Sunday, February 06, 2005

Cancer Care in the NHS

David over on A Tangled Web, reports on a post to Civitas's blog which reports a Sunday Times article which reports on this report on cancer care in the UK, published by Reform on behalf of Doctors for Reform (as of the 7th, also reported on the BBC). The joy of hyperlinks! Anyway, I have to say that I'm always a little suspicious about independent reports that just happen to confirm the political stances of the organisations that commission them but, while I might not agree with the conclusions of the report's authors (lots more on that below), the cancer care system in the UK is certainly not responding to the injection of state cash in the manner that one might hope.1

Basically put, when the Labour government came into office, they identified a few areas that they intended to devote resources to and cancer, being a major killer, was one of them. The NHS cancer plan that was drawn up "included three major commitments:
• To reduce the delay from referral to the beginning of treatment to two months;
• To reduce smoking in lower socioeconomic groups; and
• To invest an extra £50 million in palliative care each year from 2004.

While the first aim seems to have been achieved, I don't think the second has and, as the report at hand makes clear, the third commtment has made very little difference. The money, the authors argue, has largely been wasted. In short, "the Cancer Plan is simply not delivering as hoped and there are no reasons for expecting any dramatic improvements in the future."

Pointing out that, despite the large amount of money being pumped into cancer care, there has been no impact on death rates, the authors of the Reform report argue that
• although referrals have fallen, people are dying because of the gap between diagnosis and treatment. A study in Glasgow, for example, "found that 21 per cent of lung cancer patients became unsuitable for curative treatment during the wait for radiotherapy."
• Treatment is not as aggressive as it could be, partly because of a lack of communication of new treatments across the country and partly as a result of insufficient and unequal resource allocations.
• A lack of staffing. Although there has been an investment in facilities and in procedures, the small numbers of new staff mean that new radiotherapy machines are not being used.

The report makes for pretty depressing reading. Essentially, government investment hasn't made much difference. Now I suspect, admittedly from my healthcare amateur's perspective, that part of the problem is that these things take time. The hiring and training of staff, especially, can be a long process. As a result, I may be less pessimistic than the report's authors on prospects for the future.2

But the report's conclusions (entitled 'The Way Forward') do trouble me.3

It seems to me that the three key words in the conclusions are choice, information and outsourcing.

I have to say that I find these suggestions somewhat strange. At least, while they may not be particularly harmful to patients, I don't see how they will improve mortality rates. Let's take them in turn:

Choice: Surely people with cancer want the most effective cure: providing them with choice entails a distinction between the most effective and less effective treatments, which doesn't strike me as denoting choice in any significant sense at all. Thankfully, the ability of patients to act upon different tastes is not at the base of the attachment to choice. Strangely, however, it's rooted in the spread of incentives and in allowing "the relative costs of different providers to be dissected." So, choice would have a national auditing function. Now, I think this is all laudible, but I suspect that it's a terribly inefficient method for providing high standards of care. Largely for reasons to do with information...

Information: The authors seem to be concerned with information, although I'm not entirely sure what they're getting at when they refer to it. I suspect that they regard informaton as being a sub-set of choice. That is, that information is provided in order for patients to make rational choices, presumably so that the market-like system can be an efficient mechanism for providing information to the state etc. But the assumptions regarding information seem optimistic. After all, the idea of rational choices based on information does depend on the literacy of patients and on the capacities of patients and their GPs to process information when under significant stress. Their choices will also be driven by a variety of actual and opportunity costs (such as the cost for a family of supporting a patient in the Royal Marsden hospital if they're from, say, Scotland. I just think that direct bureaucratic systems must be more efficient and mroe effective at supplying information without burdening either staff or patients than the market-like constructions suggested by the concept of choice.

Outsourcing: The authors' idea is that outsourcing would have a number of beneficial effects. First, it would bring extra resources into the healthcare system. Second, it would help in providing choice and, with it, higher standards. Third, it would encourage innovation. Now, I'm not hostile to private sector involvement in healthcare, provided the profit motive is not favoured over what the system should be doing, which is, well, providing people with healthcare. But, apart from what I've already said about the inadequacy of the concept of choice in this environment, I suspect, given the UK's experience with part and full privatisations, that expected efficiency gains won't manifest themselves. Instead, the state will end up paying for costs plus profits. Also, hoping for the private sector to innovate through this system is a touch naive. After all, the costs of developing new technologies are enormous and the UK would be better off devoting R&D costs directly, rather than as a side-effect of some sort of market.

