Aligning SCN’s work programme to the end-end pathway as defined in the National Cancer Strategy

The Patient Pathway - Cancer

cancer flow commg guidance



Primary prevention has a key role to play in reducing the number of people who are diagnosed with cancer.


Many factors are influential including:

Smoking is the most important preventable cause of cancer in the world. It is a causal factor in at least 14 cancers; lung cancer and the upper aero digestive tract cancers have the highest proportions of cancer cases caused by smoking.

Less healthy diets cause nearly one in ten cancer cases in the UK.  Diets high in fibre and fruit and vegetables may reduce cancer risk whilst a diet high in salt, saturated fats and red or processed meat can increase cancer risk.

Overweight and obesity has been identified as a causal factor in over ten types of cancer including breast and bowel cancer.

Physical Activity can help to prevent cancer, it has been estimated that 3400 cases could be prevented in the UK each year by keeping active.

Alcohol causes 7 types of cancers including breast, mouth and bowel cancers. It is thought to be responsible for around 4% of UK cancers, about 12,800 cases per year.

HPV Vaccination is offered to girls between the ages of 11-14 and will prevent at least 70% of cases of cervical cancer in future years.

Supporting actions in Prevention

cancer prevention supporting docs no shadow

Web resources

Work with local providers, such as Solutions 4 Health to refine approach
Rationale and evidence for giving “Very brief advice” – Ask, Assess, Advise, Assist, Arrange
NICE guidance (and wider pathway) – Smoking Cessation in secondary care services

Commissioner recommendation

  • Make every contact count in all healthcare settings to support people to reduce their risk of cancer through healthy choices
  • Implementing NICE guidance on smoke free NHS trusts (PH48), ensuring access to smoking cessation services for staff, patients and visitors with clear pathways for referral to services
  • As part of the STP’s prevention plans, address cancer risk factors including smoking, alcohol, excess weight, diet and physical activity as identified through your local Joint Strategic Needs Assessment
  • Work closely with local government through joint planning and/ or commissioning.
  • Promote breast, bowel and cervical cancer screening programmes, and ensure local services are well placed to respond to Be Clear on Cancer campaigns
  • CCGs and LAs commission providers to establish multidisciplinary alcohol care teams in all acute hospitals. This is proven to be a cost-saving intervention that coordinates the care across departments and enables rapid access to personalised ‘brief advice’ and referral to specialist services in other settings
  • CCGs and LAs facilitate local agreements with GPs to screen patients (e.g. Audit-C scratch card), with medical staff trained to offer and provide very brief advice and refer to local specialist services as required. This is proven to lead to reductions in alcohol consumption and related hospital admissions
  • Improved approach to food and catering in health and care settings and the implementation of the Government’s forthcoming Childhood Obesity Strategy
  • Investigate opportunities, including STPs, to work in partnership with other Commissioners and Provider services to invest in public health interventions.

Screening - saving lives

screening programme outcomes

Bowel screening data image

Bowel Screening data in Thames Valley highlights uptake rates are performing above average in only two CCG areas in the region

Breast screening

Breast screening data highlights strong performance in all but two CCG areas in the region

cervical screening image

Cervical screening data for the 25-49 age range is poor across Thames Valley and reflects the national performance. Oxfordshire CCG has been working nationally to produce guidance on possible interventions to encourage uptake locally


Supporting actions in Screening

cancer screening supporting

Web resources

Evidence of how combined, tailored approaches can have an effect on increasing bowel screening uptake (CRUK)

National awareness weeks in Cervical Cancer/Screening take place every six months (January/June) – free resources and tools can be accessed here

For people with learning disabilities – a strategy document and toolkit has been developed in the South West (including letter templates to be used) by the National Development Team for inclusion


Commissioner recommendation

  • Ensure pathways & interfaces between symptomatic and screening services are robust to enable screen detected patients receive timely treatment
  • Ensure adequate capacity in symptomatic services including endoscopy and mammography to mitigate the risk of screening diagnostic capacity being utilised for symptomatic patients
  • Make every contact count in the primary care setting to maximise the proportion of eligible patients who take up the offer of screening
  • Investigate opportunities to work in partnership with other Commissioners and Provider services to minimise the variation in screening uptake at GP practice level.

