Phase 2 letter for cancer restoration



Classification: Official

Publications approval reference: 001559 / C0511


  • Cancer Alliance Chairs,
  • Cancer Alliance Clinical Chairs,
  • Cancer Alliance Managing Directors,
  • ICS and STP Leads,
  • Regional Directors,
  • Regional Cancer SROs


  • CCG Accountable Officers
  • Trust CEOs

8 June 2020

Dear colleagues,

On 29 April, Simon Stevens and Amanda Pritchard wrote to colleagues across the NHS to set out key actions for the second phase of the response to COVID-19.

Local systems and Cancer Alliances were asked to identify ring-fenced diagnostic and surgical capacity for cancer, so that referrals, diagnostics and treatment can be brought back to pre-pandemic levels at the earliest opportunity to minimise potential harm, and to reduce the scale of the post-pandemic surge in demand.

Your work to do so should now be well advanced and in place across your Cancer Alliance. This letter sets out further guidance and support.

Key principles

There are three guiding principles for this phase of our work:

  • Capacity: there needs to be sufficient capacity to ensure anyone referred with suspected cancer can be diagnosed and treated promptly;
  • Fairness: access to cancer diagnostic and treatment services should be equitable and based on clinical priority; and,
  • Confidence: patients need to have confidence their diagnosis and treatment will take place in an environment and manner that is safe.

In practice this will mean local systems working through their Cancer Alliances, with support from regional teams, to provide:

  • dedicated diagnostic and surgical capacity for people referred with suspected cancer to enable a return to pre-pandemic levels of activity, including by maximising use of independent sector capacity; and
  • cancer diagnosis and treatment in facilities which, in line with the operating framework for urgent and planned services in hospitals, minimise the risk of COVID-19 infection for patients and staff.

The number of patients waiting over 62 days to start treatment has grown during the pandemic, partly as a result of the impact of COVID-19 on endoscopy and other diagnostic services, and partly from clinical decisions to re-schedule treatments to reduce the risk for individual patients of COVID-19 infection.

Booking appointments for this group of patients is a priority. Local systems should schedule diagnostics or treatment for this group, alongside new patients referred into cancer services, on the basis of clinical priority. To support appropriate clinical decision making, the focus for operational management should be on reducing the number of patients waiting more than 62 days.

Urgent cancer referrals

At the peak of the pandemic we saw a significant drop in the number of urgent cancer referrals across the country largely as a result of fewer patients contacting GPs for investigation. This is now starting to recover.

Previous guidance stated that referrals should be made in line with NG12, and that, where referrals or treatment plans depart from normal practice, safety-netting must be in place so that patients can be followed up. We are grateful to primary care colleagues for continuing to make referrals in line with this guidance.

We are encouraging people to contact their GP if they have worrying symptoms as part of the ‘Help us to help you’ campaign. Cancer Alliances are promoting these messages locally, including to communities that are less likely to go to their GP.

We recognise there are also challenges in persuading patients to attend diagnostic tests and will continue to reassure the public in the next phase of the Government’s public information campaign. Alliances should also ensure that local communications address this issue.

The national cancer team will support Alliances to amplify these messages by:

  • sharing communications resources that can be used locally; and
  • ensuring that cancer messages remain central to the ‘Help us to help you’ campaign.


Cancer Alliances should ensure appropriate arrangements are in place to manage two-week urgent cancer referrals.

Alliances should consider drawing on the principles of the surgical hubs they have established – for example, offering services in COVID-protected environments where possible.

The national cancer team is supporting this planning by providing:

  • clinical guidance on changes to diagnostic pathways that may be required to reduce the risk of COVID-19 infection – for example, by moving straight to imaging for some referrals and providing multiple same-day tests to minimise patient visits to hospital;
  • analytical modelling at a Cancer Alliance level about the scale of local capacity required to catch up on demand for diagnostics;
  • guidance on how the development of COVID-protected diagnostic hubs/environments can accelerate the delivery of the NHS Long Term Plan commitment to establish Rapid Diagnostic Centres; and,
  • a central link to the independent sector partnership and to national and regional diagnostics planning so that local systems can be supported with additional capacity where required.

Further advice on planning for diagnostics is included in Annex A.

