Cancer strategy 2023 to 2033

1. The Strategy and its Context

1.1 Our Vision and Strategic Aim

Cancer remains one of Scotland’s single biggest health challenges, affecting every one of our citizens in some way throughout their lifetime. In recent times there have been huge changes in our understanding of the disease and how to improve its prevention, diagnosis and treatment, and it is incumbent on governments across the world to keep pace with the most up-to-date ways of managing cancer within their populations. The scope of these possible interventions is wide-ranging, from evolving our public health system to continuing the search for better scientific understanding; introducing new case-finding and treatment techniques; and doing what really matters to people with cancer by building care and treatment around their specific needs and preferences.

The challenge remains formidable. Cancer survival has improved in Scotland but not at a satisfactory rate. The necessary coalition of effort to meet this challenge is complex, involving many organisations and thousands of individuals. Strong and clear coordination of this effort is required at all levels, and this strategy will provide common direction for all. Our vision for cancer in Scotland in 10 years’ time is:

More cancers are prevented, and our compassionate and consistent cancer service provides excellent treatment and support throughout the cancer journey, and improves outcomes and survival for people with cancer.

By 2033 every person with cancer will have access to the comprehensive support they need, clinical and non-clinical, reflecting what matters to them. Digital and technological advances will allow people with cancer to access services in different ways, attending clinical settings only where necessary, with wider support provided in ways that work best for them. There will be less unwarranted variation in service delivery and clinical management across Scotland. Systems will integrate to provide efficient and effective care founded on national clinical consensus. Increasing numbers of people with cancer will have access to curative and other cancer treatments, with full supportive and palliative care available where a cure is not possible, all underpinned by a culture of Realistic Medicine. People will be well informed about prevention, signs and symptoms, and people with cancer will be informed about their treatment and care and possible outcomes. People with cancer will know how to access the support they need and be clear about the next step in their journey.

Our strategic aim is to improve cancer survival and provide excellent, equitably accessible care underpinned by the following outcomes:

a. Reduced relative population burden of disease

b. Reduced later stage diagnosis

c. Timely access to treatment

d. More people receiving curative treatment

e. Improved experience of services, across all areas of care

f. Optimised quality of life for each individual

g. Embedded research, innovation and data capture in all services.

We will aim to reduce inequalities in all these areas.

1.2 Steps to Success

As we publish this strategy, the NHS is under enormous pressure following the impact of the COVID-19 pandemic and the long-term challenges of an ageing population. This requires an increase in diagnostic and treatment capacity for each person with cancer. These pressures are felt across a range of other services and organisations that are crucial to cancer care. NHS Boards across Scotland continue in the ‘recovery’ phase of the 2020 Re-mobilise, Recover, and Re-design framework. This phase has been included in The NHS Scotland Delivery Plan Guidance for Boards as they set out their Medium Term Plans (three years) and define their Annual Delivery Plan (12 months). During the Medium

Term Plan, success of the strategy will be to recover and stabilise systems and services, maintaining cancer as a priority while necessary recovery takes place in health systems and the wider economy. Actions to recover and stabilise services are covered in our first three-year action plan 2023-2026 and aligned with the Medium Term Planning guidance.

Concurrently, it will be necessary to renew our services and approaches to cancer control. This means working collaboratively with people who use services to develop new models of care, and delivering the changes needed to better meet what matters to the people NHS Scotland cares for. Planning for renewal and redesign phases will be underway to help shape and build on recovery phase.

We will develop plans for longer term redesign of services as part of a wider transformation framework that will guide our service development, further harnessing the potential of innovations, integrating many more of our systems, removing associated barriers and, where the evidence is clear, embracing novel treatments and digital opportunities.

