Recovery and redesign: cancer services - action plan

Detection & Diagnosis

The earlier the stage at which cancer is found and treated, the higher the chance of long-term survival, or cure. Over recent years, we have continually been improving detection and diagnosis through our Detect Cancer Early Programme, including undertaking a clinical review of the Scottish Referral Guidelines for Suspected Cancer, and investing in diagnostic innovations. Continued improvement in detection and accelerating diagnosis further will aid our aim of improving the patient journey and outcomes. We have already released an additional £10 million to Health Boards in 2020/21 to support swift access to diagnostics and treatment, helping to maintain cancer performance. We will provide additional investment of up to £5.67 million for cancer diagnostics and scopes.

Individuals from areas of higher deprivation remain more likely to present with later stage disease and are less likely to take part in screening when invited, which continues to be one of the most effective ways to find some cancers at an early stage. Inequalities are not only socio-economic but are evidenced across different cancer types. Survival rates in some cancers, including lung, pancreatic, liver, brain, oesophageal and stomach have improved at far slower rates than others and therefore require additional focus. We will continue to work with the Less Survivable Cancers Taskforce to develop practical and impactful actions to support the increased detection of these cancers.

Primary care services are also vital to the early detection of cancer, patient care and serving on the front line of our NHS. However, it can be difficult for primary care to assess and diagnose individuals with non-specific symptoms. Emerging international and UK evidence supports the exploration of a model that offers GPs a single point of access to a diagnostic pathway for patients with non-specific symptoms suspicious of cancer (e.g. weight loss, fatigue). Early Cancer Diagnostic Centres (ECDCs) have a key role in delivering earlier diagnoses and improved patient care in Scotland by providing patients with multiple tests at one appointment, where possible, rather than consecutive individual appointments. The delivery of Early Cancer Diagnostic Centres is more timely than ever as the pandemic has demonstrated the need for local delivery of diagnostics and reducing footfall within secondary care.

Following a cancer diagnosis, it is important for patients to receive timely treatment in accordance with the 31 and 62 day waiting times standards. We will support this with investment of up to £24 million over the period of this plan. The Framework for Effective Cancer Management, initially developed in 2018, is used to support Boards meet these standards. Visits to review Boards’ pathway management were undertaken across NHS Scotland and detailed recommendations provided to support the efficient process of urgent suspicion of cancer referral through to treatment.

In order to improve detection and diagnosis further, we will:

Screening and Surveillance

9. There is a need to consider whether the inequalities in uptake of, and access to, screening programmes have been exacerbated further by the pandemic, particularly as the programmes resume following the temporary pause. We will therefore amend the focus of our fund, with up to £2.45 million made available over the plan, to tackle inequalities in the national population screening programmes to identify and address the impact of COVID-19.

10. To broaden the reach of the cervical screening programme and address inequalities, we will develop a programme of work and pilot approaches to self-sampling. This will enable us to explore and determine the potential for the use of self-sampling at national level.

11. For some patients with specific gene mutations, or otherwise increased clinical risk of developing cancer, ongoing surveillance can assist early detection. We will monitor surveillance and follow up services, providing national guidance on these as required.

Diagnostic Testing

12. Improving the diagnostic experience- Early Cancer Diagnostic Centres (ECDC)

We will invest up to £3 million into Scotland’s first Early Cancer Diagnostic Centres, which will create a timely, person-centred fast-track pathway for those with symptoms suspicious of cancer. It will enable patients with non-specific serious symptoms (i.e. weight loss, fatigue, nausea), to be assessed and tested by a team of specialists during one visit.

Currently, there is disparity in how cancer patients that present with non-specific symptoms enter and flow through NHSScotland, compared to those with site-specific symptoms, that are reflected in the Scottish Referral Guidelines for Suspected Cancer. The Centres, which will be developed within existing NHSScotland infrastructure, aim to reduce this variation and work towards delivering equity of access for all patients with a suspicion of cancer in Scotland.

