What changes are being made?
Last year we undertook a consultation on proposals to modernise and simplify the cancer waiting time standards. The consultation showed widespread support from clinicians and patients for the proposal, which would move from the 10 standards in place currently to three outcomes-focused standards:
- Faster Diagnosis Standard: patients to receive a diagnosis or ruling out of cancer within 28 days of referral
- 31-day treatment standard: all cancer patients to commence treatment within 31 days of a decision to treat
- 62-day treatment standard: patients to commence treatment within 62 days of being referred either by a GP or through cancer screening, or from consultant upgrade
The government has now given its backing to making that change.
The Faster Diagnosis Standard itself was introduced in 2021 at an initial target of 75%. Although it is therefore relatively new, it is already in force as one of the ten standards. The main changes being announced are:
- Removal of the Two Week Wait standards requiring a first appointment within two weeks
- Combining together the Urgent Suspected Cancer GP referral, Urgent Screening and Consultant Upgrade 62-day standards to create one headline performance standard
- Combining together the first and subsequent treatment 31-day standards to create one headline performance standard
As part of the changes, all patients upgraded onto a cancer pathway will be required to be counted as a ‘consultant upgrade’ at the point at which they are initially referred to a cancer multi-disciplinary team. Currently, patients who are initially referred on a routine or emergency pathway can receive a ‘consultant upgrade’ onto a cancer pathway, meaning that from that point forward they are covered by the requirement to start treatment within 62 days, ensuring the same urgency is applied to their pathway as anyone else with a suspected cancer. However, this is currently inconsistently applied, with some providers upgrading nearly every patient diagnosed with cancer, and some upgrading none.
Already, as of 1 July 2023, patients diagnosed with cancer following a breast symptoms referral (i.e. where cancer wasn’t suspected) and on non-specific symptom (NSS) pathways are included in the 62-day standard, and this will continue.
Subsequent treatments will be included in the new headline 31-day treatment standard, with the exception of Active Monitoring and Palliative Care.
At the same time as these standards come into effect, we will revise and improve the publishing of monthly cancer waiting time statistics to provide a more complete and granular breakdown by different types of cancer. We will commence a consultation on the nature of these changes soon.
Why are you making this change?
The proposed standards are in line with recommendations made by the Independent Cancer Taskforce in 2015 and the subsequent clinical review, which was started in 2018. The new standards are more in line with the requirements of modern cancer care, with a greater focus on outcomes and incentivising the completion of the pathway rather than arbitrary process measures. They will ensure equitable access to care because the new treatment standards will measure waiting time for all patients regardless of their route into the system, rather than just those who were urgently referred by their GP.
There are several benefits of modernising and simplifying the standards, including:
- We will give clinicians greater flexibility to adopt new technologies such as remote image review and AI, and avoid disincentivising modern working practices such as One-Stop-Shops and Straight-to-Test.
- Consolidating the existing 10 standards into 3 standards more clearly focused on outcomes rather than process will ensure we always incentivise the best decisions for patients.
- The changes will increase the level of focus on delivering improvements to the Faster Diagnosis Standard, delivering greater certainty to patients more quickly.
Why are you removing the Two-Week-Wait standard?
The Two-Week-Wait standard is no longer a relevant measure because of the changes and advances made in cancer diagnostic pathways since it was introduced 23 years ago. Many patients now go straight to test without needing an initial outpatient appointment with a specialist first, meaning faster diagnosis and more certainty, sooner. The Two-Week-Wait standard, however, incentivises providers to implement pathways which include an initial outpatient appointment, as this is usually easier to arrange than a diagnostic test. Often this initial outpatient appointment is not actually required to move the pathway forward, slowing down the pathway to diagnosis and inconveniencing patients.
The NHS has published a series of Best Practice Timed Pathways to give providers a step-by-step guide to ensuring patients are diagnosed within 28 days – they cover seven different cancer types (Oesophagogastric, Lower GI, Prostate, Lung, Head and Neck, Gynaecology and Skin) with more on the way. Almost all of these include diagnostic tests of one form or other in fewer than 14 days.
Shifting to focusing on the Faster Diagnosis Standard means we’re focused on the outcome of a referral, not the process. will give clinicians greater flexibility to adopt new technologies such as remote image review and AI, and modern working practices such as one-stop-shops and straight-to-test.
What did you learn from the consultation you ran last year?
There was widespread support from NHS staff, patient groups and cancer charities, to these proposals in last year’s consultations.
There were also a number of useful comments made through the consultation which we will consider, in particular in how we communicate Cancer Waiting Times performance going forward. In particular, these related to a greater availability of data on specific cancers, and to feelings from some patients that the 62-day, 31-day or 28-day standards represented too long a time to wait.