If you would like further information about local commissioning arrangements for NHS cancer screening programmes and opportunities to work in partnership to improve screening uptake please contact

Early Diagnosis & Assessment

Earlier awareness, detection and assessment is crucial to enable a greater prospect of survival and improved quality of life for those experience cancer symptoms or a diagnosis.

Awareness & Support

Societal and behavioural norms can delay in getting medical help when faced with possible symptoms; fear of what a doctor may find, worry about wasting practitioner’s time, lack of knowledge about specific cancer signs and symptoms and an inability to book a GP appointment can all contribute to presentation at a GP.CDS button cancer







a dual focus on primary care education and appropriate/prompt referrals from primary care are key to driving this agenda

case for change on early detection - cancer.emf

Earlier diagnosis has the greatest potential for improving outcomes and survival. Variation exists across the region which helps identify this opportunity. The implication of earlier diagnosis is “ramped up” diagnostic referral volumes to match the demand.

under 75 mortality

While under 75 mortality rates across Thames Valley are average, early detection remains a high priority as 1 year survival rates could be much improved (click for data)

Improvement has been seen across the whole TV region, with South Reading and Wokingham CCGs seeing the biggest improvements in staging coverage (click for data)

Improvement in staging has been seen across the whole TV region, with South Reading and Wokingham CCGs seeing the biggest improvements in staging coverage (click for data)

Case mix of cancers being detected at an early stage will have an impact on the proportion of early cancers. Breast is more likely to be detected at an early stage, vs Lung so areas with higher proportion of breast cancers will have better outcomes than those with higher proportion of lung

Case mix of cancers being detected at an early stage will have an impact on the proportion of early cancer detection. Breast is more likely to be detected at an early stage, vs Lung so areas with higher proportion of breast cancers will have better outcomes than those with higher proportion of lung (click for data)











Insufficient Capacity for Diagnostics in Thames Valley

Rising demand for referrals in secondary care is playing a role in the increasing time it takes to reach diagnosis.

England’s rates of endoscopy for lower gastrointestinal cancers per 100,000 population lag behind comparable countries.  Endoscopy services themselves, also vary in quality with many not JAG accredited (the marker of a quality service) and some patients experiencing 6+ and 13+ week waits for endoscopy. The impact of this is felt in England’s poorer cancer outcomes for bowel cancer than in comparable countries.

Thames Valley SCN completed a cancer diagnosis demand & capacity project in March 2016- full details and reports including the modelling tool can be accessed from the link opposite.

Top Line findings of the reportcancer - report

Between now and 2021, suspected cancer referrals will rise between 7 and 31%

Between now and 2021, suspected cancer referrals will rise between 7 and 31% in the Thames Valley




diagnostic capacity top line

Cancer Standards

Preparation for implementation of the 28 day cancer standard (from 2020) highlights current performance across Thames Valley is poor (click for data)
Cancer Standards - 28 days






cancer - main improvements







Upper GI & Urol

Upper Gastroenterology & Urology (per CCG)

Lung & Skin

Lung & Skin (per CCG)

Head/Neck & Lower GI

Head/Neck & Lower GI

Breast & Gynaecology (per CCG)

Breast & Gynaecology (per CCG)





GP direct access requests only account for 1/4 of all tests used to diagnose or discount cancer. This will significantly increase once all pathways are developed in accordance to NICE guidance (click for access)

GP Direct Access





Supporting Actions to achieve Early Diagnosis & Assessment AmbitionsSupporting actions early diagnosis cancer

Commissioner recommendation

  • Commission locally-developed awareness campaigns to improver earlier detection of cancer, for example the London Get to know Cancer pop up shop and cancer activist programmes
  • Contact Macmillan to access the free Cancer Decision Support Tool:
  • Invest in CCG GP Cancer leads to provide local leadership and co-ordination for early detection activities.
  • Request your Provider Trust stages at least 70% of all cancers
  • Access advice & guidance for GPs from the Cancer SCN Primary Care Resource Toolkit 
  • Commission sufficient capacity to manage national Be Clear on Cancer campaigns – see details of current and upcoming campaigns
  • Commission additional endoscopy capacity for lower gastrointestinal cancers ensuring only JAG accredited providers are used
  • Request your Provider Trust books the 1st Outpatient appointment for 2week wait referrals within 5 working days
  • Commission in accordance with the pathways agreed by the Thames Valley Cancer Network

