As demand outstrips capacity, doctors face the moral injury of knowing that we can’t do the best for our patients.
This article first appeared in The New Statesman on 6 July 2023.
We have a fundamental problem of capacity and demand in cancer treatment. Over decades we have failed to grasp this, and we have sleepwalked into a chasm between the two. The government will say they’ve increased staff numbers. They have, but the problem is demand has increased more.
Cancer incidence rises year-on-year as the population ages, and so does its complexity. Each year we’re giving more complex treatments to more patients, and more complex patients for that matter. With a 15 per cent shortfall in clinical oncologists, we’re barely treading water. As a result, almost half of cancer centres now report that patient treatment is delayed most months or every month because of staff shortages. Some oncology departments have even considered pausing access to new treatments; they’re so busy getting through their everyday work that they struggle to facilitate bringing new treatments in.
We’re also doing more diagnostic tests each year – for the same reasons that we’re giving more cancer treatment, but also because of our welcome ambitions for earlier diagnosis. Earlier diagnosis is key to improving cancer survival but we must resource it properly, and right now we’re struggling – with a 29 per cent shortfall of radiologists, set to escalate to 40 per cent in five years’ time.
While the pandemic has undoubtedly made this worse, these are not new issues. The main target for cancer waiting times, that 85 per cent of patients start treatment within two months of an urgent referral, hasn’t been met in almost a decade. How did we get here?
A major reason is a chronic failure to do strategic workforce planning. The long-awaited NHS workforce plan promised to change this, with proper capacity- and demand-modelling at its core. The plan, published on 30 June, signals a step change in ambition and realism, and getting the maths of supply and demand right will take us far, but it isn’t the whole solution. The plan will only succeed if this is tackled through long-term funding, and if the basics – including infrastructure, IT and staff pay – are fixed too.
We must also acknowledge that it takes longer than a term of government to get through medical training, so an investment in medical school places won’t immediately result in shorter waiting lists. This isn’t an argument against investing in the workforce – it’s an argument to find short-term victories as well, by making more of the capacity we already have.
We’re in a retention crisis, so we must stem the flow of doctors leaving the NHS – both junior doctors moving to Australia, and people retiring early. Over 75 per cent of clinical oncologists and radiologists who left the NHS last year were under 60.
While the workforce shortfall is undoubtedly the single biggest issue holding us back on cancer, tackling it won’t be a quick fix. For both the government and the opposition, the pressure is on – with the Conservatives setting challenging targets for recovery from elective care (especially given how stretched the workforce currently is) and Labour promising to meet all waiting times standards within the first term of a Labour government.
Reducing inefficiencies in how we all work would go a long way here. Poor IT is the bane of my working life. It’s not uncommon to have to enter passwords five or six times before being able to log on to the system. How many more scans could I review if IT supported my productivity rather than held it back?
The potential gains in technology are huge, particularly in radiology, where AI is likely to play a huge part, streamlining what we do and helping us make better decisions. Of course, we must approach this with care, taking time to understand how we can use this new technology while maintaining quality and avoiding bias.
Finally, we must turbocharge implementation. The NHS is full of good ideas, sitting on a digital shelf somewhere, changing the game in one NHS trust but not another one just down the road. Some good structures are in place – imaging networks (which are formed from neighbouring trusts collaborating to deliver imaging services) are making good progress, for example – but we could and should do more. In cancer, I’d like to see more of a push from the centre on implementation and supporting cancer alliances to share ideas and innovation. These alliances bring together clinical and managerial leaders from nearby hospital trusts to transform the diagnosis, treatment and care of cancer patients in a local area.
As we approach the next election, cancer must remain a salient issue. Too many of us know the anxiety of waiting either for a diagnostic test or to start the cancer treatment that could save your life. As doctors, we constantly face the moral injury of knowing there is more we could be doing for our patients, to diagnose them early, give them the best treatment quickly and give them the best chance of survival.
The reality of failing to grip the capacity and demand equation over recent decades has already meant worse care and worse outcomes for countless patients who deserve better, and this tragedy will continue if the next government does not tip the balance in favour of patients. I sincerely hope they do.
Dr Katharine Halliday, RCR President