In spite of many developments in surgery, chemotherapy and molecular biology, radiotherapy remains a mainstay of cancer treatment, both for cure and palliation, and its use has steadily increased over the last decade. There have also been dramatic improvements in technology, imaging and computing which are rapidly changing practices and already improving outcomes.

The two Royal College of Radiologists (RCR) reports on radiotherapy equipment, workload and staffing provide a good picture of the progress between 1992 and 2002. In most of the years 1992 to 1997, provision of equipment was subject to local negotiation between purchasers and providers. This seemed to work reasonably well for small departments but for larger ones the complex negotiations often led to disagreement and delay so that machine replacement and installation of extra capacity was frequently delayed. The consequence was a national picture of under provision and unequal access varying by a factor of three, plus a legacy of out-of-date machines. Direct investment via the Lottery New Opportunities Fund and the Department of Health funding through the National Cancer Plan in England, between 1998 and 2003, has done much to short-circuit the previous laborious planning process and has resulted in the replacement of many old machines plus a modest increase in capacity. The exercise clearly demonstrated that central allocation and funding informed by a national overview works and is cost-effective. The increase in capacity has, however, been equalled by a parallel increase in demand. While some of the major black spots have been addressed, the overall mismatch between demand and capacity has not changed enough and waiting lists for radiotherapy are still much too long and compromise cancer cure. Provision of linear accelerators will have increased from 3.5 to 4.2 per million population between 1998 and 2004, but at the same time comparable European countries have increased their provision to between 5.5 and 7 linear accelerators per million.

Over the last 10 years, the trends in cancer incidence and the need for radiotherapy have risen in a very predictable way. It is not too difficult to predict the requirements for the next 10 years and to plan accordingly to ensure that equipment is replaced on time, new capacity is installed and that the staff necessary to run the service are trained in adequate numbers. The move from a one-year to a three-year treasury funding cycle is welcome, but experience has shown that the installation of new radiotherapy facilities takes several years and that a longer planning framework is needed.

There is a fear that a return to local commissioning of radiotherapy services will slow up the process as it did between 1992 and 1997. If there is a fragmented approach to capital funding and the revenue needed to support it, this will affect not only radiotherapy but also other major capital equipment programmes which include essential items like CT and MRI scanners. This need not necessarily be the case provided that long term plans which meet agreed objectives are approved and that targeted funding is delivered to strategic health authorities and primary care trusts to enable them to achieve the objectives. It is too early to say whether these new bodies can act cohesively with sufficient speed to maintain the required momentum.

By 2005, the National Cancer Standards will apply and all patients should start radiotherapy within four weeks of diagnosis (at the moment, less than 50 per cent do). This target will not in itself improve things unless there is an implementation plan to ensure that there is enough equipment and staff to deliver a responsive service. In the past, we have always been driven by successive waiting list crises and have responded in piecemeal fashion which has never got us ahead of increasing demand nor fully taken on board the exciting opportunities provided by new technology. There is much to do to improve radiotherapy services but this needs to be informed by a long term plan and implementation strategy which will ensure that adequate equipment and staff are available for the predictable future. Extra capacity has been established to expand staffing and it is hoped that this will redress staff shortages over the next few years. Audits like those done by the RCR will still be needed to ensure that projected targets are going to be achieved so that they can be modified if necessary.

The question arises "what can be done now?" In the short term, work is already underway with the Cancer Services Collaborative to ensure that what capacity is available is being fully used. Unfortunately linear accelerators cannot be bought off a shelf and plugged in overnight. They require a complex and lengthy commissioning process and if a new building is needed to house them, this requires highly specialised and complex building work. By now, most of the nooks and crannies around existing radiotherapy departments have been filled and new build sites will increasingly be required to install extra machines. Recent experience has shown that this can take up to 10 years. Even if new machines are made available, they can't be put into service without skilled radiographers, physicists, technicians and doctors to run them; therefore there needs to be a parallel programme of training for extra staff. International recruitment is unlikely to fill this gap because of a world-wide shortage in this speciality. There is no quick fix and this makes the need to plan for the long term even greater and to persist until the need is met.