We will in future publish a greater breakdown of performance for different cancer types for 62-day performance, moving beyond the current Breast, Lower GI, Lung, Skin and Urology categories. From the December 2023 Cancer Waiting Times data publication (covering data for October 2023), the intention is to publish 62-day and 31-day performance individually for Lung, Breast, Skin, Lower GI, Prostate, Other Urological, Lymphoma, Other haematological, OG, Hepatobiliary, Head and Neck, Gynaecological and ‘All Other’ cancers.
We will also seek to communicate, alongside the headline performance against the standards, the shorter time breakdowns, for example noting that 44% of people were diagnosed within 14 days in April 2023, alongside the headline figure of 71.4% for the 28-day target, emphasising that many people are diagnosed more quickly than the headline target might suggest.
Will you publish the outcome of the consultation?
Yes, we will publish this when we make a public announcement on moving ahead with implementing the changes. NHS England » Cancer
What needs to happen to bring these changes into effect?
These changes will be implemented from 1st October 2023. Trusts will not need to change much in terms of their data reporting – the only change of note in terms of overall process will be their reporting of performance against the 62-day standard to include patients who’ve entered cancer pathways via screening or consultant upgrades as well as those who were referred by their GP. The dataset itself will not need to change to implement the changes.
Will there be changes to the way Cancer Waiting Times statistics are published?
Statistics will still be published by NHS England monthly. Once the changes are in place, the published figures will cover the three standards. We will still be collecting and publishing some data on the other process-based standards beyond the two-week-wait, such as first and subsequent radiotherapy or chemotherapy treatments. While these will no longer be standards against which trusts are held to account, this data will remain important in terms of being able to analyse and understand reasons for any changes in overall performance against the main standards for the better or the worse. We also plan to increase the number of cancers for which we provide a breakdown for both 31-day and 62-day performance.
Will a greater breakdown of different cancers be provided as part of the changes?
Yes. At the same time as we make this change, we will also take the opportunity to improve the granularity of Cancer Waiting Times stats we publish, to provide figures broken down by cancer type in a more detailed way. There is still a bit of work to do to finalise which cancers we will be publishing data on in future, and we’ll talk more about this as we finalise the new publication, but we know it’s something that matters to patients and cancer charities.
Are you concerned that removing the two-week-wait standard would result in slower diagnosis?
During the testing period, there was no evidence that areas where the two-week-wait standard was removed saw slower diagnoses for any cancers. Overall, areas that were part of the testing saw slightly higher performance on the Faster Diagnosis Standard than areas that were not part of testing.
The goal in removing the two-week-wait standard is to focus the Cancer Waiting Times standards clearly on two clear goals: achieving the fastest possible diagnosis, and for those who are diagnosed and require treatment ensuring they receive treatment as quickly as possible. We don’t want the standards to provide arbitrary rules about how that is achieved that could disincentivise the best clinical practice.
The Faster Diagnosis standard was piloted in selected areas before it was implemented nationally, to look at the impact it had. Data from the test sites collected between April and July 2021 showed:
- Performance against the 62-day standard was significantly higher in the test group than in the rest of the country – 74.9% vs 71.7%
- The test group significantly outperformed the control group on Faster Diagnosis Standard performance – 78.7% vs 71.9%
- The test group’s FDS performance was maintained at a higher level after the test period ended than other areas.
- Analysis showed that the two-week-wait performance in test sites and the control groups was the same.
Will cancers that are diagnosed quickly like breast cancer be disadvantaged by the change?
This move is designed to make sure we’re speeding up cancer diagnoses and that must be true for breast cancers too. We will introduce a best practice timed pathway for suspected breast cancer, which includes a recommendation to deliver a triple assessment within two weeks.
When the use of Faster Diagnosis Standard was piloted between October 2020 and July 2021, performance against the FDS (the proportion of people with suspected breast cancer receiving a diagnosis or cancer being ruled out within 28 days) was marginally better in the test group than in the control group (92.9% vs 91.0%) and the benefits of using FDS rather than two-week-wait became clearer as the pilot period went on: in June and July 2021 performance was 4% better in the test group than the control group. In each of the three months up to and including July 2021, the percentage of patients meeting the FDS within two weeks was better in the test group than the control group – for example, 65.9% vs 56.0% in July 2021.
A recent Getting It Right First Time survey showed that 30% of trusts were providing separate appointments for the triple assessment, as the first appointment stops the two-week-wait clock and allows them to meet the target. The focus on the Faster Diagnosis Standard is intended to shift the focus from the provision of an appointment to the reaching of a diagnosis, removing any incentive to break up the optimal structure of pathways in order to meet process-focused targets and ensuring patients receive appropriate and ideal models of care.
For breast cancer, we have ensured that all referrals (both suspected cancer and symptomatic where cancer is not suspected) are in scope of the Faster Diagnosis Standard.
