Dr Karen McEwan describes legislation and guidance that needs to be considered when commissioning services for improved outcomes in women with breast cancer

Breast cancer accounts for over 30% of all cancers in women, affecting one in eight of them in their lifetime.1 Although survival rates for breast cancer have been steadily improving—5-year survival rates are now estimated to be approximately 85%—it is still the second most common cause of cancer deaths in women.1 A number of documents have been published with the aim of improving outcomes in cancer, including the Cancer reform strategy2 in 2007 and Improving outcomes: a strategy for cancer3 in 2011. The latter aims to help the reformed NHS deliver outcomes that are among the best in the world; several key target areas were identified as important to fulfilling this goal:3

  • prevention and early diagnosis
  • better treatment
  • quality of life
  • patient experience
  • reducing inequalities
  • provision of information
  • patient choice
  • autonomy and accountability.

In June 2011, Dr Michael Dixon, Chairman of the NHS Alliance, highlighted that: ‘Clinical commissioners have a crucial role to play in ensuring that care is integrated and delivered in the community, with maximum input of local people and patients. Also, by working to overcome the barriers between the NHS and social care, they will be able to provide patients with better, seamless and more accessible care.4

This article discusses the published government legislation and guidance documents pertinent to the commissioning of breast cancer services. The vision for future cancer services is set out in two strategies2,3 and the details for delivering these services are laid out in the NICE quality standard for breast cancer.5

Early diagnosis and screening

One of the key elements to improving early diagnosis of breast cancer is the provision of effective screening services. The NHS Breast Screening Programme (NHSBSP) service specification6 proposes measures to ensure a consistent and equitable approach to the provision and monitoring of breast screening across England and Wales. The aim is to deliver a high-quality, independently monitored and effective breast screening service, which is supported by suitably trained and competent staff, and subject to regular and ongoing audit. By providing this service, the NHSBSP aspires to:6

  • reduce the number of women who die from breast cancer
  • maximise detection of breast cancer at stages 1 and 2
  • refer women promptly to treatment services
  • achieve high coverage across all patient groups in society, and minimise inequalities
  • minimise adverse physical, psychological, and clinical aspects of screening
  • encourage early presentation of interval cancers.

The NHS Commissioning Board recommends that breast screening units should cover a population of between 500,000 and 1,000,000 patients, and offer screening to women between 50 and 70 years of age, although this will be extended to 47–73 years by 2016.7 Screening usually occurs at 3-yearly intervals, but can be more regular for specific individuals. Provision of good quality, appropriate information empowers patients to make an informed choice and allows patients to opt out of the service on a temporary or permanent basis.5 Patients might choose to opt out of screening through personal choice, if already undergoing treatment for breast problems, or if there are medical/social issues that would make attendance of screening difficult.

An effective screening service for breast cancer needs to be underpinned by: comprehensive and timely communication with patients, GPs, and multidisciplinary teams (MDTs); adherence to quality standards; regular audit; and evaluation of performance. Use of accredited IT systems, such as the National Breast Screening System (NBSS) and The National Health Application and Infrastructure Services (NHAIS), facilitates efficient management of patients from the screening process through to accurate recording of data outcomes, and patient recall. It is important that failsafe mechanisms are in place to ensure that all eligible women are identified and invited for screening within a specified time period, as well as to ensure that all abnormal results are appropriately acted upon in a timely manner.6

Quality standard for breast cancer

NICE published the quality standard for breast cancer5 (QS12) in September 2011, which defined best practice within this clinical area. The quality statements describe measures of high-quality, cost-effective care, and provide a baseline to measure improvements against, to identify any gaps in the service, support best practice, and encourage evidence-based treatments. The quality standard covers the management of early, locally advanced, and advanced breast cancer in adults, including the management of symptomatic cancers and those detected from the point of referral to a specialist team. It does not cover adults with rare breast tumours, benign breast disease, lobular carcinoma in situ, or the care of women at high risk because of family history.5

The quality standard stipulates that an integrated approach to provision of breast cancer services, with coordination across all relevant agencies, is fundamental to delivering high-quality care. It should contribute to improvements in breast cancer care in the following ways:5

  • prevent people from dying prematurely
  • enhance quality of life for people with long-term conditions
  • help people to recover from episodes of ill health or following injury
  • ensure that people have a positive experience of care
  • treat and care for people in a safe environment and protect them from avoidable harm.