1.3 Development of the Strategy

Our public consultation and engagement events during the development of the strategy provided evidence of a strong appreciation of existing cancer services, as well as recognition of the fundamental impact of earlier diagnosis and safe, effective treatment. The respondents included people with lived experience of cancer, healthcare professionals, academics, private and third sector representatives amongst others. Those who took part emphasised the importance of action across the whole cancer pathway from prevention to pre-treatment and post-treatment. In addition, respondents also told us that there needs to be a strong focus on the key cross-cutting enablers such as a well-resourced and skilled workforce, capacity for research and innovation, and comprehensive data and intelligence systems. The strongest recommendations emerging from the consultation related to the holistic aspects of providing high quality care. This means putting the person with cancer at the centre of the response, providing holistic care (including psychological support), providing excellent communication and applying the principles of Realistic Medicine.

1.4 Interconnectivity with wider Healthand Social Care

This strategy is for all people affected by cancer, but the distinct needs of children and young people are specifically covered by the Collaborative and Compassionate Cancer Care: Cancer Strategy for Children and Young People (2021), delivered through the Managed Service Network for children and young adults.

In addition to that document, the delivery of the strategic ambitions here will be interdependent with a range of other strategic aims in health and beyond. This strategy cannot stand alone, nor can it supersede wider strategies. Rather it complements, links to and will operate within the broader health aims of the Scottish Government. It is accompanied by a 3-year Cancer Action Plan and underpinned by actions in Annual Delivery Plan guidance to Boards alongside Medium Term Planning with longer-term planning and redesign. Actions will change, adapt or be superseded by innovations as yet unknown, and will reflect the change needed in evolving contexts, including NHS capacity and the ability to make new financial investments. Embedding research and focused data collection will help to build a ‘learning health system’ and will be supported by key drivers including the Scottish Health Industry Partnership (SHIP) and the Accelerated National Adoption (ANIA) Pathway.^[4]

Cancer control will be key to meeting Scotland’s National Performance Outcome that we are healthy and active, not only through providing treatment and care for those with cancer, but also through a variety of population measures that will help prevent cancers in the future. These will be addressed through plans, strategies and interventions targeted at specific cancer risk factors including tobacco, obesity and alcohol. There are clear, inextricable links between health inequalities and poverty. Our long-term approach is through the national mission to tackle child poverty: Best Start, Bright Futures (2022). It aims to reduce health inequalities in the long-term by reducing child poverty now.

We will continue the direction of travel laid out in the National Clinical Strategy for Scotland (2016):

• planning and delivering integrated primary care services, like GP practices and community hospitals, around the needs of local communities
• restructuring how our hospitals can best serve the people of Scotland
• making sure the care provided in NHS Scotland is the right care for an individual, that it works, and that it is sustainable
• changing the way the NHS works through new technology
• supporting people to practice Realistic Medicine

The National Clinical Strategy recognises that people often lack a full understanding of the prognosis or outlook for their illness (or the risk of developing a harmful event). They might well make different decisions if they were fully informed about their condition and the treatment options available. Indeed, in many cases, they may choose less aggressive treatment rather than more. This aspect needs to be better reflected in clinicians’ discussions with patients about treatment options. A reinvigorated Realistic Medicine approach will support this element of the cancer strategy.

During the pandemic many new and innovative ways of working were developed to support the continued delivery of critical services. These were born out of necessity but, in many cases, they also delivered improvements. We want to build on this work, as set out in the NHS Recovery Plan (2021). This will support innovation in and redesign of services to ensure that more people with cancer receive person-centred care in the right place, at the right time, and in a way and that enables staff to deliver high quality care and treatment. As set out in our steps to success, research, innovation and the redesign of services will be integral to recovery and stabilisation. There are a range of partner organisations that are central to this including the Centre for Sustainable Delivery, NHS National Services Scotland and its Scottish Cancer Network, the Digital Health and Care Innovation Centre, Healthcare Improvement Scotland, and the Scottish Health Industry Partnership. All their work will be rooted in the principles of Realistic Medicine and aligned with broader Scottish Government care and wellbeing programmes. Our Health and Social Care: National Workforce Strategy (2022) will ensure we have a skilled and sustainable workforce to support delivery of our health and social care services. Success will be required across all pillars of that strategy to meet our strategic aims.

