Last reviewed 14 November 2023
The NHS in England has streamlined ten existing cancer performance standards, including the Faster Diagnosis Standard (FDS) that was introduced in April 2021, into three key cancer waiting time standards with associated targets and covering additional patients. This feature looks at the reforms which were brought in on 1 October 2023, how they will better support patients with suspected cancer, and how primary care services will be affected by the changes.
Faster Diagnosis Standards
Three new FDSs have been identified as the best measures to ensure patients are being diagnosed and treated as quickly as possible, they reflect what matters most to patients during the diagnosis process and align with modern clinical practice.
The three standards are as follows.
28-day FDS: patients with suspected cancer should be diagnosed or have cancer ruled out within 28 days. This applies to people who have been urgently referred:
by a GP for suspected cancer
following an abnormal cancer screening result
by a GP for breast symptoms (where cancer is not suspected).
The NHS target is for 75% of people with suspected cancer to meet this standard.
62-day referral to treatment standard: patients who have been referred for suspected cancer from any source and go on to receive a diagnosis should start treatment within 62 days of their referral.
The NHS target is for 85% of people to meet this standard.
31-day decision to treat to treatment standard: patients who have a cancer diagnosis, and who have had a decision made on their first or subsequent treatment, should then start that treatment within 31 days.
The NHS target is for 96% of people to meet this standard.
What this means for patients
The “28-day FDS” ensures that patients will be diagnosed or have cancer ruled out within 28 days of being referred urgently by their GP for suspected cancer. It is different to the previous cancer waiting time standard, where patients were to get their first specialist appointment within two weeks, because it measures instead the time it takes to confirm or rule out a cancer diagnosis.
For patients who have cancer, their treatment can start as soon as possible and, for those who are not, their minds will be put at rest more quickly. The standards also enable a more patient-centred and flexible approach to diagnosis. Furthermore, the standards should ensure that patients get equal focus and priority, regardless of their point of entry to the pathway, whether this be through cancer screening, GP referral or consultant upgrade.
These standards will contribute towards achieving the NHS Long Term Plan commitments for earlier diagnosis including a target that, by 2028, 75% of people with cancer will be diagnosed at stage one or two.
How the standards affect primary care
GPs will refer patients onto urgent suspected cancer pathways in the same way as before, but the speed of actual diagnosis, rather than the time to first specialist appointment, is now being measured.
The new standards support faster ways of getting tested now available, where patients with suspected cancer won’t necessarily need a specialist appointment first, such as “straight to test" pathways, remote consultations and advances in technology such as artificial intelligence and teledermatology.
The standards should enable GPs and consultants alike to set out clearer expectations for patients and ensure better accountability through the referral process. Where speed is an important factor when being referred for tests, reassurance, transparency and good information on referral are also key. Somerset, Wiltshire, Avon and Gloucestershire Cancer Alliance Clinical Director Dr Amelia Randle said: “Since the introduction of the 28-day FDS I have been better able to discuss with patients what to expect and the timescales involved…Those who do need treatment have had a co-ordinated start to their journey and are able to access high-quality, compassionate care in a timely way.”
Submission of waiting time data by primary care providers won’t change. Some references to the “Two Week Wait” are still present in the dataset, although this standard is replaced and no longer applies. The latest version of the National Cancer Waiting Times Monitoring Dataset Guidance came into force on 1 October 2023 and, until the dataset is updated, it says GPs should use the “Priority Type — Two Week Wait” data item to record performance against this pathway.
NHS England confirmed that the target for meeting the 28-day FDS will be gradually increased, from the current 75% to 80% by 2026. And trusts have been asked to prioritise improving performance against the new 62-day standard, with an interim target of 70% by March 2024 in place.
Cancer waiting time statistics will continue to be published monthly by NHS England, and a pledge has been made to now improve granularity of the statistics by cancer type.
