“There’s Not Enough Bodies to Do the Demand:” An Exploration of Key Stakeholder Views on the Role of Health Service Capacity in Shaping Cancer Outcomes in 7 International Cancer Benchmarking Partnership Countries

Document Type : Original Article


Department of Health Services Research & Policy, London School of Hygiene & Topical Medicine, London, UK


Differences in cancer survival are shaped by differences in health system capacity in workforce and infrastructure. Part of the International Cancer Benchmarking Partnership (ICBP), this study explored stakeholders’ perceptions of the role of health system capacity necessary for cancer care in influencing cancer survival in 7 high-income countries.
We conducted semi-structured interviews with 79 key informants from national, regional, and local tiers of health systems, professional bodies, patient associations, and academic experts in Australia, Canada, Denmark, Ireland, New Zealand, Norway, and the United Kingdom. Data collection was guided by a conceptual model linking characteristics of health systems and cancer survival along the cancer patient journey, from recognition of symptoms at pre-diagnostic stages through to survivorship or death. Data were analysed using a thematic approach.
We identified 3 themes as important in shaping cancer outcomes: primary care and access to diagnostic evaluation, specialist care and access to treatment, and workforce pertaining to diagnostic and treatment phases. Improved infrastructure for diagnosis and treatment had improved cancer outcomes in all jurisdictions. However, this was seen as insufficient if staffing was inadequate. Consolidation of services and greater surgical specialisation was important in some jurisdictions if accompanied by a reconfiguration of services, in particular the creation of specialist multidisciplinary teams, along with supporting capacity in the wider health system. Staff shortages were commonly cited as reasons why some jurisdictions lagged behind others.
Continued improvement in cancer outcomes will require sustained investment in plans to deliver and maintain the workforce engaged in cancer care and in the infrastructure on which they depend. However, strategic plans must recognise that systems for cancer care do not work in isolation from the rest of the health system and a whole systems approach is essential if we are to improve outcomes for an ageing, increasingly multimorbid population.


  1. Allemani C, Matsuda T, Di Carlo V, et al. Global surveillance of trends in cancer survival 2000-14 (CONCORD-3): analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries. Lancet. 2018;391(10125):1023-1075. doi:10.1016/s0140-6736(17)33326-3
  2. Arnold M, Rutherford MJ, Bardot A, et al. Progress in cancer survival, mortality, and incidence in seven high-income countries 1995-2014 (ICBP SURVMARK-2): a population-based study. Lancet Oncol. 2019;20(11):1493-1505. doi:10.1016/s1470-2045(19)30456-5
  3. Carinci F, Van Gool K, Mainz J, et al. Towards actionable international comparisons of health system performance: expert revision of the OECD framework and quality indicators. Int J Qual Health Care. 2015;27(2):137-146. doi:10.1093/intqhc/mzv004
  4. De Angelis R, Sant M, Coleman MP, et al. Cancer survival in Europe 1999-2007 by country and age: results of EUROCARE--5-a population-based study. Lancet Oncol. 2014;15(1):23-34. doi:10.1016/s1470-2045(13)70546-1
  5. Organisation for Economic Co-operation and Development (OECD). Cancer Care: Assuring Quality to Improve Survival. Paris: OECD; 2013.
  6. Organisation for Economic Co-operation and Development (OECD). Health at a Glance 2019: OECD Indicators. Paris: OECD; 2019.
