Beating Cancer: Ambition and Action (2016) update: achievements, new action and testing change

An update to our 2016 cancer strategy - Beating Cancer: Ambition and Action.

New actions and tests of change

A wide range of work is underway to consider what changes and improvement can be delivered through the next cancer strategy which will be published next year, whilst ensuring changes or improvements that can be made now are taken forward as quickly as possible.

We will take forward work in all of the areas listed below. These 53 actions will help ensure we are making impacts now to improve patient experience and outcomes, but also build evidence and business cases to take forward larger programmes through the next strategy. They are all additional to or will enhance existing actions in the Beating Cancer: Ambition and Action strategy of 2016.

Actions on public health and cancer prevention

We will continue with existing activity and begin new actions to create healthier environments for people, make improvements and refinements to existing screening programmes and work to consider the safe and effective introduction of new technologies and ways of working where they will benefit patients.Some 40% of cancers are preventable, and we will continue to take brave and radical measures to combat the various risk factors for cancer. The Scottish Government has made long-term commitments to halve childhood obesity by 2030 and create a tobacco-free generation by 2034.

We believe that work on these commitments will have a significant protective effect on the Scottish population and cancer incidence. Scotland's new public health body, Public Health Scotland, will be established in April 2020 and will have a key role in embedding the preventative and protective actions and commitments into a wide, whole-system approach across health, care and other key areas where change will help prevent cancers.

We will take positive action to prevent cancer through our public health strategies – in particular our four delivery plans on smoking, diet and healthy weight, physical activity and alcohol. These commitments have an overarching aim to reduce health inequalities, focusing on people in our least well-off communities, where we know there is a disproportionate level of cancer.

Specific activities to support the prevention of more cancers include:

1) We will make progress to remove smoking from more public places, such as around hospitals; and restrict the advertising and marketing of electronic cigarettes.

2) We are consulting on actions around restricting alcohol marketing. Consuming any amount of alcohol on a regular basis increases the risk of developing a range of cancers, and that level of risk increases in line with the amounts of alcohol being drunk. Just over a quarter (28%) of deaths fully or partly attributed to alcohol consumption in 2015 were due to cancer, the largest contributor by disease type.

3) We are considering over this year the evidence for introducing the 9-valent vaccine to prevent more HPV-related cancers. Huge progress has been made in detecting more cervical pre-cancers, but we will monitor opportunities to continue to improve.

4) Recognising the potential of our existing population cancer screening programmes we will further develop our approach to bowel and breast screening to enable us to better target areas of low uptake, particularly in our most deprived communities. We must do all we can to look at ways to encourage participation in screening programmes by educating people on the benefits of screening and empowering them to attend when invited, to ensure those in most need benefit fully.

5) We will monitor research into Cytosponge™, one method of detecting Barrett's Oesophagus, a precursor condition to oesophageal adenocarcinoma, to assess the potential benefits for people in Scotland.

6) We are working now to define a national consensus and approach on the best use of the FIT test in primary care for people with potential cancer symptoms. With the same test having had very significant impacts on detecting early stage cancers and pre-cancerous polyps of the bowel, there is understandable interest in its potential for testing people with potential cancer symptoms. We will support focussed work to ensure a national approach that follows the best evidence.

7) We will work to fully assess the options for the safe introduction of self-sampling for cervical cancer screening.

Actions on early detection

Improving early stage detection has been a crucial factor in improving survival and outcomes for people with cancer, and we will continue to place significant focus in this area; through public and professional awareness, and optimising systems and processes within services, whilst looking at all opportunities to improve patient experience throughout. We will take forward a range of work to continue improving the awareness of symptoms among professionals and the public.

All Health Boards are expected to deliver against 31 and 62 day waiting times standards for cancer, but we recognise that some people are still taking too long to receive the help they need. Our Waiting Times Improvement Plan focusses on this challenge and we expect more boards to be improving performance against these standards over the coming period. The plan includes the goal of 95% of cancer patients receiving their first treatment within 62 days of an urgent suspicion of cancer referral.

8) We will continue to air our latest campaign 'Survivors', which aims to tackle the fear of cancer and encourage people to present to their GP with any worrying signs or symptoms that could be cancer.

9) As part of the £850 million Waiting Times Improvement Plan, we have made £102 million available to Health Boards in 2019-20 to drive down the length of time patients wait for appointments and procedures, prioritising those who are waiting the longest.