Living With & Beyond Cancer

There are 2 million people living with or beyond cancer (anyone who has had a diagnosis of cancer) in the UK. This figure is set to rise to 4 million by 2030.

cancer recoverySupported aftercare should be in place to improve the lives of people affected by cancer (often people who have finished treatment report having life difficulties – financial, medical, emotional, practical etc);

Recovery Package – key interventions when delivered together can greatly improve lives

Holistic Needs Assessment – identifies the individual needs of the person affected which contributes to a consultation, with care plans developed and onward referrals to be made

Treatment Summary – developed by a multidisciplinary team to inform health services and family of the care and treatment received. This can also inform emergency/unplanned admissions

Cancer Care Review – 6 month GP practice review following diagnosis to enable self-management

Health & Wellbeing Clinics – educational sessions to provide holistic information to enable rehabilitation and self-management

Supporting actions for Living with and beyond cancer ambitions

recommendations living with

Commissioner recommendation

  • Continue the roll-out of the Recovery Package, expanding coverage and uptake, moving from Holistic Needs Assessment, Care Plan and Treatment Summary, to include all aspects of the Recovery Package
  • Commission stratified pathways, recognising their dependency on the availability of the Recovery Package
  • Ensure that all MDTs have referral pathways in place for lymphoedema services, pelvic radiation disease, sexual dysfunction support and psychological support
  • Consider how cancer support and follow-up can be integrated with the on-going management of other long term conditions
  • Work together with Primary Care to improve the quality and delivery of the Cancer Care Review.


End of Life/Palliative Care

Palliative care can play an important role at all stages of the cancer pathway, particularly for people with active and advanced disease.  It should be seen as an essential component of management, not something that commences when active treatment ceases.

End of Life activities cancer

Commissioner recommendation

Explore the potential for personalised outcome goals, to be developed by patients in partnership with clinicians, to focus care on what matters most to patients.

Patient Experience

The result of the National Cancer Patient Experience Survey for Trusts and CCGs was published in July 2016.  It is not possible to directly compare data from the 2015 survey to findings of the previous CPES survey even for identical questions due to the changes made in the questionnaire and its administration to take into account changes in patterns of service use, policy and the regulatory landscape.

The 2015 survey adopted the CQC standard for reporting comparative performance, based on calculation of “expected ranges”.  This means that Trusts/CCGs will be flagged as outliers only if there is statistical evidence that their scores deviate (positively or negatively) form the range of scores that would be expected for Trusts/CCGs of the same size.

Across Thames Valley the performance of each CCG against each of the 12 sections that make up the survey was average with the majority performing within the expected range for a CCG of similar size.  Across the range of questions, there were 16 instances where some of the Thames Valley CCGs were positive outliers and 41 instances where they were negative outliers.  The table below provides a summary:

patient experience 1

The above table is a summary of Outlier Performance (rating 1 or 3). If no positive or negative outlier exists, it isn’t shown. For example. NHS Newbury & District CCG is not on the table as it has no outlier (rating either 1 or 3).


cancer experience 1

As indicated in the chart above, overall within Thames Valley the majority of CCGs performed within the expected range for their size although they also performed lower than the national average. As shown performance for Q59 within the “Your overall NHS care” section, Oxfordshire CCG was a negative outlier as it performed lower than the expected range for a CCG of similar size.

cancer experience 2

Performance for Question 2 within the “Seeing your GP” section, both Milton Keynes and Aylesbury CCGs were negative outlier as they performed lower than the expected range for a CCG of respective size.

cancer experience 3

Performance for Question 8 within the “Finding out what was wrong with you” section, Winsor, Ascot and Maidenhead CCG was a negative outlier performing lower than the expected range for a CCG of respective size. Both North & West Reading and Wokingham CCGs were positive outliers performing higher the expected range for a CCG of their respective size.




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