This article appears as part of the Inside the NHS newsletter.

"None of these targets are perfect but they do tell us when a system is failing".

That was the message this week from Professor Farhat Din, a colorectal surgeon and clinician scientist for Cancer Research UK who was giving evidence to MSPs on the health and sport committee about the state of NHS Scotland's cancer services and – among other things – the ongoing failure to meet the 62-day waiting time standard, last met in 2012.

The session on Tuesday came just seven days after statistics revealed a 20% increase between December and March in the number of people on waiting lists for a CT scan (up by nearly 4,600), and a 7% increase in the number waiting on an MRI (up by 1,888).

Many – but not all – will be patients with a suspected cancer.

The 62-day standard stipulates that 95% of cancer patients should begin treatment within 62 days of an urgent referral for tests. It is currently hovering around 71%.

For cancer patients, a timely scan is a crucial step towards surgery and treatment planning – for example, identifying whether the disease has spread.

But diagnostic pathways are under pressure from growing demand from an ageing population and referrals relating to non-cancerous conditions.

Peter Hastie, of Macmillan Cancer Support, urged MSPs to "hold the government to account" on cancer waits as he stressed that the deterioration in performance against the 62-day target over the past 12 years is "a really strong indicator something is going badly wrong in cancer services".

He noted that September's Programme for Government promised a "demonstrable improvement in cancer waiting times".

"That target was meant to be hit by April, it hasn't been met, so what would demonstrable improvement mean in the context of cancer waiting times?," said Mr Hastie.

The Herald:

‘Tip of the iceberg’

Prof Din stressed that it was to the credit of the NHS that "the bulk of cancer surgery did take place" during the pandemic, but what is less clear is the impact from patients who "did not come forward".

She said: "I've seen several patients who would phone up [their GP], get the Covid message, not wait to make an appointment, who presented six to eight months later.

“So I think we're only starting to see the tip of the iceberg in terms of patients who have not come forward. You couple that with a pause in screening, a pause in pretty much all diagnostics, there's a huge backlog, and we won't really know what the magnitude of the unmet need is."

Yet even without Covid our ageing population was always going to drive a surge in cancer incidence and thus demand for diagnostics, treatment, and the staff and equipment needed to cope.

"We have simply not put in the workforce planning for that," said Mr Hastie.

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Productivity

Nonetheless, one of the oddities of the post-pandemic era is why increased investment and resources have not translated into recovery even to 2019 levels.

As Max Warner, a research economist for the Institute for Fiscal Studies, told MSPs: "NHS Scotland as a whole is struggling to recover – it's not just a cancer thing.

"There's a productivity challenge where there's additional funding, additional staffing, relative to pre-pandemic, but we're not seeing those corresponding increases in output.

"Most treatment volumes for other parts of the NHS in Scotland are below pre-pandemic levels, so there's a broader productivity challenge that is playing a role in cancer and these other elective waiting times."

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At least one factor is maintenance backlogs: operating theatres temporarily closed by leaks and power cuts, or broken scanners awaiting repair.

Bed shortages are another factor, linked to delayed discharges and sicker patients spending longer as hospital inpatients, both of which contribute to an overall reduction in capacity.

Against this backdrop, getting the 62-day cancer wait back above 80% – let alone to 95% – would be a significant achievement.