NHS cancer services have developed significantly in the last decade. Clare Lomas talks to cancer tsar Professor Mike Richards about how nurse-led services have been at the heart of these advances and the future role that all nurses can play in tackling the disease
Nurses are key to delivering the message that adopting a healthy lifestyle can significantly reduce the risk of developing cancer, says Professor Mike Richards (pictured), national cancer director at the Department of Health.
Since taking up his appointment as the government’s first ‘cancer tsar’ in October 1999, Professor Richards has been instrumental in some of the most important reforms of cancer services in England.
‘We know that well over half of all cancers could be prevented by people adopting healthy lifestyles,’ Professor Richards told Nursing Times. ‘The largest single element is still smoking, which is directly responsible for one-third of all cancer deaths.
‘But second to that comes the combination of diet, obesity, physical inactivity and excessive alcohol consumption and their impact on cancer,’ he added.
A recent report from the World Cancer Research Fund found that around 40% of breast and bowel cancers could be prevented if people led healthier lifestyles. And in February a report from Cancer Research UK revealed that consuming just one or two alcoholic drinks a day could increase the risk of women developing cancers of the breast, liver and larynx.
‘This was a very powerful study involving over one million women and it does show that any level of alcohol carries some degree of risk. That does not mean that we say to everybody you must immediately stop drinking, it just means that people should be made aware of the risks,’ said Professor Richards.
‘It is important to get the messages about healthy living across, through primary and community care for example, and this is certainly something that nurses can contribute to. It would set a very powerful example if all healthcare professionals responded to these messages and showed the way on healthy living,’ he added.
Next year will see the 10th anniversary of the NHS Cancer Plan. Launched in September 2000, it promised to deliver the fastest improvement in cancer services by increasing funding, providing more staff and equipment, and developing comprehensive guidance to ensure high standards of treatment and care across the whole of the NHS.
It also pledged that, by 2010, the five-year survival rates for people with cancer would compare with the best in Europe.
‘We have made a great deal of progress since the cancer plan was launched,’ said Professor Richards. ‘The death rate from cancer is continually coming down for most cancers, and survival rates for those diagnosed with cancer are going up.’
‘We also have strong evidence that patients’ own experiences of care services have improved,’ he added. ‘The Department of Health did a large-scale survey around the time the cancer plan was published, and then the national audit office did a further one in 2004 which showed marked improvements in a lot of important areas, such as patients getting the information they need, being treated with dignity and respect, and having trust and confidence in their doctors and nurses.’
According to Professor Richards, it is highly likely that these improvements are down to two key elements – much better multidisciplinary team (MDT) working in cancer services, and specifically the role of clinical nurse specialists (CNSs) within these teams.
‘Clinical nurse specialists are the largest single element of the specialist cancer workforce,’ he said. ‘All the patients I’ve talked to welcome the role, and doctors have also said they would not want their MDT to be without a nurse specialist – that’s fairly powerful support.’
However, Professor Richards said that trusts needed to get better at providing evidence to show the important contribution that a CNS can make to cancer services.
‘That way, not only will we have the evidence to show the benefits in terms of quality of care, but also the potential benefits in terms of cost effectiveness.’
For example, he cited anecdotal evidence that proactive phone calls from CNSs to patients can reduce emergency hospital admissions.
When the Department of Health launched the Cancer Reform Strategy in December 2007, it emphasised the importance of the CNS role and urged trusts to pay ‘particular attention’ to ensuring adequate provision of nurse specialists in cancer services.
But, according to data gathered in 2008 as part of the national cancer peer review programme, around 20% of local MDTs in gynaecology, lung and urology cancers were without CNS cover.
‘Around the time of the Cancer Reform Strategy, we conducted a survey which showed there were just under 2,000 site-specific tumour nurse specialists,’ said Professor Richards. ‘On top of that, you’ve got the chemotherapy nurse specialists and the palliative care nurse specialists.
‘Although the numbers have increased substantially since the year 2000, do I think we’ve reached the right place yet? We are in a much better place than we were, but no, we do not have enough CNSs. We know that certain tumour types are under-represented in comparison with others, so we’ve still got further to go,’ he added.
‘Our peer-review cancer measures say that every team must have a clinical nurse specialist, and it is absolutely imperative that we monitor these numbers. The more detailed analysis we do about how nurse specialists are being used, the more we can demonstrate to trusts how beneficial they are,’ he added.
Just last month NICE guidance recommended that specialist nurses were ideally placed to take on the role of ‘key worker’ to oversee the management of patients with advanced breast cancer.
Professor Richards said that the 34 cancer networks in England, working with the national cancer action team, were currently repeating the government’s previous survey to establish the number of CNSs working in cancer services.
