Evidence from Cancer Research UK– MT 31

Cancer Research UK submission to the National Assembly for Wales Health and Social Care Committee inquiry into access to medical technologies

October 2013

Cancer Research UK welcomes the opportunity to respond to the Health and Social Care Committee inquiry into access to medical technologies in Wales, our response is based on consultation with radiotherapy experts from Velindre Cancer Hospital.

Cancer Research UK is leading the sector in championing improvements to the radiotherapy service in the UK. In 2011, we ran the ‘Voice for Radiotherapy’ campaign which led to a commitment from the Prime Minister to improve access to advanced radiotherapy. In 2012, we supported the implementation of the Radiotherapy Innovation Fund (RIF), a £23 million investment by the UK Government designed to increase access to Intensity Modulated Radiotherapy (IMRT) across England.

Radiotherapy is a highly effective way of treating cancer. Four in ten people whose cancer is cured have received radiotherapy, and every year radiotherapy helps cure more people than cancer drugs. Cancer Research UK believes that all patients in the UK should have access to the most appropriate, high-quality treatment that their doctor recommends.

Access to radiotherapy in Wales is still lower than optimal – around 37%[1] of cancer patients in Wales receive radiotherapy as part of their treatment, which falls below the recommended level of 52%.[2]

Although the UK invests far more in cancer research than any other country in Europe, it is often much slower to take up the fruits of this research. Innovations such as Intensity modulated radiotherapy (IMRT) were developed in the UK, but have been adopted more swiftly into practice elsewhere.

Key recommendations

We want to see improvements to the number of cancer patients accessing radiotherapy every year in Wales, and to see faster adoption of new techniques within the NHS in Wales. We welcome recent developments to improve the service such as the implementation of specialised commissioning and the Welsh Government Technology Fund. However, it is vital that there is a clear roadmap underpinning such activities to ensure that Wales can develop a world-class radiotherapy service in the future. Regarding new techniques, we would welcome the publication of a comprehensive plan in place setting out a plan for future service improvements.

We would urge the Committee to undertake further work to understand the barriers to research being carried out within the Welsh NHS, and to ensure that commissioners use clear and transparent criteria to determine whether the evidence for use of a new technology is sufficient for routine use within the NHS.

We support the principle of having a national specialised commissioning service for radiotherapy. However, this must work in practice to minimise the bureaucracy required to make improvements to the service and should use a transparent, consistent set of principles in commissioning new technologies.

We would welcome greater clarity around the WHSSC approval process and, where possible, we want to see this process become more efficient.

Locally, we also believe that structures for the approval of additional service delivery could be streamlined to help patients in Wales to gain quicker access to radiotherapy treatment.

Closer alignment of capital and revenue funding is needed, and experts tell us that a more streamlined and transparent approach is needed for decisions on the revenue commissioning of radiotherapy, and that the process needs to be more facilitative so that cancer centres can make the best possible case for providing innovative treatments to patients.

We would welcome the publication of a progress update on the report, Radiotherapy Equipment Needs and Workforce Implications 2006 – 2016, and more data on how radiotherapy is being delivered.

Working with other nations to ensure that all patients the best possible treatment.

Faster adoption of new technologies and Developing the evidence base

We would like to see faster adoption of new radiotherapy techniques in Wales. An equivalent of the All Wales Medicines Strategy Group (AWMSG) for medical technologies could help develop this.

Research is vital to developing the evidence base supporting routine funding of new technologies within the NHS. However, radiotherapy research in the UK is underfunded and we are concerned that there are not enough incentives for research to be carried out within the NHS across the UK.

The commissioning of radiotherapy in Wales

We support the principle of having a national specialised commissioning service for radiotherapy, but the current system must be streamlined and its processes made more transparent.

Currently, Welsh Health Specialised Services Committee (WHSSC) is responsible for specialised commissioning. Whilst there are robust processes in place to assess the need for changes and introduction of new techniques to the radiotherapy service - through the WSAC Clinical Oncology Subcommittee, the Cancer Networks and the Cancer Centres - experts suggest that the specialised commissioning process is not joined up.

In addition, experts report long timescales between the point where detailed proposals for service developments are submitted by cancer centres and the point at which they are approved by the WHSSC. Also, that the decision making process that occurs between the various stages is not transparent and centres receive very little communication during this time. Therefore, greater clarity around the WHSSC approval process and where possible greater efficiency would be welcomed.

Streamlining of the bureaucratic process

At the moment, Local Health Boards (LHBs) are required to approve requests from cancer centres to deliver additional services before these are referred to the Welsh Health Specialised Services Committee (WHSSC). Experts tell us that it can take a long time for plans to be scrutinised at local level, and the cancer centres also have to manage the different processes undertaken by each LHB. Once requests are referred to the WHSSC, this adds further time to the bureaucratic process and therefore delays these services reaching patients.