The delivery of Early Cancer Diagnostic Centres is more timely than ever as the COVID-19 pandemic has demonstrated a need for reducing footfall within secondary care and making continued efficient use of NHS resources. The Centres will result in fewer hospital visits for patients, providing them with the right tests in the first instance. This is in contrast to multiple referrals to different specialties, which include the risk of unnecessary investigations or inadvertent repeat investigations, until a diagnosis is confirmed, be it cancer or another serious condition. There will be a small cohort of complex patients moving through any Centre at one time. Social distancing and the increase in virtual ways of working will support effective clinical triage, same-day radiology reporting and speedy onward referral to specialty services.

The introduction of Early Cancer Diagnostic Centres marks a radical change in how cancer is detected in Scotland - providing faster access to specialists, adopting a holistic approach to diagnosis and supporting the patient with vital one-to-one contact throughout the process. Phase one of the Centres is expected to begin Spring 2021, in at least two sites. A robust evaluation process will be undertaken to embed learnings and work towards the delivery of a Centre in every cancer region in Scotland.

13. Radiology investigations for suspected cancer patients have continued to be prioritised throughout the COVID-19 pandemic. However, as other services begin to re-mobilise, additional capacity will be required. This will be supported by the addition of six mobile MRI and three mobile CT scanners.

14. We will continue to work with and encourage Health Boards to increase GP direct access to CT scans for people with symptoms potentially indicative of cancer, helping more people be tested more quickly. This will be particularly important for patients presenting with vague symptoms.

15. Early detection and innovative endoscopy solutions such as Colon Capsule Endoscopy and Cytosponge™, have the potential to reduce demand on traditional, more invasive, endoscopy techniques, improve patient experience, and increase screening capacity. We will introduce these across Scotland, and evaluate their efficacy and impact on patient outcomes.

16. The colorectal pathway remains one of the most challenged in NHSScotland due to the reliance on scope-based diagnostic tests, the capacity of which reduced significantly during the pandemic as a result of emerging evidence, including that from the British Society of Gastroenterology. Capacity for scope-based diagnostic testing will not return to pre-COVID-19 levels for some time as a result of social distancing and enhanced PPE requirements. To ensure patients have timely access to key diagnostic tests, we will support the creation of an Endoscopy Renewal Plan with the oversight group due to meet in early December. The role of qFIT, a simple test used to detect small amounts of blood in stool samples, in risk-stratifying those for endoscopy will be reflected in the Plan. The possibility of utilising the private sector to increase capacity, Boards supporting each other through mutual aid, ongoing clinical prioritisation and national guidance on COVID-19 testing patients pre-procedure, will also be considered in the Plan.

17. Gallium services provide an opportunity to improve the detection of advanced prostate cancer. We will continue to invest an initial £2 million in gallium services across four Health Boards, with two due to go live in 2020 and the remaining two early in 2021.

18. We will continue to support the National Cancer Diagnosis Audit that will enable reflection, learning and quality improvement within primary care to improve patient outcomes and support earlier diagnosis. Initial insight is expected early 2021.

Patient Pathways

19. The Scottish Referral Guidelines for Suspected Cancer support clinicians in ensuring that the right patient is on the right pathway at the right time. The Guidelines - a result of clinical consensus and a robust evidence review - underwent a refresh in 2018 with eight pathways updated. An audit of the adoption of the Guidelines will be undertaken in Spring 2021, to understand any differing referral trends following the refresh. This will also help inform the need for, and timings of, a full refresh, in close consultation with primary care.

20. To incorporate the new ways of managing cancer pathways and services across NHS Scotland that have emerged as a result of COVID-19 (e.g. increased virtual consultations), we will undertake a refresh of the Framework for Effective Cancer Management. To support clinicians and managers to drive improvements, Board visits will begin early 2021 with a revised Framework published Summer 2021. This will provide every Board in Scotland with the tools to effectively manage cancer patients and recover waiting times.