10) A further £9.9 million has been made available to specifically target improvement in cancer and diagnostic waiting times.

11) We will continue to work with boards to increase GP direct access to CT scans for people who may have cancer, and will deliver other tests of change in diagnostic pathways, helping more people be tested more quickly, where they would benefit.

12) We are supporting boards with the Effective Cancer Management Framework and education sessions for staff to improve monitoring of people with suspicion of cancer to make sure that cases are escalated effectively when required. Most recently we have seen success in NHS Tayside's adoption of this, with 96.6% of cancer patients receiving treatment within 62 days, up from 81.4% the previous year.

13) We will evaluate and identify the potential to scale up successful projects from the screening inequalities fund, using the opportunity of the next cancer strategy to accelerate progress in this area.

14) Our DCE programme social marketing campaigns will focus on people who are most likely to present with later stage disease and less likely to participate in screening.

15) We are also supporting the dissemination of the updated Scottish Referral Guidelines for Suspected Cancer, including the development of dedicated e-learning, to support primary care clinicians to ensure those with symptoms suspicious of cancer are referred on the right pathway at the right time.

16) We will invest an initial £2 million in gallium scanner technology to improve the detection of advanced prostate cancer.

Actions on smoother patient journeys

Many people have multiple tests for cancer, and this process can cause very significant anxiety for them and loved ones. The required sequencing of tests and all the expert staff needed to administer and interpret them can lead to delays. Occasionally tests have to be repeated. All of this is in the context of increasing demand on the service, with 10% more patients being treated in 2018 compared to 2013 and 21% more being referred for diagnostic tests in the same period.

17) We are working with clinical leads to discuss with boards how diagnostic pathways can be expedited for patients with potential pancreatic cancer

18) We are also working with clinical leads and the Scottish HepatoPancreatoBiliary Network to discuss the possible redesign and development of an early intervention / "first responder (CNS)" for patients referred with a suspicion of pancreatic cancer

19) We will this year take forward new pilots to test improvements in this area, including examining whether the introduction of rapid diagnostic centres may benefit people being tested for cancer. We will examine evidence and impacts from other similar models in the UK and internationally, and consider how this approach could best benefit people in Scotland.

20) We will also consider whether the introduction of new or refined pathways may benefit patient experience and outcomes.

21) We will increase capacity in our health service, including by expanding capacity at the National Waiting Times Centre, increasing clinical effectiveness and efficiency by implementing targeted action plans for key specialties and clinical areas, and implementing new models of care. For instance, as part of our waiting times improvement plan, we are delivering six elective, diagnostic and treatment centres that will provide additional, sustainable capacity which meets the need of a growing and increasingly elderly population.

Actions on unmet need

The evidence of a significant disparity in survival between certain types of cancer is very clear, with long-term improvements in survival not being seen for particular types of cancer including those of stomach, oesophagus, pancreas and brain. Overall improvements in cancer survival emphasise even more the disproportionately poor progress for these cancers. Rarer cancers and those particularly hard to diagnose and treat require greater focus. We will take new action now to address this unmet need, whilst building continued action into the next cancer strategy.

We will regularly review how lessons and experiences from work in specific cancer areas should be applied to other types of cancer facing similar challenges. Unmet need is also seen in some areas where survival may have improved significantly overall, but the needs of many patients could still be better served, such as those with secondary breast cancer.

Acting on this unmet need will be additional to rather than replacing any continued and necessary action across the wide range of other areas covered in our cancer strategy and this update. We recognise the need for continuous improvement across all cancers requires ongoing action and our wider strategic efforts will work towards these.

22) We will consider new stretching targets for key areas of unmet need- including around cancers with poorer survival rates, rarer cancers, and social economic inequalities. Any targets would have to be linked to a range of focussed actions and resourcing, to ensure they were meaningful and that patients as well as staff from across the health service, third sector and national groups can all play their part in working to meet them.

23) In the immediate term we are, through effective cancer management framework, discussing with boards appropriate swift processing of "red flag" radiology referrals.

24) We are collaborating with the Less Survivable Cancers Taskforce to develop further actions on how to address the unmet need of the cancers where survival has not improved at the same rate as others. We will share expertise and experience with them to consider approaches for the next cancer strategy.