Cancer surgery

We have previously issued guidance on the establishment of hubs. Regional cancer SROs are responsible for assuring that surgical hubs are fully operational in line with this guidance.

The purpose of the surgical hubs has been to ensure the continuity of urgent and essential cancer surgery. The hubs should now expand capacity so that:

  • cancer surgical capacity is, as a first step, restored to pre-pandemic levels;
  • as we move into the recovery phase, there is active management of local systems to work through surgical cases that have had to be rescheduled; and
  • there is appropriate prioritisation, based upon both clinical urgency and a consideration of delays to operations resulting from the pandemic, to avoid unacceptable waiting times.

Further advice on planning for cancer surgery is included in Annex B.

In addition, we are bringing forward the full roll out of SABR radiotherapy across England to further reduce the burden on other treatment modalities and reduce travel for patients.

Next steps

Cancer Alliances should work with their STPs/ICSs to lead delivery of the actions set out above as soon as possible. Regional Cancer SROs are responsible for assuring this is being done and that appropriate arrangements are in place to meet demand.

Where such services have been affected, Cancer Alliances should also begin to restore other treatment modalities (such as non-surgical oncology), follow-up care for people living with a cancer diagnosis, and access to clinical trials.

Looking to the next phase of our work, Alliances, working with the national team and their system partners, should quantify the size of the additional backlog of patients requiring diagnostics and treatment and the service type and activity volumes that will be needed.

We hope this letter will help to inform your work as you plan the next phase of delivery. We are committed to supporting you, and to responding as quickly as possible to any issues and challenges that you are facing.

Thank you once again to you and your teams for your continued commitment and hard work.
Best wishes,

Dame Cally Palmer | National Cancer Director

Professor Peter Johnson | National Clinical Director for Cancer

Annex A

Plans for COVID-protected diagnostic hubs/environments should:

Identify and secure capacity for diagnostics in a way that protects staff and patient safety by:

  • identifying and ringfencing local capacity (including from the independent sector) to support the restoration of diagnostic capacity (including for surveillance tests);
  • ensuring sites where diagnostic tests are taking place are COVID-protected, and consolidating kit and workforce in these sites where possible; and
  • incorporating new guidance on adaptations to pathways required to maximise productivity and reduce the risk of COVID-19 infection.

Make the best use of the capacity available for diagnostics in a way that is equitable, safe and promotes the best possible outcomes by:

  • ensuring there is a mechanism for clinical prioritisation of patients waiting for diagnostics so that all diagnostic activity across the Alliance is managed efficiently, equitably and in accordance with clinical need;
  • accelerating the adoption of Rapid Diagnostic Centre principles as set out in the specification, including:
    • centralised, virtual triage to prioritise backlogs and allocate patients to appropriate tests; and
    • hot reporting and multiple same-day tests/one stop clinics where possible to minimise patient visits to hospital;
  • ensuring guidance for essential endoscopy services is implemented, and plan on the basis that many patients normally receiving endoscopy will initially require CT imaging, and some will then need endoscopy to collect tissue; and
  • accelerating any plans for high capacity networking imaging and pathology services to help increase productivity.

Annex B

Plans for the expansion of capacity through surgical hubs should:

  • ensure there is a mechanism for clinical prioritisation of patients requiring surgery across the hub geography so that all surgical activity is managed efficiently, equitably and in accordance with clinical need, taking account of the additional need to prioritise people whose surgery has been rescheduled;
  • ensure hubs maximise the use of both NHS and available independent sector capacity to support activity returning to pre-COVID levels;
  • ensure arrangements are in place for people with rare and less common cancers to receive surgical treatment, whether through the hub, or by maintaining referrals to specialist tertiary centres;
  • continue to use the relevant guidance on prioritisation in those areas where capacity remains constrained, but, as capacity is restored, resume locally-led clinical decision-making; and
  • identify any extension to the independent sector agreement required – including specific facilities and duration.

Arrangements are already in place for pre-operative testing of cancer patients who are not showing symptoms of COVID-19. Alliances should also refer to guidance on minimising the transmission of COVID-19 infection within hospitals published on 14th May. This builds on the work that providers and local systems are doing to ensure services are safe.