One of the major elements of the Cancer Reform Strategy is the national cancer survivorship initiative. This overviews the whole care package for people following a diagnosis of cancer, particularly after they have finished their first treatment.
‘It’s a question of assessing patients’ needs at the end of treatment, not just their needs in terms of follow-up, but their needs in terms of what they want to do about things like getting back to work, and whether they are feeling anxious or depressed. They need a holistic assessment and nurses will be central to this,’ said Professor Richards.
Nurses could also play key roles in genetic – or family history – cancer services. Nottingham University researchers are currently evaluating seven pilot sites for cancer genetic services, including primary care and outreach services.
‘What we are doing is looking at the different models of how we can provide people, often women, with advice about their risk of cancer based on their family history,’ said Professor Richards.
‘Based on assessment, we will be able to reassure a lot of people that they are at no more risk than the rest of the population. But we will also be able to point people in the right direction if they need genetic testing, to go on a surveillance programme or to start screening earlier,’ he added.
The results of the pilots will be used to create a chapter on family history services, which will be added to the cancer commissioning guide, published earlier this year.
Another core part of the Cancer Reform Strategy is its national awareness and early diagnosis initiative. This focuses on raising people’s awareness of the symptoms of cancer, and getting patients diagnosed as early as possible. The Department of Health is currently working with the independent Healthy Communities Collaborative to promote the earlier presentation, diagnosis and treatment of cancer in 19 ‘spearhead’ PCTs across England.
‘When we compare our cancer survival rates with other countries, and see that they are worse than some, we know it’s because we have later diagnosis,’ Professor Richards told Nursing Times. ‘We need to get right to the community level and raise people’s awareness of the symptoms of cancer, and of the benefits of early diagnosis and treatment so that people know it’s important to come forward earlier.
‘We are learning lessons from the 19 PCTs – all of which are in deprived areas – about what messages we need to be giving out and what impact these messages are having. Most important is to get the messages across to the right target groups, and help primary care get it right as often as possible in terms of assessing patients and knowing when they need to be referred on,’ he added.
Another area which will have a significant impact on nursing could be streamlining cancer services for hospitalised patients, said Professor Richards. ‘There are about five million bed days related to cancer in any year at the moment. That means there are around 14,000 patients with a cancer diagnosis in hospital at any one time,’ he said.
‘By using an enhanced recovery programme – which involves different approaches to nursing, anaesthetic and the surgery itself – we believe we could reduce lengths of stay for surgery and substantially reduce the number of patients in hospital, saving around a million bed days a year,’ he added.
The enhanced recovery programme is a structured, evidence-based approach designed to prepare patients for surgery and reduce its physical impact, helping patients to recover more quickly.
According to Professor Richards, a significant number of bed days could also be saved by reducing the number of emergency admissions, and proactive work from nurses is central to this.
‘We know from working with colleagues in other countries that there are patients coming into hospital in this country who would not be if they were in the US, for example,’ he said.
‘More frequent contact from nurses – particularly when people are going through the period after chemotherapy when their blood count is likely to be low – and more patient education and self-management might well avoid many hospital admissions,’ he added.
As with all areas of care, the NHS Next Stage Review, published last summer, will have an impact on cancer services, acknowledged Professor Richards, who particularly cited its focus on quality, leadership and improving patients’ experience of the NHS.
These elements are highly relevant to cancer care, said Professor Richards, and are key to delivering high-quality cancer services across England.
‘The fact that in the future all NHS trusts will have to publish a quality account alongside their financial account will bring quality up the agenda, and that should be something that I hope all nurses will welcome,’ he added.
Professor Richards also believes that nursing leadership will play a key role in the future of cancer services. This brings into the equation a second major political development – the Prime Minister’s Commission on the Future of Nursing and Midwifery.
As revealed by Nursing Times, one of the commission’s key terms of reference is to identify services over which nurses can be given more control and how the profession can achieve greater autonomy with doctors and managers in service design and development.
‘New roles for nurses have been developing quite considerably over the last decade. We’ve seen consultant nurse roles and nurse practitioner roles develop in both diagnostic and treatment services,’ he said.
‘The idea, 10 to 15 years ago, that nurses would do the initial assessment of patients with breast cancer symptoms just wasn’t thought about. But we now know that, given the proper training and support, nurses can take on this role and perform it very well. Nurses have also had an extremely important role in palliative care for a long time, and are a hugely important part of that workforce.’
Professor Richards cited the nursing as vital to the progress that has been made on tackling cancer and that the profession would be equally, if not more important, in future success.
‘We have made a very good start in implementing the cancer reform strategy, and nurses have been central to this,’ he said. ‘I believe we will go on seeing not only better outcomes in terms of quantity of life and survival rates, but also ongoing improvements in quality of life.’
Find out more: attend Nursing Times’ Cancer Nursing 2009 conference in June