Alongside the announcement of changes to the standard, we have already made clear that for some pathways that are simpler and already perform well, like breast cancer, the level of performance needed to achieve the all-cancer 75% target will be higher than 90%.
Is the target ambitious enough?
We want to see the target for the Faster Diagnosis Standard increase over time. The target is currently set at 75% and we are committed to meeting it by March 2024. The target will then increase gradually to 80% by 2026.
The number of urgent suspected cancer referrals has trebled over the last 14 years. We are putting in place extra diagnostic capacity, improving existing pathways and harnessing technology to rise to the challenge that extra demand creates – we know we have a way to go on this but we’re making important progress.
As an indication of the improvements we expect to see following this investment in diagnostic capacity, we are also announcing that we will raise the Faster Diagnosis Standard to 80% and achieve this level of performance by the end of the financial year 2025/26.
Is it possible to meet the targets by delivering performance improvements only for those who have cancer ruled out?
The data we have collected so far show this isn’t the case. Although there is for some cancers a gap in performance between those diagnosed with cancer and those without, the most recent data showed that for those diagnosed with breast cancer, performance was 72.7% in April 2023, and was over 80% in February 2023. Although that is lower than overall performance on the breast pathway, and we want to see that gap reduce, it does clearly demonstrate that improving performance against the Faster Diagnosis Standard will deliver results both for those diagnosed with cancer and for those who have cancer ruled out. Many other cancers have similar performance for both the group diagnosed with cancer and those who have cancer ruled out, particularly those with relatively simple diagnostic pathways which usually require only one diagnostic test – for example, colorectal cancer where a colonoscopy can usually diagnose or rule out cancer.
Does reducing the number of standards lower the level of ambition for cancer performance?
No, it doesn’t. These changes will still set the same high performance bar for all the same groups of patients as were covered by the previous standards, and will actually increase the number and proportion of patients covered by the standards.
The change is intended to focus more clearly on outcomes over process, put all patients on a level playing field regardless of the origin of their referral, and make it easier for patients and stakeholders to hold the NHS to account by simplifying the number of targets set whilst increasing the data breakdowns published.
How will delivering the Faster Diagnosis Standard support earlier diagnosis?
The Long-Term Plan set out NHS England’s commitment to improving the proportion of cancers diagnosed at an early stage to 75% by 2028. Reducing the time taken to diagnose cancer will clearly have a small impact itself on earlier diagnosis – there will be some patients who have reduced waiting times and whose cancer therefore doesn’t progress when it otherwise may have done. However, we expect the direct impact to be small – most cancers take a significant amount of time to progress, and in general achieving a stage shift to earlier diagnosis will require us to diagnose cancers months and years earlier rather than days and weeks.
However, the successful delivery of the Faster Diagnosis Standard is still a key enabler of earlier diagnosis. The establishment of rapid, high-quality diagnostic pathways that the Faster Diagnosis Standard will encourage, ensuring that the ever-increasing volume of suspected cancer referrals are able to be dealt with quickly and efficiently will ensure that when we have identified a potential cancer early, patients do not then face the anxiety of waiting to have that diagnosis confirmed, or the fear that a cancer might progress during the diagnostic period.
We also know that when people don’t have confidence in health services they are less likely to come forward. Demonstrating that patients who come forward will receive a fast and effective diagnostic pathway that will either diagnose the problem and allow rapid treatment, or that will quickly rule cancer out and provide reassurance, will help to encourage people to come forward if they are worried.
Why have you set the interim performance target for 62-day performance at just 70% when the target is 85%?
Following the pandemic and the increases we saw in the number of people awaiting diagnosis and treatment, our focus has been on bringing the waiting list down, with a particular focus on the number of people who have been waiting longer than 62 days. Thanks to the tireless efforts of NHS staff, the number of people waiting longer than 62 days has now reduced year on year for the first time since 2015, and we are on track to meet our target of bringing this down to no more than 7% of the total waiting list by March 2024. The overall number of patients waiting longer than 62 days has reduced from a high of 34,000 last year to around 21,000 today. Focussing on the longest waiters does mean that we have seen performance fall significantly, but has been the right thing to do.
As the number of longer waiters reduces, it is now the right approach to start to renew our focus on the constitutional standards, starting with the Faster Diagnosis Standard, which we have committed to meeting by March 2024, and beginning to renew our focus on the 62-day standard. We do, however, have to recognise that as we start to renew that focus, it will take time and investment to improve performance back to where we want it to be – consistently meeting the standard set at 85%, whilst continuing the progress that has been made on reducing the number of long waiters. This initial goal of 70% sets a clear ambition and trajectory back to delivering on the 62-day standard, but is only the first step in what will be a longer process.