  7. Ades F, Senterre C, de Azambuja E, et al. Discrepancies in cancer incidence and mortality and its relationship to health expenditure in the 27 European Union member states. Ann Oncol. 2013;24(11):2897-2902. doi:10.1093/annonc/mdt352
  8. Stevens W, Philipson TJ, Khan ZM, MacEwan JP, Linthicum MT, Goldman DP. Cancer mortality reductions were greatest among countries where cancer care spending rose the most, 1995-2007. Health Aff (Millwood). 2015;34(4):562-570. doi:10.1377/hlthaff.2014.0634
  9. Neal RD, Tharmanathan P, France B, et al. Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? systematic review. Br J Cancer. 2015;112 Suppl 1:S92-107. doi:10.1038/bjc.2015.48
  10. Nicholson BD, Mant D, Neal RD, et al. International variation in adherence to referral guidelines for suspected cancer: a secondary analysis of survey data. Br J Gen Pract. 2016;66(643):e106-113. doi:10.3399/bjgp16X683449
  11. Rose PW, Rubin G, Perera-Salazar R, et al. Explaining variation in cancer survival between 11 jurisdictions in the International Cancer Benchmarking Partnership: a primary care vignette survey. BMJ Open. 2015;5(5):e007212. doi:10.1136/bmjopen-2014-007212
  12. Vedsted P, Olesen F. Are the serious problems in cancer survival partly rooted in gatekeeper principles? an ecologic study. Br J Gen Pract. 2011;61(589):e508-512. doi:10.3399/bjgp11X588484
  13. Sharpe E, Hoey R, Yap C, Workman P. From patent to patient: analysing access to innovative cancer drugs. Drug Discov Today. 2020;25(9):1561-1568. doi:10.1016/j.drudis.2020.01.004
  14. Nolte E, Corbett J. International Variation in Drug Usage: An Exploratory Analysis of the "Causes" of Variation. Santa Monica: RAND Corporation; 2014.
  15. Martinalbo J, Bowen D, Camarero J, et al. Early market access of cancer drugs in the EU. Ann Oncol. 2016;27(1):96-105. doi:10.1093/annonc/mdv506
  16. World Health Organization (WHO). The World Health Report 2000: Health Systems: Improving Performance. Geneva: WHO; 2000.
  17. de Azambuja E, Ameye L, Paesmans M, Zielinski CC, Piccart-Gebhart M, Preusser M. The landscape of medical oncology in Europe by 2020. Ann Oncol. 2014;25(2):525-528. doi:10.1093/annonc/mdt559
  18. Leung J, Forstner D, Chee R, James M, Que E, Begum S. Faculty of Radiation Oncology 2018 workforce census. J Med Imaging Radiat Oncol. 2019;63(6):852-861. doi:10.1111/1754-9485.12939
  19. Lwin Z, Broom A, Sibbritt D, et al. The Australian medical oncologist workforce survey: the profile and challenges of medical oncology. Semin Oncol. 2018;45(5-6):284-290. doi:10.1053/j.seminoncol.2018.06.004
  20. Loewen SK, Doll CM, Halperin R, et al. Taking stock: the Canadian Association of Radiation Oncology 2017 radiation oncologist workforce study. Int J Radiat Oncol Biol Phys. 2019;105(1):42-51. doi:10.1016/j.ijrobp.2019.04.035
  21. The Royal College of Radiologists (RCR). Clinical Oncology: UK Workforce Census Report 2018. London: RCR; 2019.
  22. Fundytus A, Hopman W, Hammad N, et al. Medical oncology workload in Canada: infrastructure, supports, and delivery of clinical care. Curr Oncol. 2018;25:206-12.
  23. Seruga B, Sullivan R, Fundytus A, et al. Medical oncology workload in Europe: one continent, several worlds. Clin Oncol (R Coll Radiol). 2020;32(1):e19-e26. doi:10.1016/j.clon.2019.06.017
  24. Grau C, Defourny N, Malicki J, et al. Radiotherapy equipment and departments in the European countries: final results from the ESTRO-HERO survey. Radiother Oncol. 2014;112(2):155-164. doi:10.1016/j.radonc.2014.08.029
  25. Harris M, Vedsted P, Esteva M, et al. Identifying important health system factors that influence primary care practitioners' referrals for cancer suspicion: a European cross-sectional survey. BMJ Open. 2018;8(9):e022904. doi:10.1136/bmjopen-2018-022904
  26. Harris M, Thulesius H, Neves AL, et al. How European primary care practitioners think the timeliness of cancer diagnosis can be improved: a thematic analysis. BMJ Open. 2019;9(9):e030169. doi:10.1136/bmjopen-2019-030169
  27. Cancer Research UK. ICBP partnership. https://www.cancerresearchuk.org/health-professional/data-and-statistics/international-cancer-benchmarking-partnership-icbp.  Accessed April 13, 2020.
