Background
Shorter cancer waiting times can lead to earlier diagnosis, faster treatment, lower risk of complications, enhanced patient experience and improved cancer outcomes.
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. 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. Leaked data showed that by the end of July 2022 there were 327,395 people on the cancer waiting list, and around 3% had waited 104 days or more.
A review of NHS Access Standards was undertaken, and the final recommendations relating to cancer waiting times have been published. The report proposed a simplification to three standards for cancer, which would include replacing the two-week wait with the faster diagnosis standard. Eleven hospital trusts tested the proposed new standards. A consultation on the proposals for cancer targets ran between 9 March and 6 April 2022. In the meantime, NHS England continues to report on performance against nine standards. 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.
Wait time to see a cancer specialist
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%. From 2015 to 2018, average yearly performance dropped slightly to about 94%, after which it has declined year on year. The two-week standard has not been met since Q4 2017/18 (January to March 2018). In Q4 2022/23 (January to March 2023), 84% of patients had their first consultant appointment within two weeks.
For patients with breast symptoms (where cancer is not initially suspected), performance against the two-week wait target has declined at a faster rate. Between Q4 2017/18 and Q4 2022/23, the percentage of patients with breast symptoms seen by a consultant within two weeks of an urgent GP referral fell from 92% to 78%.
Wait time for cancer treatment following decision to treat
There are three main types of treatment 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.
There is a target for 96% of patients to start any type of treatment for a new primary cancer within one month (31 days) from the decision to treat. The proportion of patients who start cancer treatment within one month has decreased over time. The 96% target was last met in Q3 2019/20 (October to December 2019). Since then, performance has fallen to 91% in Q4 2022/23.
The anti-cancer drug regimen target (operational standard: 98%) was consistently met until Q4 2022/23 where it fell just under target at 97%. Performance against the radiotherapy target (operational standard: 94%) was previously being met but declined from 97% in Q1 2021/22 to 88% in Q4 2022/23. Performance against the surgery target (operational standard: 94%) has declined since 2014 and the target was last met in Q1 2018/19. By Q4 2022/23, performance had declined to 78% of patients waiting less than 31 days for surgery following a decision to treat.
The clinically-led review of NHS cancer standards proposed that the four existing treatment standards be brought together into one simplified standard. This implied that there would be one operational threshold for the maximum one-month (31-day) wait from decision to treat to starting any cancer treatment.
Wait time for cancer treatment following GP urgent referral
The target for all cancer treatment pathways is for at least 85% of patients to start their first treatment for cancer within two months (62 days) of an urgent GP referral. Patients who are referred from an NHS cancer screening serviceshould also start treatment within 62 days, and the operational threshold for this is set at 90%.
The proportion of patients waiting less than two months to start cancer treatment following an urgent GP referral has decreased significantly over time, from 87% in Q4 2008/09 to 59% in Q4 2022/23 – the worst performance since records began. The target has not been met since Q3 2013/14.
At the start of the Covid-19 pandemic the NHS was forced to shut down or reduce non-Covid care so that clinicians would have the capacity to treat Covid-19 cases. The number of patients who started treatment following an urgent GP referral fell sharply to 29,646 in Q1 2020/21 (April to June 2020), 30% less than the previous quarter (data not shown). The BMA estimates that in Q1 2020/21, there were between 274,000 and 286,000 fewer urgent cancer referrals.
The national screening service was also impacted by the management of the Covid-19 outbreak. Breast and bowel screening services were paused locally in March 2020 and invitations for cervical screening were suspended in April 2020. The number of patients starting treatment following referral from a screening service fell sharply to 1,375 in Q2 2020/21 – a 77% decrease from Q4 2019/20 (data not shown). In Q1 2020/21, performance against the two-month waiting time target fell to a low of 62%, then recovered to 85% in Q3 2020/21 before decreasing again to 66% in Q4 2022/23. In Q4 2022/23, 5,681 patients started treatment following a national screening service.
As with the 31-day targets, the clinically-led review of NHS cancer standards proposed that the maximum 62-day wait targets be brought together into one simplified standard.
Wait time for cancer diagnosis
A newly proposed target set by NHS England in April 2021 mandates faster diagnosis by March 2024, such that at least 75% of patients either receive a cancer diagnosis or have it ruled out within four weeks (28 days) of an urgent GP referral. This target was expected to be met from October 2021 onwards, but the NHS delivery plan pushed the ambition to meet the target back to March 2024. Waiting for a diagnosis can be a very stressful experience for patients and their loved ones, making reduced wait times helpful in alleviating patients from needless worry if cancer is not detected. Alternatively, it can result in early detection and shorter time to begin treatment.
The proportion of patients waiting less than four weeks to receive a cancer diagnosis following an urgent GP referral was 72% on average per month in 2021/22, three percentage points below the performance target. Between April 2022 and January 2023, the performance dropped to 70% on average per month. In February 2023, the performance target of 75% was achieved, 13 months earlier prior to the deadline. This performance needs to be maintained up until March 2024.
About this data
These indicators use data from NHS England 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 continued to be included in the national time series, so data is unaffected by the field testing. Data on the new Faster Diagnosis Standard has been included in the cancer waiting times publication since April 2021. Recommendations for the clinically-led review of NHS cancer standards published in March 2022 can be found here.