Improving Cancer Outcomes – Why ICSs Must Tackle Health Inequalities

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