Shorter cancer waiting times can lead to earlier diagnosis, faster treatment, a lower risk of complications, an enhanced patient experience and improved cancer outcomes. The cancer pathway in the NHS, from urgent GP referral to first treatment for cancer, is currently spanned by nine operational standards, including the new faster diagnosis standard introduced in April 2020. Here we look at how the NHS in England performs against these standards.
During the coronavirus (Covid-19) pandemic, NHS England told trusts that essential cancer treatment must continue. However, delays to treatment were widely reported. Modified Cancer Waiting Times guidance was issued which stated that, where capacity was constrained, processes should be in place to prioritise particularly urgent cases, including downgrading or avoiding referrals where possible. As Covid-19 cases rose in winter 2020-21, there were further reports of cancellations to urgent cancer treatments. In March 2021, local systems were asked to fully restore all cancer services and ensure there was sufficient diagnostic and treatment capacity to address the shortfall in first treatments for cancer by March 2022.
A review of NHS Access Standards is being undertaken, but the publication of its recommendations has been delayed due to the Covid-19 pandemic. The interim report proposed a simplification to three standards for cancer, one of which would include the new faster diagnosis standard. Eleven hospital trusts began testing the use of a 28-day faster diagnosis standard in late August 2019, in place of the current standard of seeing a specialist within 14 days. NHS England’s 2021/22 priorities and operational planning guidance set out that 75% of patients referred for suspected cancer should find out if they do or do not have a cancer diagnosis within 28 days of referral. The adoption of the other two proposed standards for cancer will depend on the proposals set out in the review’s final publication. In the meantime, NHS England continues to report on performance against the original eight operational standards.
The target relating to the first part of a patient's journey states that, following an urgent GP referral for suspected cancer, at least 93% of patients should be seen by a specialist within two weeks. The standard is the same for patients with breast symptoms (where cancer is not initially suspected).
Between 2009 and 2014, the percentage of people with suspected cancer having their first consultant appointment within two weeks of an urgent GP referral fluctuated at around 95%. After this, performance dropped slightly to about 94%, until 2018 where it declined further. The two-week standard has been missed for the last three years. In Q4 2020/21 (January to March 2021), 89% of patients had their first consultant appointment within two weeks.
Between 2010 and 2014, waiting times for patients with breast symptoms were similar to those with suspected cancer. However, over the last four years performance has declined at a faster rate, especially in Q1 (April to June) of each financial year. Between Q1 2020/21 and Q3 2020/21, the percentage of patients with breast symptoms who had their first consultant appointment within two weeks of an urgent GP referral fell sharply from 90% to 70%. In Q4 2020/21, it increased very slightly to 71%.
In April 2020, a new faster diagnosis standard was introduced, and in March 2021 the target was set which states that 75% of patients should be told whether or not they have cancer within 28 days of an urgent referral from their GP or a cancer screening programme. Trusts are expected to meet the standard by Q3 2021/22, however data on performance against the standard is not yet published.
There are three main types of treatments for cancer: drug therapy, radiotherapy and surgery. It is common for cancer patients to need more than one treatment, which could be a combination of several episodes of one type of treatment, or a combination of multiple types.
The target, for all cancer treatment types, is for at least 96% of patients to start a first treatment for a new primary cancer within one month (31 days) of the decision to treat. Performance has declined over time, and this operational standard was missed for the first time in Q4 2019/20 (January to March 2020), with 95.8% of patients waiting less than 31 days.
In Q1 2020/21 (April to June 2020), performance fell to 94.7% but recovered slightly to 95.7% in Q3 2020/21 (October to December 2020), before falling again to 94.5% in Q4 2020/21 (January to March 2021). The number of patients starting a first treatment for cancer fell to 56,707 in Q1 2020/21 (data not shown), 26% lower than in Q1 2019/20, during the Covid-19 pandemic. In Q4 2020/21, 73,606 patients started a first treatment for cancer, 9% lower than in Q4 2019/20.
The anti-cancer drug regimen target (operational standard: 98%) and radiotherapy target (operational standard: 94%) have both consistently been met since they were introduced. Performance against the surgery target (operational standard: 94%), however, has declined since 2014 and the target has not been met for over two years. By Q4 2020/21, performance had declined to 87% of patients waiting less than 31 days for surgery following a decision to treat.
The interim review of NHS access standards proposed that the four cancer treatment standards would be brought together into one simplified standard. This implies that there would be one operational threshold for the maximum one-month (31-day) wait from decision to treat to starting any cancer treatment.
The target that spans the patient pathway is for at least 85% of patients to start a first treatment for cancer within two months (62 days) of an urgent GP referral. Patients who are referred from an NHS cancer screening service should also start treatment within 62 days, but the operational threshold is set at 90%.
The proportion of patients waiting less than two months to start cancer treatment following an urgent GP referral has decreased considerably over time, from 87% in Q4 2008/09 to 76% in Q4 2019/20. The target has not been met since Q3 2013/14. Compared to those referred by a GP, prior to the Covid-19 pandemic a higher proportion of people referred via a national screening service started treatment within 62 days. However, performance has also worsened over time, and the target has not been met for over three years.
In Q1 2020/21 (April to June 2020), during the Covid-19 pandemic, the number of patients starting treatment following an urgent GP referral fell sharply to 29,646 (data not shown), 27% lower than in Q1 2019/20. Only 73% of patients started treatment within 62 days following an urgent GP referral. In Q4 2020/21 (January to March 2021), the number of patients starting treatment had increased to 39,332 (7% lower than in Q4 2019/20), but performance fell to 72%.
The percentage of patients starting treatment within 62 days following referral from a national screening service fell dramatically to 62% in Q1 2020/21, then increased to 85% in Q3 2020/21 before falling again to 76% in Q4 2020/21. The number of patients starting treatment following referral from a screening service fell sharply to 1,375 in Q2 2020/21 – a 75% drop (data not shown). This follows breast and bowel screening services being paused locally in March 2020 and invitations for cervical screening being suspended in April 2020. In Q4 2020/21, the number of patients starting treatment following referral from a screening service increased to 4,733 – 21% lower than in Q4 2019/20.
As with the 31-day targets, the interim review of NHS access standards proposed that the maximum 62-day wait targets be brought together into one simplified standard.
About this data
These indicators use data from NHS England that are derived from patient records held on the Cancer Waiting Times Database. The national levels of activity and performance are provider-based figures. For further information outlining the methodology, please see the NHS England website.
During the review of NHS access standards, performance of the field test sites continues to be included in the national time series, so data is unaffected by the field testing. Data on the new Faster Diagnosis Standard is expected to be published from spring 2021.