  28. Goodman RM, Speers MA, McLeroy K, et al. Identifying and defining the dimensions of community capacity to provide a basis for measurement. Health Educ Behav. 1998;25(3):258-278. doi:10.1177/109019819802500303
  29. Sandelowski M. What's in a name? qualitative description revisited. Res Nurs Health. 2010;33(1):77-84. doi:10.1002/nur.20362
  30. Statistics Canada. Population and Dwelling Count Highlight Tables, 2016 Census. https://www12.statcan.gc.ca/census-recensement/2016/dp-pd/hlt-fst/pd-pl/Table.cfm?Lang=Eng&T=101&S=50&O=A.  Accessed April 13, 2020.
  31. Australian Bureau of Statistics. Population Density. https://www.abs.gov.au/AUSSTATS/[email protected]/Previousproducts/3218.0Main%20Features702016-17?opendocument&tabname=Summary&prodno=3218.0&issue=2016-17&num=&view.  Accessed April 13, 2020.
  32. Morris M, Landon S, Reguilon I, Butler J, McKee M, Nolte E. Understanding the link between health systems and cancer survival: a novel methodological approach using a system-level conceptual model. J Cancer Policy. 2020;25:100233. doi:10.1016/j.jcpo.2020.100233
  33. Patton M. Qualitative Research & Evaluation Methods. London, UK: SAGE Publications; 2002.
  34. Palys T. Purposive sampling. In: Given LM, ed. The SAGE Encyclopedia of Qualitative Research Methods. Thousand Oaks, CA: SAGE Publications; 2008:697-698.
  35. Knai C, Nolte E, Conklin A, Pedersen J, Brereton L. The underlying challenges of coordination of chronic care across Europe. Int J Care Coord. 2014;17(3-4):83-92. doi:10.1177/2053434514556686
  36. Pitchforth E, Nolte E, Corbett J, et al. Community hospitals and their services in the NHS: identifying the transferable learning from international developments. Health Serv Deliv Res. 2017;5(19). doi:10.3310/hsdr05190
  37. Atun R, Ogawa T, Martin-Moreno JM. Analysis of National Cancer Control Programmes in Europe. London: Imperial College London; 2009.
  38. OECD.Stat. Welcome to OECD.Stat. https://stats.oecd.org/.  Accessed April 13, 2020.
  39. Jensen H, Tørring ML, Olesen F, Overgaard J, Fenger-Grøn M, Vedsted P. Diagnostic intervals before and after implementation of cancer patient pathways-a GP survey and registry based comparison of three cohorts of cancer patients. BMC Cancer. 2015;15:308. doi:10.1186/s12885-015-1317-7
  40. Neal RD, Din NU, Hamilton W, et al. Comparison of cancer diagnostic intervals before and after implementation of NICE guidelines: analysis of data from the UK General Practice Research Database. Br J Cancer. 2014;110(3):584-592. doi:10.1038/bjc.2013.791
  41. Vedsted P, Olesen F. A differentiated approach to referrals from general practice to support early cancer diagnosis - the Danish three-legged strategy. Br J Cancer. 2015;112(Suppl 1):S65-9.
  42. National Institute for Health and Care Excellence (NICE). Suspected Cancer: Recognition and Referral. https://www.nice.org.uk/guidance/ng12.  Accessed April 15, 2020.
  43. National Cancer Control Programme. Report on the Implementation of ‘A Strategy for Cancer Control in Ireland 2006.’ Dublin: National Cancer Control Programme; 2014.
  44. Accounts Commission for Scotland. Fighting the Silent Killer: Optimising Ovarian Cancer Management in Scotland. Edinburgh: Accounts Commission for Scotland; 1998.