21. A firm focus will remain on Cancer Waiting Times performance and ensuring cancer patients continue to be seen and treated as a priority as we progress through mobilisation and respond to any new COVID-19 peaks. We will continue increased oversight of patients moving through the 31 and 62 day cancer pathways through weekly monitoring with Boards. This involves monitoring referral numbers, sharing best practice across Board Cancer Teams, challenging any emerging backlogs and supporting innovative solutions where appropriate.

22. Patient pathways through cancer services help define a patient’s overall experience and access to treatment and, potentially, their outcomes. We will analyse whether new pathways for specific cancers would benefit patients, working with the Scottish Health Technologies Group (SHTG) where applicable. A focus will be placed on less survivable cancers. Our first priority will be to work with the Scottish Hepatobiliary Network and support clinical consensus on redesign of pancreatic and liver cancer pathways.

23. Urology pathways can vary across Health Boards and are challenging to navigate due to the number of diagnostic tests required, often complex nature of cases and specialised treatments needed. A collaboration of Scottish Government improvement programmes through the Centre for Sustainable Delivery (CfSD) (including Scottish Access Collaborative and Modern Patient Pathways Programme) will explore ways to reduce variation in urology pathways and ensure equitable access from the point of suspicion of cancer to post-treatment follow-up. This programme of work will consider GP direct access to diagnostics, implementation of new clinical pathways, emerging technologies to support patient initiated review (PIR) (such as an app for patients to monitor their PSA levels through), adoption of mpMRI guidance, Active Clinical Referral Triage (ACRT), and community-based follow-up.

Pre-Treatment

24. Cancer Prehabilitation- Testing and Evaluating

Cancer prehabilitation is an emerging field, with a growing evidence base which requires further evaluation in a Scottish context. It helps a patient prepare as best they can for treatment. A ‘universal’ prehabilitation focusses on physical activity, psychological support, nutritional care, smoking cessation and alcohol reduction to prepare people for their cancer treatment.

The Scottish Government aims to spearhead prehabilitation and will invest up to £1.15 million to implement a programme of work in a number of cancer types, to test and evaluate the concept for delivery across Scotland. The evaluation will focus on implementation of prehabilitation into existing pathways with access to timely treatment remaining a priority.

25. Some evidence suggests prehabilitative measures, focusing on physical activity, nutrition and psychological support, will improve a patient’s ability to receive treatment and their outcomes after treatment. We will develop a digital resource to raise awareness of the benefits of prehabilitation among the public and professionals.

26. Nutritional care is a key component to the universal approach of prehabilitation. We will convene a nutritional care for cancer advisory group to develop a framework for nutritional care to be used across cancer prehabilitation in Scotland.

27. Positive mental health is key to an individual’s overall health. To ensure consistency of support across Scotland, we will look to the well-established West of Scotland’s Psychological Therapies and Support Framework to identify potential learning which can be adopted across the country.

The graphic shows a timeline, displaying the end of each quarter and running from December 2020 to March 2023, and the expected completion times for action points 9 to 27, as described above. It shows that action points 10, 11, 21 and 23 are expected to be completed by March 2023. Action point 9 displays the aims of focusing on a COVID-19 impact fund until March 2021, thereafter continuing with an annual Screening Inequalities fund until March 2023. For action point 12, a multi-disciplinary group will be convened by end of December 2020, and phase 1 pilots will be established in 2 sites by end of June 2021. Action points 13 and 16 are expected to be complete by end of December 2020, and action point 14 and 18 will start following December 2020 and be completed by end of March 2021.

It shows that expected completion of action points 15 and 17 will be by June 2021. Action point 19 will start end of March 2021 and be completed by June 2021. Action point 20 will begin Peer Review Visits in March 2021 until June 2021, and moving on to publishing framework by September 2021. For action point 22, a review of liver and pancreatic cancer will be completed by September 2021, and a review of other pathways done by March 2023. Action point 24 is shown to be in development and pilot stage until September 2022, with a full evaluation of these by March 2023.

Finally, Action points 25, 26 and 27 are shown as finishing by September 2021, however while point 25 will commence immediately, both points 26 and 27 will commence at the end of March 2021.