Faster Diagnosis Framework
Previously, there was a range of objectives for the faster diagnosis of cancer across a number of different programmes including rapid community diagnostic centres (CDCs), the FDS and best practice timed pathways. This framework has brought together objectives and key requirements for cancer alliances across England under a single programme.
Together with driving earlier and faster diagnosis, this framework aims to deliver “excellent patient experience, a holistic assessment of patient needs and streamlined support across community, primary and secondary care”. It also prioritises increasing capacity in the system through more efficient diagnostic pathways, and support for healthcare providers to achieve the FDS.
The framework is made up of three elements.
The non-specific symptoms (NSS) pathway.
Best practice timed (BPT) pathway implementation (including work with cancer alliances and integrated care systems, and regional diagnostics programmes to ensure sufficient capacity).
A series of improvements across all pathways, regardless of cancer type.
How the framework affects primary care
Cancer alliances and the Integrated Care Boards they work with are leading local delivery of what NHS England calls “one of the most comprehensive strategies on early diagnosis anywhere in the world”; NHS England is providing over £390 million in cancer service development funding to the cancer alliances in each of the next two years to support this.
There are, however, developments in diagnostic pathways and care supported within the framework, which will have an effect on primary care services.
Experience of care
Being referred for a suspected cancer can be a very worrying time for people, many of whom won’t actually be diagnosed with cancer, so the framework commits to ensuring that a “good experience of care” is a priority alongside clinical effectiveness and safety.
Thirty quality markers have been developed to guide local systems on how to provide this experience of care when diagnosing cancer, which can be found in Annex 3 of the framework. These quality markers include ensuring that GPs are fully aware of criteria for referral, that GPs make sure all information about onward referral is easy for each patient to understand, ensuring that a patient only has to tell their story once, that all letters sent to primary care include the patient, and that on discharge the GP and patient are kept informed of the next steps.
Cancer alliances have been tasked with assessing their services against these quality markers to improve the experience of cancer care.
Non-Specific Symptom (NSS) pathways
Patients who presented with concerning but non-specific cancer symptoms have in the past been sent back and forth between primary and secondary care, often referred onto multiple urgent pathways, which led to delays in diagnosis, higher rates of late stage and emergency presentation and poorer patient outcomes.
Primary care should see fewer frustrating visits and delays like this as, from 2019, cancer alliances have developed a dedicated NSS urgent diagnostic pathway to get patients the right tests at the right time, in as few visits as possible. By March 2024, the aim is to ensure all NSS patients are referred onto this pathway, which can be based in primary care, run by GPs, or in hospitals as a consultant or nurse-led service.
Best practice timed (BPT) diagnostic pathways
BPT diagnostic pathways are “best-evidenced structures and timings of various tumour-specific pathways” to meet the FDS. The aim is to shorten cancer diagnosis pathways by identifying clinical events and tests for patients referred with certain symptoms, as well improve patient experience and offer models to support sustainable improvement. BPT pathways are currently available for head and neck; gynaecology; colorectal; lung cancer; prostate; oesophago-gastric; and skin.
Breast, urology (non-prostate) and hepatobiliary are in development, and NHS England is aiming to have BPT pathways in place for all cancer pathways by the end of 2023/24. The Best Practice Timed Diagnostic Cancer Pathways Summary — Guide to support these pathways was issued in October 2023.
The reforms are a big step in the right direction, according to Cancer Research UK, because “they focus on tangible outcomes for cancer patients rather than processes” and could play an important role in driving improvements and capacity in diagnostic services going forward, as well as streamline the referral process within primary care.
NHS Cancer Programme: Faster Diagnosis Framework, NHS England
Priorities and Operational Planning Guidance 2023/24, NHS England
Rapid Cancer Diagnostic and Assessment Pathways, NHS England
National Cancer Waiting Times Monitoring Dataset Guidance (Version 12) (August 2023), NHS England
Cancer Experience of Care, NHS England
Network Contract Directed Enhanced Service — Early Cancer Diagnosis Guidance (March 2020), NHS England
Suspected Cancer: Recognition and Referral Updates (NG12), NICE