  45. Department of Health. The NHS Cancer Plan. London: Department of Health; 2000.
  46. National Institute for Health and Care Excellence (NICE). Guidance and Advice List. NICE; 2020. https://www.nice.org.uk/guidance/published?type=csg.  Accessed April 16, 2020.
  47. Chamberlain C, Owen-Smith A, Donovan J, Hollingworth W. A systematic review of geographical variation in access to chemotherapy. BMC Cancer. 2015;16:1. doi:10.1186/s12885-015-2026-y
  48. Chan J, Polo A, Zubizarreta E, et al. Access to radiotherapy and its association with cancer outcomes in a high-income country: Addressing the inequity in Canada. Radiother Oncol. 2019;141:48-55. doi:10.1016/j.radonc.2019.09.009
  49. Lewison G, Aggarwal A, Roe P, Møller H, Chamberlain C, Sullivan R. UK newspaper reporting of the NHS cancer drugs fund, 2010 to 2015: a retrospective media analysis. J R Soc Med. 2018;111(10):366-373. doi:10.1177/0141076818796802
  50. Rachet B, Maringe C, Nur U, et al. Population-based cancer survival trends in England and Wales up to 2007: an assessment of the NHS cancer plan for England. Lancet Oncol. 2009;10(4):351-369. doi:10.1016/s1470-2045(09)70028-2
  51. Woo YL, Kyrgiou M, Bryant A, Everett T, Dickinson HO. Centralisation of services for gynaecological cancer. Cochrane Database Syst Rev. 2012;2012(3):CD007945. doi:10.1002/14651858.CD007945.pub2
  52. Fung-Kee-Fung M, Kennedy EB, Biagi J, et al. The optimal organization of gynecologic oncology services: a systematic review. Curr Oncol. 2015;22(4):e282-293. doi:10.3747/co.22.2482
  53. Archampong D, Borowski D, Wille-Jørgensen P, Iversen LH. Workload and surgeon's specialty for outcome after colorectal cancer surgery. Cochrane Database Syst Rev. 2012(3):CD005391. doi:10.1002/14651858.CD005391.pub3
  54. Varagunam M, Hardwick R, Riley S, Chadwick G, Cromwell DA, Groene O. Changes in volume, clinical practice and outcome after reorganisation of oesophago-gastric cancer care in England: a longitudinal observational study. Eur J Surg Oncol. 2018;44(4):524-531. doi:10.1016/j.ejso.2018.01.001
  55. Wennervaldt K, Kejs AM, Lipczak H, et al. Regional variation in surgery for pancreatic cancer in Denmark 2011-2015. Dan Med J. 2018;65(9):A5503.
  56. Butler J, Gildea C, Poole J, Meechan D, Nordin A. Specialist surgery for ovarian cancer in England. Gynecol Oncol. 2015;138(3):700-706. doi:10.1016/j.ygyno.2015.03.003
  57. Morris S, Ramsay AIG, Boaden RJ, et al. Impact and sustainability of centralising acute stroke services in English metropolitan areas: retrospective analysis of hospital episode statistics and stroke national audit data. BMJ. 2019;364:l1. doi:10.1136/bmj.l1
  58. Fundytus A, Sullivan R, Vanderpuye V, et al. Delivery of global cancer care: an international study of medical oncology workload. J Glob Oncol. 2018;4(4):1-11. doi:10.1200/jgo.17.00126
  59. Ireland MJ, March S, Crawford-Williams F, et al. A systematic review of geographical differences in management and outcomes for colorectal cancer in Australia. BMC Cancer. 2017;17(1):95. doi:10.1186/s12885-017-3067-1
  60. Mahar AL, Coburn NG, Kagedan DJ, Viola R, Johnson AP. Regional variation in the management of metastatic gastric cancer in Ontario. Curr Oncol. 2016;23(4):250-257. doi:10.3747/co.23.3123
Volume 11, Issue 7
July 2022
Pages 1024-1034
  • Receive Date: 12 October 2020
  • Revise Date: 24 November 2020
  • Accept Date: 09 December 2020
  • First Publish Date: 22 December 2020