures hidden for confidentiality

We wanted to provide actionable solutions to pressures faced by SACT units

Engagement with trusts and thorough analysis led to the identification of four wide areas for opportunity:

• Capacity
• Efficiency
• Workforce
• Operations

We developed creative and practical opportunities that Trusts could utilise to help tackle these growing problems, such as increasing self-administration of subcutaneous SACT to manage capacity pressures or developing non-administrative and managerial professional growth avenues to help increase the retention of workforce.

To aid Trusts with their future demand and capacity planning needs, we produced an interactive demand model. This allows Trusts to use pre-generated demand projections or input their own figures for future workforce planning and has already been used as part of TVCA’s bi-annual demand and capacity planning.

Integrated Care Boards (ICBs) and cancer alliances both provide operational and strategic support for Trusts in delivering cancer care. However, supporting Trusts can be challenging for system partners who often only have access to scattered data that updates infrequently from isolated systems. This means that identifying capacity bottlenecks often occurs after treatment standards have already been breached, which  adversely affects critical 28-day diagnostic standard and 62-day treatment standards.

The CanCollaborate tool, developed by Edge Health in partnership with the Northern Cancer Alliance (NCA), The North Tees and Hartlepool NHS Foundation Trust, and The South Tees Hospitals NHS Foundation Trust, was named to reflect its purpose of enhancing collaboration between Trusts and system partners. CanCollaborate is a system-wide cancer patient management tool, featuring patient tracking and demand forecasting, that helps users proactively identify and act to mitigate capacity bottlenecks.

What is CanCollaborate?

CanCollaborate is a cloud-based solution featuring seamless data integration, real-time updates, and a secure, user-friendly web application interface for monitoring and managing cancer waiting lists.

• Seamless Data Integration: At the core of CanCollaborate is its robust data integration capability. We established a secure, automated data transfer process with Trusts, with encrypted data uploaded to our system every hour. Our methodology enables us to link patient pathways from disparate systems (e.g. Infoflex/Somerset), enabling an integrated view of complex pathways across both Trusts, while eliminating manual intervention.
• Real-time updates: CanCollaborate takes a proactive rather than a reactive approach to cancer pathway management. Our system ensures that North Tees, South Tees and NCA always have access to the same live information. The ability to monitor the PTL dynamically allows for responses to emerging issues, helping NCA to deliver shared solutions.
• Leveraging cloud technologies for data processing: We developed robust pipelines in Azure, integrated with Databricks, to ensure efficient and secure data handling and timely output of the processed data to a SQL database.
• Web application interface: Leveraging our established data pipeline, CanCollaborate provides AI-enabled predictions of a patient’s risk of missing cancer waiting times standards (e.g. 62-day target), which users can interact with through a variety of tabs, including:
  • ‘Waitlist Summary’ tab which provides a snapshot of the current state of the cancer waiting list across both Trusts, helping users quickly grasp the overall state of the patient pathways in their Trust as well as patients that are being tracked by both Trusts.‘Current Cancer PTL’ tab which allows users to identify specific pathway issues and mitigations in real-time. The tool presents patients’ risk of breaching, helping to prioritise the patients that require immediate actions.
  • ‘Demand & Capacity’ tab utilises patient-level data to forecast demand and capacity 12 weeks into the future, facilitating provider planning and system-wide discussions around mutual aid.

Figure 1. Example of CanCollaborate workflow for system and Trust users, for lung cancer

Based on early testing, if our recommendations are actioned by Trusts, CanCollaborate has the potential to increase the percentage of patients meeting targets by an average of 15% across tumour sites (e.g. from 60% to 75%).

Lessons learned and next steps

• Information governance: Secure and compliant management of data across North Tees and South Tees was crucial in the development of CanCollaborate. Before undertaking this work, we supported a joint information governance process between North Tees, South Tees and the NCA.
• Linking data: At the outset of this work, data reconciliation was one of the main challenges faced by the Trusts due to their data being in separate, unlinked systems. To protect patient-level data we established advanced encryption techniques, ensuring data security and confidentiality throughout the integration process. Finally, we implemented novel linking techniques to integrate the data from the different sources.
• Fostering user engagement: CanCollaborate is a tool aimed at meeting the various needs of different types of users (e.g. cancer managers, system partners, BI teams, clinicians). As CanCollaborate continues to be operationalised, we are continuing to work with the NCA and Trusts to identify the user groups that would most benefit from the tool.