25) Recognising the unmet need around Scotland's lung cancer rates, we will this year make significant investment through our DCE programme on a new symptom awareness campaign for lung cancer.

26) We have supported a clinical audit of pancreatic cancer services that has made a range of recommendations for improvements and are working with clinical leads and people affected by cancer to take these recommendations forward. These recommendations could benefit patient experience by reducing the number and/ or frequency of appointments, improving how they are communicated with and potentially increase their chances of better outcomes.

27) We are also undertaking work to consider how some people may benefit from targeted lung cancer health checks, whilst balancing the harms of unnecessary interventions, incidental diagnosis and avoiding "all clear" messaging for those with negative results who still remain at high risk.

28) Recognising the significant number of women living with secondary breast cancer, we will work with Breast Cancer Now on: ways to improve symptom awareness among the public and health professionals; how we can improve data about secondary breast cancer; improving access to specialist nursing, including what funding and training could support his; support for NHS employees with breast cancer; and access to clinical trials.

Actions on "prehabilitation"

29) Working with Macmillan Cancer Support, we have convened a range of experts from across Scotland to begin work to introduce "prehabilitation" into our cancer services, helping patients receive lifestyle support and advice that can improve their experience of cancer treatment and maximise their chances of positive outcomes.

30) In working towards the next cancer strategy, we will also consider how people can be more broadly prepared for treatment, understand how various types of treatment are administered and what to be aware of. We will include action to ensure that existing excellent patient information resources, including from charities such as Maggies, on this, can be shared as widely as possible.

Actions on treatment

Regardless of where anyone lives in Scotland, they should be able to expect a consistency of treatment and experience to anyone else in the country. We will take various actions to match this expectation, challenging unwarranted variations in our service. In line with Realistic Medicine, all patients should feel empowered to discuss their treatment fully with healthcare professionals, including the possibility that a suggested treatment might come with side effects – or even negative outcomes. These actions will also work towards the National Clinical Strategy aims of ensuring patients receiving the right tests and treatments, in the right place, at the right time.

31) Through the Scottish Cancer Registry and Intelligence Service, we will this year integrate two key datasets - Radiotherapy and Systemic Anticancer Treatment - providing a national picture of cancer treatment, allowing benchmarking and facilitating consistency of treatment for patients across Scotland.

32) We will begin work immediately with Scotland's cancer networks to support common approaches to the development of cancer clinical management guidelines. Networks and NHS boards will regularly meet to share evidence and plans for future guidelines, making sure these are harmonised as much as possible.

33) We will support the Innovative Healthcare Delivery Programme, funded by Scottish Government in working with the NES Digital Service (NDS) to develop a technical solution to allow use of cancer treatment summaries for patients in Scotland, giving key information in a clear format.

34) We will work over this year with NHS National Services Scotland to ensure that access to specialist surgery where it would be of benefit to patients is the norm for all people with cancer.

35) We will monitor and consider potential new initiatives and service changes to improve recovery after surgery, such as the Enhanced Recovery After Pancreatic Cancer Surgery (ERAS) programme. Poorer recovery from surgery can result in longer stays in hospital and readmissions, which can affect quality of life. Complications sometimes prevent further treatment options, which may in turn affect outcomes.

36) Concerning variation exists around access to specialist surgery for ovarian cancer. This is unacceptable and we will prioritise challenging health boards to find solutions in this vital area.

37) We will work with the Scottish radiotherapy community to this year develop a national plan for the best possible radiotherapy service. Building on the solid foundation of delivering modern radiotherapy in all our centres, ahead of any other UK nation, our plan will use this to embed research across all centres. One in four people in Scotland will receive radiotherapy and this plan will also ensure that more people with cancer in Scotland are treated with a view to curing their cancer.

38) We will conduct our final manual survey of delivery of modern radiotherapy treatment across Scotland's cancer centres- using this to again challenge for improvement and benchmark current delivery. Following this we will introduce shortly the automated Radiotherapy Data Set (RTDS), which will routinely collect this data and, through our national groups we will regularly interrogate this to drive continuous improvement.

39) A common approach to patient consent for systematic anti-cancer therapies will soon be launched, ensuring patients across Scotland have the same support for fully informed consent in their treatment.