As Scotland builds back from the COVID-19 pandemic, we urgently need to tackle the long-standing inequalities in health and wellbeing that have been exacerbated by COVID-19. To do that we have established the Care and Wellbeing Portfolio that brings together work aimed at improving population health and reducing health inequalities, through health and social care and wider public sector service reform. The Portfolio seeks to create the best environment to stimulate national and local action to tackle these issues and takes a systematic approach to planning and delivering care and wellbeing. The work set out in this strategy will make an important contribution to these challenges. The diagram below sets out the overall Portfolio mission and outcomes, cross-government priorities that in turn improve health, and the programmes and enabling functions that support delivery.

Care & Wellbeing Portfolio

Portfolio Mission & Objectives

Improve Population Health and Reduce Health Inequalities

Our mission to improve Healthy Life Expectancy and achieve Fairer Outcomes is underpinned by 3 key portfolio objectives.

Coherence

Sustainability

Outcomes Improved

The mission is achieved by taking a person-centered approach to delivering clear outcomes spanning the short, medium and long-term.

1. Everyone in Scotland gets the right care, at the right time, in the right place based on their individual circumstances and needs.

2. Prevention, early intervention, proactive care and good disease management keeps people in Scotland healthy, active and independent.

3. Communities, third sector & public sector work together to improve health and wellbeing and reduce health and inequalities in local communities

Many of the influences on health outcomes lie out with health and social care. The cross portfolio priorities align with the Scottish Government’s priorities and enable us to maximise our reach and impact.

Care and Wellbeing Programmes and Enablers

Communities & Fair Work

Children’s Health & Wellbeing

Climate Change & Net-Zero

Place & Wellbeing

Preventative & Proactive Care

NHS Recovery, Renewal and Transformation

Enablers (Analysis & Evidence; Co-Design; Digital & Data; Finance; Innovation; Quality improvement; Workforce

Together the Care and Wellbeing Programmes and Enablers provide a comprehensive and progressive health and social care reform package.

The increase in digital health – planned for before the pandemic and significantly accelerated as part of our response – will increasingly become a choice for people accessing services and for the staff delivering them. It will allow more people to manage their condition(s) at home, enable remote pre- and post-operative assessments, as well as allowing people with cancer to manage their recovery from home. The Digital Health and Care Strategy will be the key driver in all of this and we will engage on its commitment to develop a Digital Front Door (DFD). The DFD work will be a key enabler for people interacting with health and social care services in Scotland. This development aims to allow anyone to manage appointments and conduct routine ‘transactions’ online. Digital technology can also facilitate the collection and capture of patient-reported outcomes and experience measures (Patient Reported Outcome Measures (PROMS) and Patient Reported Experience Measures (PREMS)).

The Scottish Cancer Network (SCN) will be at the heart of our strategic ambitions. There is evidence that those countries with empowered and clinically led central cancer agencies delivering clear government-owned plans have seen greatest success in cancer control.^[5] The SCN will continue to be at the forefront of defining clinical management pathways for cancer from the point of diagnosis. These unique pathways encompass treatment and care right through to the end of life, setting out clinically agreed best practice, and assuring people with cancer of common standards of care, no matter where they live. The SCN will also host national networks, where national integration and collaboration for specific cancers can make best use of expert resources and improve outcomes for people with cancer. It will drive ‘Once for Scotland’ work, where appropriate, and work closely with regional networks where work is better delivered at that level.

This work will be underpinned by the Scottish Cancer Quality Programme, which will define and drive quality of care in Scotland, using agreed quality performance indicators (QPIs) that meet our strategic aims and wider measures to define quality of treatment and care. Clinically agreed priority indicators linked to our strategic aims will be closely monitored, working with Healthcare Improvement Scotland. The programme will continually review how these indicators are being met, with ongoing international benchmarking to ensure best evidence and comparators are being used in setting standards. All this work will be in clear sight of our overall strategic aim to improve cancer survival and provide excellent, equitably accessible care.