There is no greater source of pressure in the NHS at the moment than staff shortages. Rising demand, growing complexity and lengthening waitlists, combined with high turnover, absence and staff leaving the NHS post-Covid, have created a gap between demand and supply of staff.

Understanding and responding to this gap is a complex problem across the health system. Doing so requires a detailed understanding of future workforce requirements and innovation in model and roles. By partnering with Dearden HR, award winning HR and OD consultants, we are able to combine our robust analytics and understanding of data with bespoke people and OD solutions.

West London, Surrey & Sussex Radiotherapy Operational Delivery Network

One example of our work together was with the West London Surrey & Sussex (WLSS) Radiotherapy Operational Delivery Network (ODN). The ODN, which comprises 4 radiotherapy providers, sought to understand their future workforce requirements and opportunities to innovate and implement a new workforce model to meet demand.

Approach

Our approach revolved around three workstreams. The first two supported the development of a rich evidence base, through modelling of future demand and activity and gaining a detailed understanding of the ODN’s current workforce status. These efforts formed the groundwork for assessing the future workforce requirement and developing an action plan for meeting this requirement. Our approach was designed to ensure that the final outputs are rigorous in detail and evidence, innovative in approach, built off existing best practice and co-developed with providers and ODN leadership.

The modelling was built on anonymised attendance-level data collected from each provider. This level of detail allowed for robust modelling of the workforce requirements of current and future activity, considering changes in complexity, treatment type and pathway. This was supported by workforce data and staff engagement, including a questionnaire and interviews to better understand each Trust’s workforce model, as well as staff motivation and job satisfaction at each of the Trusts.  This multi-faceted approach ensured a comprehensive understanding of the present workforce landscape and laid the groundwork for informed workforce planning and recommendations.

Future demand was modelled based on a range of scenarios, considering changing population, demographics, population health and cancer treatment. This modelling informed future workforce requirement scenarios. An interactive workforce planning tool was developed alongside the final report, enabling scenario analysis for future workforce shortfalls or surpluses based on Trust-specific assumptions.

“Partnering with Edge Health allows us to develop recommendations and an implementation plan which is based on clear and rigorous data analysis.”

Michelle Hodgkinson, Director, Dearden HR   

Outputs

Based on the demand and capacity modelling and our understanding of current staffing levels, we calculated the additional establishment and in-post WTE required to meet the recommended level of staffing. The work also developed a series of recruitment and retention interventions, including regarding:

• Apprenticeships
• International recruitment
• Active retention and support
• Development roles
• Flexible working

The combination of quantified workforce gaps and recommended interventions has provided the ODN and each Trust with a strategy for addressing future workforce pressures. This is currently being taken forward within the ODN.

Challenges in the Existing Healthcare System for Chemotherapy Patients

Cancer patients undergoing chemotherapy have to navigate a complex healthcare system at a particularly stressful point in their lives. Various patient management apps exist to support both patients and providers with this treatment pathway. However, a lack of a single source of information disadvantages both patients and Trusts.

Integrated Solutions for Patient Management and Prescribing Process

In response to this, the industry leader in electronic chemotherapy prescribing developed a product that integrates all aspects of patient management from referral to discharge and simplifies the prescribing process for healthcare professionals. Additionally, another provider created a patient-facing mobile app that brings disparate pieces of information from across the healthcare ecosystem together and delivers personalized support for cancer patients.

A typical Trust will treat between 1,200 and 1,500 new patients with chemotherapy each year. As such there are significant benefits to integrating these two patient management solutions and offering a bundle for purchase by acute providers. Edge Health was commissioned to deliver a report on the potential impacts of the integration. Through a review of existing literature and clinical engagement, we assessed the wide range of benefits throughout the patient journey. By quantifying some of these benefits, we sought to highlight the potential magnitude of the advantages for both Trust’s finances and patients.

