By Dr Moira Fraser, Director of Policy, Campaigns and Influence, Macmillan Cancer Support
Cancer, for many people, is no longer the death sentence it once was. Over 50% of people now live 10 years or longer post-diagnosis. This is fantastic progress – although we are still lagging behind other comparable countries. So, while celebrating developments, the NHS struggles on from funding crisis to funding crisis. Cancelled operations hit the headlines, and winter pressures now seem more like all-year-round pressures.
Against this backdrop, the policy direction has been generally positive. The Cancer Strategy for England sets a progressive agenda. There has been movement in the right direction – for example, there is a new fund to boost modernisation and transformation of cancer care. Unfortunately, there has also been a shifting in the political goalposts. Promised investment has not always been delivered on time, and not always for clear reasons.
The focus is on achieving earlier rates of diagnosis, supporting people’s recovery once their treatment ends, moving away from a one-size-fits-all approach to follow-up care, and of course, caring for those who will sadly die from their cancer.
Positive as this is, it falls short of the greater prize. We need to think more profoundly about the changing demographics of cancer. More people are getting cancer – one in two of us will get a cancer diagnosis in our lifetimes. By 2030 we can expect around 4 million people in the UK to be living with cancer or beyond it – up from the current 2.5 million. And although more people are surviving cancer or living long term with it, they are not always living well – cancer and its treatment can have significant long-term effects physically and emotionally.
Cancer is not one thing. It is 200 diseases, varying enormously from person to person. We have a tradition of thinking of cancer in terms of tumour type – people with breast cancer, for example, treated within one pathway, people with bowel cancer on another, and so on. There are of aspects of their condition which need specific treatment but many aspects of their care have much in common with the needs of others.
We need to therefore think beyond diagnosis – important as that continues to be – and plan to a much greater degree for the impact of cancer on individuals. Work by Macmillan has identified three types of cancer grouped based on holistic outcome and need, which may help us rethink how we design cancer support services.
Firstly, there is the group who can expect to live for longer, where their cancer is generally treated successfully, and for whom self-management is key. Secondly, there is a group of people whose cancer is a complex ongoing disease, and who have intermediate levels of survival. They are likely to have a similar set of needs to patients with other chronic and complex health conditions. And thirdly, a group for whom, sadly, outcomes are still generally poor and for whom we expect shorter term survival rates, and palliative care and end of life support are crucial.
Although everyone’s cancer is different, adopting this kind of framework could help enable care to be delivered more effectively, based on needs rather than tumour type.
However, to do this, we need to this about who is going to provide this care, and this is one of the thorniest issues. We have high aspirations for the future of the NHS, but developments in workforce planning have not kept pace with the needs of the population, particularly in cancer. The long-promised cancer workforce review, agreed as part of the England Cancer Strategy, finally emerged in part in late 2017, but we await the crucial next phase – looking beyond the medical profession.
This needs to value the skills of the whole health and care workforce – specialist and generalist nurses; the whole raft of allied health professionals, mental health professionals, care workers and social care professionals, as well as the wider support people need when they are struggling – money and benefits advice, housing support, vocational rehabilitation and so on.
We need to change how we think about people with health conditions. Not as diseases or tumours, but as people – individuals with lives to lead who have a right to expect the right kind of care and support to be available, in the right place at the right time, to enable them to find their way through.
The NHS needs more funding. We know that. But money will always be tight. The policy agenda needs to shift from squeezing ever more out of structures which are already pared too far back and take the leap to think differently about the people who in future will use care and their needs, and crucially, the people who need to be there to provide that care.