Closer alignment of capital and revenue funding for radiotherapy

Experts suggest that a more streamlined and joined up approach is needed between the capital and the revenue funding of the radiotherapy service.

We welcome the Welsh Government Health Technology Fund which provided the capital investment for stereotactic body radiotherapy (SBRT) and stereotactic radiosurgery service (SRS) equipment at Velindre Cancer Hospital. However this service cannot be fully established without the revenue funding needed for delivering treatment to patients including staff time, the cost of implementing and operating machines, and training.

Revenue funding is commissioned through WHSSC. Experience across Cancer Centres in Wales suggests that the current system can be slow, with the business cases for intensity modulated radiotherapy (IMRT), image-guided bracytherapy and SBRT taking up to a year or more to process.

Assessing needs and planning for the future

In 2006, the Cancer Services Co-ordinating Group in Wales (now the Cancer NSAG) published

Radiotherapy Equipment Needs and Workforce Implications 2006 – 2016.[3] It stated that:

· With current equipment and manpower resources, most patients in Wales are not receiving their radiotherapy according to the Welsh National Cancer Standards which endorse the Royal College of Radiologists (RCR) Standards.

· Currently Wales has 3.7 linear accelerators per million population, significantly less than the average provision in England or Scotland which stands at 4.7 and 4.98 linear accelerators per million respectively.

· In order to provide adequate provision of radiotherapy in Wales, it is recommended that Wales should aim to provide 58,000 fractions of radiotherapy per million population by 2016.

We would welcome an updated progress report on these issues, as more data is needed to analyse how radiotherapy is being delivered and whether improvements are being made.

Standards

We believe that a robust, transparent set of standards and principles need to be developed for the commissioning of new technologies in Wales which clearly delineates the responsibilities of all stakeholders. Currently, there is no cover-all service specification for the standard of the radiotherapy service in Wales - while we welcome efforts to introduce innovative techniques to the service, it is important that the governance structures covering the existing service are fit for purpose.

Working with the other nations

Experts suggest that it will also be important for Wales to work with groups in England including the Clinical Reference Group (CRG) for Radiotherapy, the Radiotherapy Board and the programme leads for Proton Beam Therapy. Work is also being undertaken in England to determine ambitions for the radiotherapy service over the next decade and we want to ensure that patients in Wales do not miss out on future innovations. We believe that all patients in the UK should have access to the most appropriate, high-quality treatment available and Wales should be prepared to align with other nations if this guarantees patients the best possible treatment.

Conclusion

We believe that a more joined-up, consistent approach to commissioning for radiotherapy is needed in Wales, and that work could be undertaken to promote faster adoption of new techniques across Centres.

We would be happy to provide further information or an expert to discuss these issues further, as required. Please contact Clare Bath (clare.bath@cancer.org.uk; 0292 089 2834).

Glossary

· Intensity modulated radiotherapy uses hundreds of tiny devices called collimators to shape the radiotherapy area (delivering 3D conformal radiotherapy), giving very precise doses to a cancer or to specific areas within the tumour or to avoid structures that would be damaged by the radiotherapy.

· Image guided radiotherapy uses scans during radiotherapy treatment to show changes in the size and position of the tumour.

· Image-guided brachytherapy is a form of radiotherapy that delivers radiation internally by placing a radioactive source within an applicator, which sits in or around the tumour. It uses CT or MRI imaging to pinpoint exactly where the cancer is before each treatment, which makes it possible to shape the radiation dose to match the shape of the tumour and avoid damaging vital organs.

· Stereotactic body radiotherapy andstereotactic radiosurgery are similar techniques which deliver radiotherapy in fewer sessions, using smaller and highly precise radiation fields as well higher doses than 3D conformal radiotherapy. Despite its name, stereotactic radiosurgery is not a surgical technique.

· Proton beam therapy uses a different type of radiation beam called a proton beam which gives a higher dose of radiation straight to the cancer, so there is less chance of damage to nearby healthy tissue.

About Cancer Research UK

Every year around 300,000 people are diagnosed with cancer in the UK. Every year more than 150,000 people die from cancer. Cancer Research UK is the world’s leading cancer charity dedicated to saving lives through research. Together with our partners and supporters, Cancer Research UK's vision is to bring forward the day when all cancers are cured. We support research into all aspects of cancer through the work of over 4,000 scientists, doctors and nurses. In 2012/13 we spent £342 million on research. The charity’s pioneering work has been at the heart of the progress that has already seen survival rates in the UK double in the last forty years. We receive no government funding for our research.

[3] Cancer Services Co-Ordinating Group, Radiotherapy Equipment Needs and Workforce Implications 2006 – 2016 (2006), 6.