Our Analysis of Impacts and Benefits of patient management solutions

Positive Impacts on Patient Care and Risk Management

Many of the identified benefits are felt by the patients themselves. The integrated app and system facilitate the delivery of optimal patient care and minimise chemotherapy treatment’s risks and side effects. The advantages of this integration appear to be most material for patients who may require changes to their treatment, due to adverse reactions or toxicity, or for the rarer cases of more severe illnesses such as colitis and neutropenic sepsis.

Financial Benefits to the Healthcare System

There are also clear and direct financial benefits to the NHS. Chemotherapy drugs are expensive and waste is a substantial issue, whilst the costs of treating patients who develop more significant illnesses during their treatment can be very large. Through accurate capturing and sharing of patient-reported outcomes, the integration contributes to cost savings by minimising the expenses associated with treating such complications or illnesses.

The integration of chemotherapy patient management apps offers significant benefits to both patients and healthcare organizations. By streamlining the treatment process, improving patient care, and reducing financial burdens, this integrated solution has the potential to enhance the overall quality of care for cancer patients undergoing chemotherapy. Acute care providers can leverage these apps to optimize their treatment protocols and improve resource allocation, ultimately leading to better patient outcomes and more efficient healthcare delivery.

There is a recurrent emphasis on the need for Integrated Care Systems (ICSs) to address health inequalities, as highlighted by media outlets, conferences, and reports.

Addressing these disparities is a monumental task, especially for the newly established ICSs, which have been tasked with not only establishing new governance and strategies but also tackling an elective backlog and long-standing health concerns like health inequalities.

One crucial area of focus, particularly in relation to the Core20Plus5 mandates, is cancer, as we are aware of inequalities in access impacting diagnosis and survival rates. The ambitious objective set out by the NHS Long Term Plan is to diagnose 75% of cancers at Stage 1 or 2 by 2028.

Lung cancer, where 64% of patients receive a diagnosis at stage 3 or 4, is an excellent example that underscores both challenges and opportunities for ICSs.

Why avoiding emergency diagnoses is key

We examined publicly available data on lung cancer care. Patients referred by a GP are more likely to be diagnosed at an early stage than those in emergency settings.

This relationship can be seen by comparing NHS clinical commissioning groups (CCGs), where a 10% increase in GP diagnoses is associated with a 3% increase in early diagnoses (stages 1 and 2), when adjusting for confounding factors, as shown in Figure 1.

Figure 1. Source PHE 2018

Since patients are over 3 times more likely to survive more than 5 years when diagnosed at stage 1 compared to stage 3[i], detecting cases via referrals from primary care has a direct impact on lowering lung cancer mortality rates associated with a late-stage diagnosis.

Table 1. Source NCRAS 2015-16

Reducing variation in primary care referral rates

The challenge, however, lies in the unequal volumes of lung cancer referrals made in primary care, which vary dramatically across NHS regions. We have used Public Health England data and machine learning approaches to uncover the relationship between the number of GP referrals and the percentage of all lung cancer cases diagnosed from these referrals.

As seen in Figure 2, there is a clear positive relationship between the volume of referrals from primary care and early diagnosis, which is particularly strong for areas with low referral volumes.

It follows that if GPs with low referring rates could be supported increase referral volumes, there will be a high impact in driving earlier diagnosis and improving survival rates. This means that increasing referral rates would be very material for the NHS and its patients. In fact, if all ICSs were able to bring all the lowest referring GP services in line with the bottom quartile, as shown in Figure 3, we would expect 700 extra early diagnoses and 100 lives saved per year across the country.

How these findings turn into practical implications for ICSs

Variation in urgent suspected cancer referrals and early diagnosis rates is likely a combination of both GP organisation/behaviour and broader patient behaviour. For the former, it is well known that there are pressures on GP numbers and overall workload, which will impact access locally.

Nonetheless, there will be opportunities for ICSs to surface data on variation in cancer referral rates and work with practices to understand variation and support where necessary.

ICSs can also lead improvements by understanding how their local population, demographic and health system factors are influencing access. Although this highlights the complexity of the challenge, it also offers multiple sources of opportunity for systems.