Moreover, since, as the authors acknowledge, a large part of the problem is the availability of trained staff, it's hard to see how the private sector would cope with the problem. Again, it would seem that the state would be better off creating incentives in the labour market by offering radiologists etc. higher wages. The private sector is (with some exceptions) not reputed for helping like that. I'm not even sure how they might compete for existing NHS staff without increasing the costs of supply.

In short, I'm not convinced that the creation of a market for cancer care would provide the sorts of benefits that the authors envisage. I'm not entirely hostile to the idea that it might, but I don't see how there is any connection between the problems that they identify and the solutions that they suggest.

1 Although I agree that the cancer care system is not improving in line with the injection of cash, we shouldn't forget that it does do a lot of good work. 'Should do better' should not be read as 'is doing no good.'

2 My pessimism might be rooted, somewhat heartlessly, in the fact that cancer tends to hit elderly people, especially smokers (it's true that it causes 30% of deaths in those under 70, as the authors point out, but those under 70 still make up a relatively small proportion of cancer deaths). I'm not so sure that new procedures and treatments such as gene therapies will do more than what current drugs do: prolong life for a while and alleviate some suffering when people begin to die.

3 They are worth reading in full:
Patients with cancer should have the same principles of choice and variety of providers that are being offered in other areas of health care. Inclusion of cancer care in national tariffs open to competitive tendering will allow the relative costs of different providers to be dissected. We could start by pilot programmes in diagnostic services and radiotherapy, with patients being offered alternative services if they experience delays. Unless opportunities for innovation are increased with appropriate incentives, health investment will be tilted into other areas and cancer care will become disadvantaged yet again.

Big improvements in access and capacity over the next two years are essential to take the momentum forward. Local private sector initiatives, in diagnosis, surgery and radiotherapy, could raise productivity appreciably in cancer centres. Open tendering would encourage a range of providers and end the block on investment and innovation. We need to improve the information available to patients on quality and access.

We are simply advocating that cancer patients should be able to benefit from the same key principles of patient empowerment, choice and competition which have been strongly advocated for the NHS by the Secretary of State. We cannot stand by and watch while such a vital area of service falls behind the rest of the NHS.

We are optimistic about the opportunities for improving use of scarce resources across cancer prevention and care. There is much that is positive about the aim of a patient–centred service with more focus on long term illness. There is much to admire about the dedication and commitment of staff in the NHS. In terms of Britain’s long term social and economic challenges, however, we believe the NHS Cancer Plan has delivered poor value for money. It is essential to search for new initiatives which will improve the situation.

For the longer term cancer services would have much to gain from a greater variety of providers. This would draw in international capital and expertise. Reliable and effective services are becoming more feasible and fundable in smaller, networked, user-friendly cancer “hotels” as well as in larger teaching centres. The professional and human commitment of staff in cancer care could be used more effectively to improve process and outcomes for many. Mortality from cancer now counts for 30 per cent of all deaths in those under 70 and 40 per cent for women. These proportions are likely to increase further as mortality from coronary heart disease reduces. Cancer patients often live in poor health unnecessarily for long periods of time due to a lack of coordination of their care by overstretched treatment services. The Cancer Networks act as cartels dividing up the workload. We need to take steps to ensure that cancer patients benefit from a greater variety of providers:

• There are new challenges in building partnerships with patients with higher levels of concern about lack of information. Cancer services have often scored unusually low in survey evidence on the quality of communication with patients. Patient Care Advisers are needed to explain the merits of different providers.
• Within two years, 30 per cent of diagnostics, radiotherapy and chemotherapy should be outsourced to the independent sector. This would drive innovation, investment and increase the quality of services provided. Such pluralism of provision would be the basis of real patient choice.
• Patients need to be involved in funding considerations with the introduction of incentives for patients not to use high cost interventions of low benefit. We need to let patients drive the agenda involving cancer experts more widely in planning for a complete financial, operational and strategic overhaul of cancer services.
• The aim should be to create an innovative culture of reform embracing private sector expertise and investment.

In the future the prevalence of cancer will rise trebling the number of people living with cancer in Britain to 3 million at any one time. This will put further pressure on process and outcomes. Even if there are increases in real funding, such numbers point to a situation in which real expenditure per patient will rise little. Sustained improvement in system performance is essential. Real improvement will not be achieved by simply giving more money to a burgeoning bureaucracy. It requires a serious commitment to reform.

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