The Centre for Sustainable Delivery (CfSD) has been established to pioneer new, more sustainable ways of delivering services, including improving access for people with cancer. CfSD will be particularly important in driving innovation through their ANIA pathway. It will be key to supporting NHS recovery by reducing unnecessary demand for services, maximising available capacity and developing new pathways of care that are more efficient, effective and patient-focused. It will maximise value for people with cancer by devising ways of avoiding waste and will facilitate consistent, high-quality healthcare across Scotland, where possible. The CfSD will build on and accelerate work on redesigning optimal diagnostic pathways, growing Scotland’s network of Rapid Cancer Diagnostic Services (RCDS), facilitating the introduction of innovative techniques (for example, Cytosponge), maximising diagnostic capacity, and optimising theatre capacity.^[6]

1.5 Realistic Medicine, Person-Centred Care and ‘What Matters’

Our primary focus must continue to be on achieving the outcomes that matter to people with cancer. In practising Realistic Medicine, health and care professionals work in partnership with people they care for. People must be involved in decisions made about their care by health and care professionals who understand and respect what matters to them. Desired outcomes are delivered through shared decision making and discussion about the potential benefits and harms of different treatment options, including the option to do nothing. This approach allows people to make an informed choice about their care, and helps reduce regret about treatment decisions.

In cancer services particularly, these guiding principles are tested daily by the complexities of some treatments that can carry significant adverse effects. Realistic Medicine encourages

health and care professionals to go beyond explaining risks to considering the impacts, both positive and negative, that a treatment may have on the individual and their families. Making decisions as a partnership increases the likelihood that care is in tune with a person’s personal preferences and will improve psychological wellbeing and outcomes. Ultimately, practising Realistic Medicine will enable cancer services to continue to be one of the most compassionate areas of the health and care service, providing the highest quality care that people with cancer value.

Additionally, Delivering Value Based Health & Care: A Vision for Scotland (VBH&C) will help deliver person-centred care, reduce harm and waste and eliminate unwarranted variation in access to health and care, treatment and outcomes. VBH&C also encourages health and care colleagues to be creative and think carefully about how we optimise the use of the resources we have for maximum benefit.

Getting It Right for Everyone (GIRFE) is a proposed multi-agency approach of support and services from young adulthood to end of life care. GIRFE reflects similar values to this strategy. It provides a more personalised way to access help and support when it is needed – placing the person at the centre of decision making to achieve the best outcomes, with a joined-up, coherent and consistent multi-agency approach.

‘What matters’ is the ongoing reminder that what matters to people with cancer needs to be truly reflected in our thinking and delivery. Evidence from people with cancer has shown that while clinical outcomes are clearly important, so too is treatment and care that reflect their personal preferences and what matters to them. Collectively this means:

• Equity of access to services – the treatment and care that people with cancer can access does not vary in quality depending on where they live, or because of characteristics including gender, ethnicity, disability or socio-economic status (see Tackling Inequalities).
• Non-clinical needs are supported – a cancer diagnosis entails a clinical pathway for the person with cancer, but it also can have enormous impacts on their physical, mental and spiritual wellbeing as well as areas such as finances, social interactions, employment, housing and access to wider services (see Person-Centred Care for All).
• Information and communication - regular, clear and inclusive information can benefit people with cancer and the service provider, facilitating shared decision making and an understanding of what happens next, in line with the principles of Realistic Medicine (see Best Preparation for Treatment and Excellent Care After Treatment).

Our aim is to ensure people with cancer are at the heart of service design. To achieve this, we will co-design whenever possible and we will regularly seek people’s voices through direct feedback, for example through the Scottish Cancer Patient Experience Survey and Care Opinion. We will support the generation of relevant and actionable data on both person-centred processes of care and person-centred outcomes. This will further enhance our understanding of quality and value, and what matters, from the perspective of people affected by cancer.

How the person at the centre interacts with services and policies and what we are trying to achieve through this strategy is shown here, noting that many components may be influenced but not controlled.