In our experience, some of the key actions for ICSs to address the above are:

• Involve primary care networks (PCNs) and cancer alliances early into conversations about improving cancer detection – we are currently working with a cancer alliance on data-driven research to better understand the drivers of variation in the detection rate and the most effective interventions for addressing them.
• Provide practices and PCNs with tools to better understand their local population and their health needs (see here for a population health management dashboard we developed for Surrey Heartlands).
• Plan adequately for workforce, particularly in primary care, to make sure there is enough capacity to boost referrals and avoid workforce overwhelm. Given the falling numbers of full-time equivalent GPs, this is a priority area for ICSs and nationally.
• Assess secondary care diagnostic capacity, including modelling demand and capacity and promote system-wide initiatives such as new community diagnostic centres, implementing rapid diagnostic services and supporting mutual aid between trust, as we have discussed previously.

As the landscape of healthcare continues to evolve, ICSs have a crucial role to play. The responsibility lies with them to implement innovative strategies, utilise data-driven research, and ensure a robust primary care workforce.
With a concerted effort towards these goals, ICSs have the potential to significantly influence early cancer detection rates and, ultimately, patient survival.

[i] Characteristics of patients with missing information on stage: a population-based study of patients diagnosed with a colon, lung or breast cancer in England in 2013. C Girolam and others BMC Cancer (2018). Volume 18, Page 492

Standards introduced in October 2021 mandate that at least 75% of patients urgently referred by a GP[1] for suspected cancer should receive a diagnosis (or be cleared) within 28 days. In September 2022, however, 33% of them – 78,000 a month – did not receive a timely diagnosis. This reduces their chances of survival considerably by preventing prompt treatment.

As shown in Figure 1, from April 2021 to September 2022, the number of patients meeting the 28-day target has dropped from 73% to 67%, and the 75% target has yet to be met. This is likely due to the large increase in the number of referrals registered during the past months which is constraining diagnostics capacity (as discussed in our previous post).

This varies greatly by suspected cancer. The 28-day rate for breast and children’s cancer in September 2022 was in fact close to 90%, while for tumour sites such as gynaecology, skin, lower gastrointestinal and urology (including prostate) it was as low as 50%.

For urological malignancies, the failure to meet the 28-day diagnostic target has a significant impact on the 62-day treatment target. As shown in Figure 2, the longer the delay in obtaining a diagnosis, the more likely patients are to miss the 62-day treatment benchmark. This highlights the crucial importance of timely diagnosis in ensuring prompt and effective cancer treatment.
Furthermore, as the number of diagnostic tests administered increases, so does the proportion of patients who meet the 28-day diagnostic target. This correlation suggests that delays and capacity limitations in diagnostic testing are playing a key role in the decline of cancer care outcomes nationwide[2].

This is not going unnoticed, with trusts racing to implement a number of solutions to reduce pressure on hospitals and provide quicker access for patients. There are three broad groups of approaches to streamlining cancer diagnostics:

• Creating additional diagnostic capacity using weekends, new diagnostics centres and independent sector diagnostics – For instance, the opening of new community diagnostic centres across England will provide elective diagnostics such as checks, scans and tests away from acute facilities and free up hospital capacity.
• New population screening programmes – An example of this is the new lung cancer screening programme which aims at improving early diagnosis by running a low-dose CT scan of the lungs on high-risk people and inviting them for further tests if abnormalities are shown.
• Implementing additional rapid diagnostic services for urgent patients – Like the national roll-out of fast-track testing, which from November 2022 allows every GP team to directly order CT scans, ultrasounds or brain MRIs for patients with concerning symptoms.

The examples provided above are just some of the latest initiatives aimed at cutting down waiting times for cancer patients across the NHS. In our experience, however, one approach has already shown huge potential for effectiveness: mutual aid between Trusts. In the next blog post, we’ll dive into the details of data-driven mutual aid and demonstrate the vast impact it can have on diagnostic and treatment efficiency and speeding up recovery.

[1] Along with patients referred by their GP with breast symptoms where cancer is not initially suspected; or referred by the National Screening Service with an abnormal screening result.
[2] The data used include both diagnosed and non-diagnosed patients. With more specific data this correlation is believed to be even stronger.

In England, 40% of new cancer diagnoses come from an urgent referral from a GP [1]. NHS hospitals are required to start cancer treatment for everyone who’s been urgently referred within 62 days. These cancer waiting times standards help ensure people are rapidly diagnosed and treated – critical for long-term outcomes such as survival.

