by Professor Karol Sikora
Date: May 18th 2020
This briefing note sets out a proposal for how the Independent Sector can support the recovery of NHS cancer services in England to pre-pandemic levels.
As infection and mortality rates start to decline, the NHS has entered its second phase response to COVID-19. Continued vigilance is required to mitigate the risk of a second outbreak. Recently announced cancer metrics demonstrate a significant reduction in the number of consultant referrals, and new patients taking up radiotherapy and systemic anti-cancer therapies (SACT) is minimal. There is an urgency to restore cancer services to pre-pandemic levels as soon as possible, to minimise the potential harm caused by the current disruption to services. Additional capacity is also needed to handle the backlog of patients and to get the NHS back on track to delivering the ambitions of the Long-Term Plan. However, service planning needs to remain vigilant of the risks of a 2nd wave and ensure that services are delivered safely.
There are a broad range of issues to be addressed:
Patients are choosing not to present at their GPs due to a fear of exposure to infection. This will result in a delay of patients entering the system for diagnosis. They need to be assured that their concerns about symptoms should be acted upon and will be managed in a safe environment. Primary and community care issues are not covered in this briefing note.
The availability of, and attendance at, screening programmes has significantly slowed down. This will result in early indications of cancer being missed and the start of treatment delayed.
Around 30% of urgent cancer surgery has continued. The NHS cancer hubs are providing COVID-19 free hubs to increase the throughput of patients, but there is already a backlog to address. Some of these hubs are using IS hospitals.
About 70% of post-surgical cancer treatments have continued. However, for some vulnerable patients, protection from COVID-19 took priority over starting or continuing cancer treatment and taken together with patients not yet referred or diagnosed, there is now a significant backlog to address with a surge in demand anticipated for later this year.
Post treatment services
Some patients will require ongoing support, and the NHS is already anticipating additional pressure on primary and community care following discharge from treatment.
The NHS workforce has been depleted during the pandemic through staff being ill or self-isolating with symptomatic family members. This is likely to continue and directly affect NHS ability to recover levels of service. The NHS recognises that staff are exhausted and stressed which may also impact the pace of service recovery.
The NHS supply chain has struggled to establish and maintain secure supplies of PPE to keep staff and patients safe.
Effect of delay on outcome
- A continued delay in the diagnostic pathways for cancer leading to significant upward stage migration of most solid tumours.
- Difficulties in scheduling primary surgical intervention especially for chest and abdominal surgery requiring complex excision procedures only possible under general anaesthesia.
- These delays will now inevitably cause upward stage migration in many patients so reducing overall 5-year survival significantly in many patients. As an example, a Stage 1 breast cancer patient has a 98% chance of cure whereas a Stage 3 patient has only 25% (CRUK data). Similar prognostic figures apply to most solid tumours. The timing of this upstaging is very variable and depends on both tumour and host factors. Delays in the diagnosis and treatment of cancer is the commonest cause for litigation. It is accepted that where there is breach of duty a delay of 6 months or more is adequate proof of causation in claims for compensation.
- The upstaging means that primary cancers usually confined to single organs are more likely to spread to lymph nodes and other structures. Effective treatment will require more complex surgery and require more medical intervention – chemotherapy, immunotherapy and radiotherapy to achieve optimal outcome.
- A surge in demand for post-surgical care will occur with a peak in August-October 2020. The timing and severity of this wave of new patients critically depends on the speed at which diagnostic services and cancer surgery can get back into full operation. The longer the delay, the bigger the surge. The strategy of creating 19 cancer hubs utilising the resources of the private sector has kickstarted surgery for the NHS effectively, but it is still below the demand.
- There will be inadequate staff capacity to treat all patients optimally during the peak months of cancer presentation. We will need to take carefully considered shortcuts such as fewer radiotherapy fractions, the use of oral chemotherapy to substitute for parenteral drugs and the use of regimens with fewer hospital visits.
- There will be serious emotional difficulties for cancer patients and their families who will have to be informed of the effects of delay and the possible consequences on their long-term survival.
Independent Sector (IS) Capacity
Just as the IS was an integral part of the bed capacity requirements for phase 1 of the pandemic, it has a critical role to play in the restoration of cancer services. Appendix 1 sets out the IS centres across the UK that provide cancer services. Rutherford Health’s analysis of this capacity and its availability to the NHS is as follows:
Surgery and Diagnostics
The currently operational 19 cancer hubs partially involve private sector hospitals for surgery and diagnostic biopsies. We assume this phase of activity will be transferred to Covid Free Zones (CFZs) within NHS hospitals by July 2020. This assumes no second wave coming in the autumn, predicted by the WHO, or virus mutation and the effective use of operating theatres and ICUs despite the usual onset of winter pressures.
There are 26 private linear accelerators (LINACS) currently staffed and operational. These are in addition to NHS LINACS used part time for private patients. The private sector therefore has the potential capacity to treat 31,200 new radiotherapy patients annually (see Appendix 2 for underlying assumptions).
Radiotherapy can be used as an alternative to surgery in certain circumstances. Lung, pancreatic and prostate cancer are obvious targets for this substitution.
Three precision techniques are available in the independent sector:
- Stereotactic Ablative Radiotherapy (SABR)
Low fraction number, high dose precision treatments are regularly used for lung and other cancers. Increasing their availability by harnessing the IS will dramatically enhance overall capacity. The majority of modern LINACS can easily be adapted for SABR once the appropriate software is loaded. Local collaboration to create SABR outposts of NHS centres can be developed within days. All 26 LINACS in the IS are top of the range Elekta or Varian equipment fully SABR capable. Approximately 80% are already delivering such treatments but working well below capacity.