Individual/Patient

Knowledge, behaviour, prior experience Culture Socio-economic status Geographical location

Interpersonal/Support Structures

Family, friends, colleagues Social support networks

Organisational/Cancer Services

Prevention programmes Diagnostic pathways Pre-treatment Safe, effective treatment Post treatment support Workforce Location

Community

Interface of primary, secondary care and third sector Research Support (including psychological) for long term conditions

Policy

National Performance National Clinical Strategy NHS Recovery Plan National Workforce Strategy Digital Health and Care Research & innovation, Data intelligence systems Staffing, resources Realistic Medicine

Endnote 7

1.6 Governance and Delivery

To support a more integrated and coherent approach to planning and delivery of health and care services, we have developed the NHS Scotland Delivery Plan Guidance that sets out prioritised high-level deliverables and intended outcomes to guide detailed local, regional and national planning, and inform improvement work. The Re-mobilise, Recover, Re-design Framework (RRR) was published on 31 May 2020, and set out the approach for health boards to safely and gradually prioritise the resumption of paused services.

This NHS Scotland Delivery Plan and associated approach to planning supports the transition from recovery into a renewal phase of services. This is a key part of strengthening and developing strategic and operational planning across health and care. The planning work will be supported and overseen by the NHS Scotland Delivery Group in conjunction with regular performance reporting and planning review cycle.

Ministerial Priorities

Including system pressure priorities & policy

NHS Scotland Delivery Plan Guidance

Strategic Direction

The Planning Framework

• Medium Term Plans
• Annual Delivery Plans
• National Boards Plans
• National and regional planning
• Capital infrastructure investment
• Digital health planning
• Strategic workforce planning
• Financial plan alignment
• Defined performance metrics

Ongoing Performance Management

Programmes of Change and Transformation

Care and Wellbeing, DHAC, Innovation, etc.

Planning Framework – response to national policy & strategy set by Scottish Government

A lens to view the different planning and delivery functions that take place nationally

• What drives activity in each category below?

National

Policy/Strategy

• Policy imperatives drive model
• Require national standardisation
• Reflective of interdependencies with other policy areas

Planning/Coordination

• Sustainability & resilience risks
• Scarce clinical skills
• Improving clinical outcomes
• Collaborative approach adds value
• Cost reduction

Operational Delivery

Quaternary Clinical Services

• Complex clinical services
• Low volumes of patients
• Scarce clinical skills
• High cost

Once for Scotland

• Single approach
• System wide approaches add value
• Clinical and non-clinical

Regional/ inter-regional

Policy/Strategy

• Strategies need aligned to deliver policy

Planning/Coordination

• Sustainabillity & resilience risks
• Scarce clinical skills
• Improving clinical outcomes
• Collaborative approach adds value
• Cost reduction

Operational Delivery

• Subsidiarity & proportionality
• Regional approach
• System wide approaches
• Clinical and non-clinical
• Equitable access an issue

Local

Policy/Strategy

• Strategies need aligned to deliver policy

Planning/Coordination

• Local operational service planning

Operational Delivery

• Most Services
• Board/sub-board delivery

The Scottish Government will have oversight of overall strategic progress and direction of this strategy. The Scottish Cancer Strategic Board will ‘own’ the strategy and associated action plans, and review progress against them. Beyond this, ownership of actions and delivery will be undertaken as appropriate at national, regional and local levels. Collaboration and integration between health boards, including regional working and regional networks, will be vital in enabling this. Once for Scotland approaches will be a core principle to all our work. Where decisions and agreement on action, guidelines or service design is required at a national level for work that is universally applicable across Scotland, then it will be undertaken only once and not replicated at other levels. This will free up resources at regional and local level, avoid duplication of effort at a time when the service is particularly hard pressed, make for clearer future decision making, and support equitable access. However, many other aspects of delivery will be carried out at a local or regional level, reflecting local services, geographies, populations and the needs of the individual with cancer.