The quality statements cover all aspects of the patient pathway including:5

  • referral to units, in line with NHS breast screening guidance6
  • pre-treatment diagnostics
  • good cosmetic outcomes
  • breast reconstruction options
  • timely assessment of oestrogen receptor and human epidermal growth factor receptor-2 status
  • equality of treatment, irrespective of age
  • appropriateness of staging investigations
  • patient involvement in decision making
  • provision of personalised information and support
  • post-treatment follow up
  • multidisciplinary team/clinical nurse specialist involvement in recurrent or metastatic disease.

The NICE guideline on breast cancer relates to the recommended flow of patients through the pathway, whereas the quality standard adds fine detail relating to best practice at each stage of the cancer pathway. The NICE pathways for early and locally advanced breast cancer8 and advanced breast cancer9 are shown in Figure 1, and Figure 2, respectively.

Figure 1: Early and locally advanced breast cancer overview8
Early and locally advanced breast cancer overview
Figure 2: Advanced breast cancer overview9
Advanced breast cancer overview

NHS Outcomes Framework

The NHS Outcomes Framework was first published in December 2010,10 and sits alongside similar frameworks for public health11 and adult social care.12 These three frameworks have been aligned to encourage collaboration and integration between services through the use of shared and complementary indicators.

The NHS Outcomes Framework is structured around five domains, which set out the high-level national outcomes that the NHS should be aiming to improve.10 The first domain is involved with preventing people from dying prematurely from causes such as cancer, specifically breast, bowel, and lung cancer.

Clinical Commissioning Group Outcomes Indicator Set

As proposed in Liberating the NHS: commissioning for patients,13 the NHS Commissioning Board—with support from NICE, experts, and patient groups—developed the Clinical Commissioning Group Outcomes Indicator Set (CCGOIS)14 (formerly known as the ‘Commissioning Outcomes Framework’). Having identified the priority areas in the NHS Outcomes Framework, the CCGOIS details the key indicators that CCGs will be assessed against to show improvements in these areas. From April 2013, these indicators will become an integral part of the NHS Commissioning Board’s systematic approach to quality improvement, allowing measurement and benchmarking of CCG-commissioned service outcomes.

The CCGOIS will also provide clear, comparative information on the quality and outcomes of health services, and may help patients and members of the public make more informed choices regarding their care.

The CCGOIS has five domains:14

  • Domain 1—preventing people from dying prematurely
  • Domain 2—enhancing quality of life for people with long-term conditions
  • Domain 3—helping people to recover from episodes of ill health or following injury
  • Domain 4—ensuring that people have a positive experience of care
  • Domain 5—treating and caring for people in a safe environment; and protecting them from avoidable harm.

Each domain is subdivided into various indicators, several of which are relevant to breast cancer services:11

  • 1.4 relates to mortality rates from cancer in patients aged <75 years
  • 1.4i relates to 1-year survival rates for all cancers
  • 1.4ii relates to 5-year survival for all cancers
  • 1.4iii relates to 1-year survival for breast, lung, and bowel cancers combined
  • 1.4iv relates to 5-year survival for breast, lung, and bowel cancers combined.

The above indicators measure premature mortality from cancer, which could potentially be reduced by earlier and more accurate diagnosis, optimal use of referral pathways, use of available interventions, and improving support for lifestyle changes (diet, smoking cessation, and physical exercise) after primary treatment.

Although no clear levels of ambition have been set, commissioners are challenged to make continuous progress against all of the domains and indicators. To support this process, relevant information is regularly made available on the Information Centre for Health and Social Care portal for the NHS Outcomes Framework indicators (www.ic.nhs.uk) and the Cancer Commissioning Toolkit.15 Clinical commissioning groups will need to publicise their progress in a yearly progress report, and the Go

Palliative and end-of-life care

Although not specific to breast cancer, the NICE quality standard for end-of life care in adults is worthy of mention.16 It was developed from previous DH17 and NICE18 guidance on end-of-life/palliative care. The standard defines markers of good practice across all aspects of end-of-life care, including:16

  • identification, assessment, and care planning
  • holistic treatment (psychological, practical, and spiritual)
  • information giving and communication
  • involvement of specialist palliative care services and coordination of care
  • urgent care, and care in the last days of life
  • care after death
  • education and training.