- MR LINACS
There are now four active MR LINACS in the UK – 2 NHS and 2 IS. This precise form of image guided radiotherapy could be used for selected patients with Stage I and II localised cancers as an alternative to cancer. There is IS capacity to treat 500 patients annually under appropriate joint arrangements.
- Proton Beam Therapy (PBT)
There are now four active PBT centres – The Christie, Manchester (NHS) and the Rutherford Centres in Newport South Wales, Reading and Northumbria. Three more are scheduled to come on stream shortly – UCLH, London (NHS), Liverpool (Rutherford) and Harley St, London (Advanced Oncotherapy). Where appropriate, the existing NHS Standard Operating Procedure for handling referrals could be amended to include the IS Centres to improve access to this service. The Rutherford Cancer Centres currently have capacity for up to 750 new patients per year.
SACT Including Immunotherapy and Hormone Treatment
There is a total of 65 independent chemotherapy units. Smaller versions (up to 6 couches) are embedded in private general hospitals in the Spire, BMI, Ramsay Hospitals whilst larger areas (10-15 couches) are present in IS cancer centres with associated radiotherapy facilities. This gives a total capacity of 130,000 new patients a year (see Appendix 2).
Also, Healthcare at Home, BUPA Home Healthcare and Calea Ltd (part of Fresenius) provide chemotherapy closer to home. Both Healthcare at Home and Bupa run comprehensive home chemotherapy services that include patient registration; prescription, preparation and delivery of cytotoxic drugs; supply of nurses; patient counselling, and telephone support for adverse reactions; and logistics and waste removal for a variety of chemotherapy regimens. The capacity of these services is determined by specialist nurse availability and is relatively small. Our estimate is that with enhanced use there could be capacity to treat a further 10,000 patients a year with these services.
Independent Sector Commitments to Existing Patients
IS providers will want to develop an NHS partnership model which enables them to continue treating their existing pipeline of patients. This could be achieved by the IS committing to a certain volume of capacity for a fixed period of time, with some flexibility towards the end of that period according to the progression of the pandemic.
For maximum impact, this proposal requires national support and co-ordination through the regional teams, in the same way as the bed capacity has been handled. It will need to be underpinned with a communications strategy at each of the following levels:
Coordination: a central clearing house will be established to establish overall capacity and manage the system response. This will need clear national policy, robust procedures, appropriately trained staff and reliable IT networks. This could be supported by leadership from the IS to sit alongside NHS leadership, in a similar model to managing the bed capacity. Rutherford Health can make available some senior resource on a temporary basis if required.
Prioritisation and allocation system: local guidelines will need to be created to inform Trusts of the most suitable types of patients for referral under this scheme. A decision will have to be made as to whether consultants can directly refer patients to a provider or whether the allocation is to be managed centrally to allow transparency, oversight, and prioritisation. A regional decision-making group will be needed. The NHSE guidance issued 23 March 2020 remains relevant (see Appendix 3).
NHS Framework Contracts: this plan envisages trusts referring patients to providers with whom they may not already have contracts in place. The nature of the contract, pricing and a pay mechanism require further discussion.
Access to services: each system should identify its local IS providers, establish the available capacity and incorporate it into local planning assumptions. A co-ordinator within each Cancer Alliance would facilitate the national co-ordination and local use of capacity.
Practising privileges: consultants employed by the NHS will need to be granted practising privileges in their local IS centres. This should be made as simple a process as possible using documentation already held by NHS HR departments.
IT infrastructure: most private providers have built their IT infrastructure to integrate and work with the NHS.
Protecting patients and the system from COVID-19: a key feature of this proposal is that IS providers are able to offer care to immunosuppressed patients in centres that are COVID-19-free zones. Practical measures include:
- Infection control: Patient treatment must be undertaken in a controlled safe environment, minimising unnecessary exposure to patients who have low immunity. Services must be segregated to protect the most vulnerable.
- Testing: A ‘first line of defence’ approach to the physical locations, through the introduction of Pre-Entry Assessment prior to entering facilities. These assessments risk-assess the likely presence of any infection, through temperature checks and brief questioning. Where risks are identified a swift process is implemented to clinically assess the suitability of treatment continuing that day and any necessary additional precautions where treatment can continue. This is a model that has been introduced across all Rutherford Cancer Centres and has proved extremely effective in protecting both the patient attending and patients and staff already in the centres.
- Safe staffing: Ensuring all staff and consultants undergo the daily Pre-Entry Assessments and strictly adhere to isolation requirements. This must be supported by a networked and flexible workforce to ensure treatments can continue without interruption whilst still adhering to safe practices.
- PPE: Access to adequate consumables and adherence to strict PPE requirements in line with government directives.
The surge of cancer patients is expected by late summer 2020. The IS has huge resources to assist the NHS by working in partnership. Developing a plan centrally and authorising local coordination based on existing NHS cancer centres would provide the most effective structure for implementation. This will significantly mitigate against delay and strict rationing to ensure the best long-term outcomes for our patients.
Conventional Radiotherapy: Using traditional load factors of 4 fractions delivered in 1 hour for 10 hours a day for 300 days a year (no Sunday working), gives 12,000 fractions per machine. Traditional fractionation with an average of 20F per course gives a capacity of 600 new patients per year. The safe use of hypo-fractionated regimens for breast and prostate cancer further reduces the mean course duration to 10F so doubling the capacity of each LINAC to 1200 new patients a year. The private sector therefore has the potential capacity to treat 31,200 new radiotherapy patients per year.
Chemotherapy including immunotherapy and hormone treatment: Applying a conservative estimate of 8 active chairs, treating 3 patients a day 6 days a week, for 6 cycles of chemotherapy over 4-5 months, there is capacity to treat 7,200 cycles of treatment per centre so 200 new patients a year per centre. This gives a total capacity of 130,000 new patients per year.