More patients than ever are now waiting more than 62 days for treatment. Of all completed pathways, the number of patients waiting longer than 62 days to receive treatment has almost doubled [2] from 6,242 in September 2019 to 11,910 in September 2022 – 39.5% of 62-day pathways, meaning that only 60.5% of patients are meeting the 62-day target. What factors are contributing to this?

Referrals are at record highs

After a drop in urgent referrals [3] in 2020 due to the Covid-19 pandemic, demand for cancer services is now at its highest since 2019 (a 38.0% increase from September 2019, corresponding to 249,994 urgent referrals in September 2022). There are several possible reasons behind this increase – from changes in referral patterns to the “missed” referrals during the pandemic that are now coming back to the system.

As shown in Figure 1 below, there seems to be a positive correlation between the increase in the number of 2 weeks wait referrals and the decrease in the percentage of patients meeting the 62-day target.

Figure 1

Diagnostics capacity is a bottleneck

The faster diagnosis standard, introduced as part of the long-term plan, ensures that people urgently referred from a GP [4] receive their diagnosis by day 28 of their pathway. From April 2021 to September 2022, the number of patients meeting this standard has dropped from 73% to 67%. This suggests that increased referrals are also constraining cancer diagnostics capacity. We can’t say for sure without patient-level data, but likely, many of the same patients who miss their diagnostic target (33%) also miss their treatment target.

Hospitals are working through their backlogs

Figure 2 illustrates that while capacity has been constrained throughout the pandemic, 5.1% more patients are now being treated every month compared to the 2019 average (27,332 vs 28,735). This suggests that Trusts are working hard to increase their capacity to meet the increase in demand.

Figure 2

There has been an increase in the number of extremely long waiters treated, with the percentage of people waiting longer than 104 days doubling from 5.5% in September 2019 to 12.9% in September 2022.

Trusts are focussing their increased capacity on their longest waiters – temporarily decreasing performance, but an indicator that Trusts are working to reduce their backlogs.

Managing increased referrals will continue to be a challenge for Trusts in the months to come. How will they meet this challenge?

In our next three blog posts in this series, we will explore potential solutions – including approaches to streamlining cancer diagnostics, the potential of mutual aid and strategies for identifying and reducing health inequalities.

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[1] As of 2016, https://www.ncin.org.uk/publications/routes_to_diagnosis

[2] Grown by 90.8%

[3] Note that the two-week wait (2WW) appointments are a proxy for incoming referrals. Referrals may be higher given that only 73-78% of 2WW appointments have been within the standard from July-September 2022.

[4] Along with patients referred by their GP with breast symptoms where cancer is not initially suspected; or referred by the National Screening Service with an abnormal screening result.

Since the start of the pandemic, the number of cancer patients treated has decreased, while the number of patients breaching the 62-day recommended target has risen. The risk of breach is particularly high for patients on complex pathways – partially due to the administrative time required for Trusts to exchange information on pathways and agree next steps.

 As Trusts move to gain efficiencies through shared learning and mutual aid they need integrated data and tools to inform their decision-making. This is why Edge Health developed CanCollaborate, a tool which allows Trusts and system partners (like Cancer Alliances) to monitor and risk-assess their cancer patient tracking list (PTL) across multiple Trusts. The system-wide solution unlocks information for Trusts and system partners on complex pathways, allowing them to understand and support timely access for patients who are transferred between two or more hospitals.

 CanCollaborate is compatible with all major cancer tracking systems (e.g., Somerset, Infoflex, Dendrite) and uses an approach that allows patients to be linked, while preserving anonymity. It includes both patient-level prediction of breach risk and a summary of breach risk for different tumour sites and patient cohorts linked to specific actions, making it easy for administrators to act based on recommendations. It also provides a weekly demand and capacity forecast 12 weeks in advance to align with staff scheduling, which is used to support system planning and discussions around capacity sharing. By linking demand and capacity forecasting with patient level data, Trusts and systems can easily understand how individual patient pathways contribute to overall demand for services.

 Through development of this tool, Trusts have been able to reduce administrative time, assure equity of access across Trusts in the region, plan in advance through receiving early warnings of incoming tertiary referrals, and flag patients in urgent need of actions. By enabling proactive management of patient pathways and facilitating joint working, Trusts are able to reduce 62-day breaches and improve patient experience and outcomes.