The end-of-life care quality assessment tool (ELCQuA) is a free online self-assessment tool,19 which commissioners can use to assess and support local service improvement across healthcare and social care.

Cancer Drugs Fund

In 2010, the Government announced plans to improve access to certain cancer drugs not currently approved by NICE either on grounds of lack of cost effectiveness or evidence to support their use, or because the expected number of patients likely to benefit is too small. The Cancer Drugs Fund came into existence in April 2011 to provide funding for such drugs in England (this does not apply to Northern Ireland, Scotland, or Wales).20 The aim of this fund was to empower clinicians and cancer specialists to use their professional judgment to make decisions in the best interests of their patients. A panel of specialist professionals in cancer care was set up in each region to decide which drugs should be available through the fund and in what circumstances—often called a ‘priority list’. Cancer specialists can then apply in order to fund the treatment of individual patients.

From 2013, responsibility for this fund will be delegated to the NHS Commissioning Board and will be operated via regional clinically-led panels. It is recommended that commissioning decisions relating to these cancer drugs are based on:21

  • clinical effectiveness, which should be based on measurable outcomes such as:
    • improved overall survival
    • progression-free survival
    • improved quality of life
  • cost effectiveness.

The Cancer Drugs Fund is intended only as an interim measure, and in 2014, the Government is planning to implement a ‘value-based’ pricing system for branded drugs,21 which aims to make cancer drugs more widely available on the NHS.

Reducing health inequalities

One of the key aims of the Cancer Reform Strategy was to reduce inequalities in cancer services,2 and the DH has made this a priority—the Health and Social Care Act 201222 places a legal obligation on commissioners to work towards this goal. They are challenged to improve access to healthcare for all members of society, including ethnic minorities, patients with learning disabilities or mental health problems, and the prison population: ‘Across the public sector, there is now a recognition that equality of outcomes and personalised services will only be delivered by working with communities, recognising difference and tailoring provision rather than a ‘one size fits all’ approach. Furthermore, when people find themselves in need of care they can be at their most vulnerable. It is therefore vital that those who commission and provide services proactively ensure that people’s individual needs, their dignity and their human rights are respected at every stage of the care journey. This is what it means to take equality, diversity and human rights seriously.’23

Potential barriers to change

The new commissioning system undoubtedly offers great opportunities for improvement, but there is a certain element of risk in any period of transition:

  • rapid expansion of some services could mean they are set up without full control and may destabilise smaller providers
  • lack of adequate information and local data could prevent commissioners making well-informed decisions
  • merging of cancer networks may result in them being too large to represent and inform local issues and needs effectively
  • an effective commissioning process relies on strong GP support; where this is lacking, it is likely to be severely compromised
  • poor communication between different providers and GPs is a major potential obstruction to provision of an integrated and cohesive pathway
  • lack of adherence to evidence-based practice can lead to lack of uniformity between different providers
  • the current difficult financial climate may drive decisions based on efficiency savings rather than improving outcomes.


The changes across the NHS are likely to have a significant impact on all aspects of cancer care. There is a drive to encourage more integrated working across healthcare, public health, and social care in an effort to improve the quality of services. There is increasing emphasis on benchmarking services against predetermined quality standards and for the newly emerging CCGs to be held accountable for the services they commission.

Commissioning messages are above, and key points are located on page 19

  • Commissioning services for breast cancer will become more complicated after 1 April 2013
  • Screening will be specified by Public Health England, but commissioned by the NHSCB
  • Surgery and outpatient treatment for breast cancer will be commissioned by CCGs, but commisioning and funding of chemotherapy, radiotherapy, and the Cancer Drugs Fund will become the responsibility of the NHSCB
  • CCGs will (particularly with the demise of the cancer networks) need to ensure that agencies are aligned in commissioning services and ensuring clear referral protocols between them
  • Several targets and outcomes in the Clinical Commissioning Group Outcomes Indicator Set—on which the performance of CCGs will be measured—relate to morbidity and mortality caused by common cancers (e.g. breast, bowel, prostate, and lung), and CCGs will need to commission for these diseases
  • Performance against the NHS Constitution right for patients to receive definitive treatment within 62 days of urgent GP referral will affect payments of the quality premium to CCGs from 1 April 2013
  • CCGs should ensure that the men with breast cancer (~1%) have their needs specifically addressed in care pathways.