40) We will support in the coming months the next phase of the Cancer Medicines Outcomes Programme (CMOP) to build a scalable and sustainable capability of expertise in cancer medicines intelligence to drive continued improvement in the safe and effective use of the medicines across Scotland. Better understanding the effects of medicines on patients is vital to the future provision on the best treatments, maximising patient benefits and minimising harms.

41) We will monitor and take forward any solutions from work by Health Improvement Scotland to develop testing principles and methodology to support the production of advice that will maximise use of off-patent cancer medicines, where doing so presents opportunities for improving patient outcomes.

42) We have convened a Genomics Leadership Group to advance areas of greatest opportunity for patients in Scotland. The advice from the Scottish Genomics Leadership Group will shape how we implement the benefits of genomic medicine from research to routine clinical care in Scotland.

Actions on best care and support for all people with and beyond cancer

Clinical diagnostics and treatment are crucial elements of our cancer services, but wider patient support is just as important. As well as providing the best clinical care, we have recently invested in an £18 million partnership with Macmillan Cancer Support to make sure everyone at the point of a cancer diagnosis has contact with a link officer to talk about their specific needs and receive information and support tailored to them. This will make Scotland the first nation in the UK where all people with cancer can benefit from financial, emotional and practical support that is right for them, meaning that they and their families are looked after from diagnosis, through treatment and beyond.

43) We are now rolling out the Transforming Cancer Care programme in partnership with Macmillan Cancer Support, making sure people with cancer in all parts of Scotland have access to a key support worker.

44) We will work with the Scottish Cancer Coalition to help all people with cancer receive consistent quality information and support, building on work by NHS inform and Macmillan libraries. This support can include services like counselling and psychological support provided by both the NHS and third sector organisations, such as Maggies, CLAN, Beatson Cancer Charity or Cancer Support Scotland.

45) We will assess how the Scottish Government can support the wider provision of patient information and support, including through maximising the reach and impact of local directories, and how people with cancer travelling for treatment and care can be best supported.

Whole system actions

Developments in prevention, earlier detection and treatment of cancer all rest on research, and we continue to make best use of Scotland's academic strengths in this area. Also, continuing our support for the Experimental Cancer Medicines Centres will help patients access early phase trials, and drive cutting edge research in Scotland.

Our NHS Research Scotland's Research Networks provides support for industry-led and non-commercial clinical studies, of which cancer trials form a major part. We are currently reviewing the Research Network infrastructure to ensure Scotland remains a leading centre for trials, and that those living with cancer have the opportunity to participate in world-class clinical trials.

In December 2019, we published the first Integrated National Health and Social Care Workforce Plan in the UK. Developed in partnership with COSLA, the Integrated Plan sets out how health and social care services will meet growing demand to ensure we have the right numbers of staff, with the right skills, across health and social care services.

A series of case studies and scenarios have also been published alongside the Integrated Plan, covering health and social care professions that are particularly affected by growing demand. These scenarios will allow modelling of the numbers needed for future years, in response to growing demand, and include Clinical Radiologists and Reporting Radiographers.

46) We will work with Cancer Research UK to pilot new approaches to workforce planning, with a focus on the diagnostic workforce.

47) We will also work with National Services Scotland to test the most effective and cutting edge ways to model future service needs, which could inform clinician-led workforce planning requirements.

48) Building on strong investment in our medical workforce, high levels of medical school placements, and testing these new approaches, we will build a long-term vision for the cancer workforce to be taken forward in the next cancer strategy.

Actions on using data for improvement

Many of our successes to date have been built on access to data that can build understanding of our challenges and how to address them. For many future challenges, data will be just as vital to success.

49) We will work to support the continued unlocking of data to drive improvement across the four key enablers of: sources, infrastructure, access and intelligence.

50) As well as national systematic improvements, we will work to collate new or better use existing data sources for improvements, such as around the increasing prevalence of secondary breast cancer.

51) ISD Scotland will conduct an audit of Cancer Waiting Times in 2020 to ensure consistency across data capturing and adherence to exclusion criteria.

52) As new data sources allow more timely and rigorous assessment of services, where actions are required these need to be taken at pace. To help facilitate this, we will review existing national governance structures and reporting mechanisms to ensure they are as responsive as they can be to these new opportunities for improvement.

53) With Macmillan Cancer Support, we will develop and deliver the next Scottish Cancer Patient Experience Survey for 2021, benefitting from benchmarking against two previous surveys, whilst ensuring boards are given reasonable time to make necessary changes identified.



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