NHSCB=NHS Commissioning Board; CCG=clinical commissioning group

  1. Office for National Statistics. Breast cancer: incidence, mortality and survival, 2010. London: ONS, 2012. Available at: www.ons.gov.uk/ons/rel/cancer-unit/breast-cancer-in-england/2010
  2. Department of Health. The cancer reform strategy. London: DH, 2007. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081006
  3. Department of Health. Improving outcomes: a strategy for cancer. London: DH, 2011. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123371
  4. Department of Health website. Health and Social Care Bill explained. healthandcare.dh.gov.uk/factsheets/ (accessed 8 March 2013).
  5. National Institute for Health and Care Excellence website. Quality standard for breast cancer. Quality Standard 12. London: NICE, 2011. Available at: publications.nice.org.uk/breast-cancer-quality-standard-qs12 (accessed 21 February 2013).
  6. NHS Commissioning Board. Public health functions to be exercised by the NHS Commissioning Board. Service specification No.24. Breast screening programme. DH: London, 2012. Available at: www.wp.dh.gov.uk/publications/files/2012/11/24-Breast-Screening-Programme-service-specification.pdf
  7. NHS Breast Cancer Screening Programme website. Age extension full randomised control trial. www.cancerscreening.nhs.uk/breastscreen/research-age-extension-full-rct-faqs.html (accessed 22 February 2013).
  8. National Institute for Health and Care Excellence website. NICE clinical pathway for early and locally advanced breast cancer. pathways.nice.org.uk/pathways/early-and-locally-advanced-breast-cancer (accessed 19 February 2013).
  9. National Institute for Health and Care Excellence website. NICE clinical pathway for advanced breast cancer. pathways.nice.org.uk/pathways/advanced-breast-cancer (accessed 19 February 2013).
  10. Department of Health. The NHS outcomes framework. London: DH, 2011. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131700
  11. Department of Health. Healthy lives, healthy people: improving outcomes and supporting transparency. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132358
  12. Department of Health. The adult social care outcomes framework 2013/14. London: DH, 2012. Available at: www.dh.gov.uk/health/files/2012/11/The-Adult-Social-Care-Outcomes-Framework-2013-14.pdf
  13. Department of Health. Liberating the NHS: commissioning for patients—a consultation on proposals. London: DH, 2010. Available at: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_119138.pdf
  14. NHS Commissioning Board. CCG outcomes indicator set 2013/14. Leeds: NHS Commissioning Board, 2012. Available at: www.commissioningboard.nhs.uk/ccg-ois/
  15. Cancer commissioning guidance and toolkit website. www.cancertoolkit.co.uk (accessed
    19 February 2013).
  16. National Institute for Health and Care Excellence website. Quality standard for end of life care in adults. Quality Standard 13. London: NICE, 2011. Available at: publications.nice.org.uk/quality-standard-for-end-of-life-care-for-adults-qs13 (accessed 21 February 2013).
  17. Department of Health. End of life care strategy: promoting high quality care for all adults at the end of life. London: DH, 2008. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_086277
  18. National Institute for Clinical Excellence. Improving supportive and palliative care for adults with cancer. Cancer service guidance, CSGSP. London: NICE, 2004. Available at: www.nice.org.uk/CSGSP
  19. End of life care quality assessment tool (ELCQuA) website. www.elcqua.nhs.uk (accessed 19 February 2013).
  20. Cancer Research UK website. Cancer drugs fund. www.cancerresearchuk.org/cancer-help/about-cancer/cancer-questions/cancer-drugs-fund (accessed 19 February 2013).
  21. Department of Health. The cancer drugs fund: guidance to support operation of the cancer drugs fund in 2012–2013. London: DH, 2012. Available at: www.nwcancerdrugsfund.nhs.uk/documents/DH-Drugs-Fund-Guidance-2012-13.pdf
  22. Legislation.gov.uk website. Health and Social Care Act 2012. www.legislation.gov.uk/ukpga/2012/7/contents/enacted (accessed 22 February 2013).
  23. Department of Health. Department of Health single equality scheme 2009–2012. London: DH, 2009. Available at: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_100963.pdf G