Command but no control
What chance do patients have of accessing new cancer technologies if funding routinely fails to reach front line services, asks Munizha Ahmad
Technological and medical advances in cancer research are brought to our attention with increasing frequency, which indeed is cause for hope. However, while it is necessary to keep pace with such developments, the over-emphasis of the media on findings that are still many years from leaving the laboratory risks diverting our attention from the state of cancer care as it presently stands. The latter raises as much concern as hope and points to the wide gulf between scientific advancement and the continuing unevenness of basic cancer services at a local level.
Last year, the House of Commons Science and Technology Select Committee report, Cancer Research - a follow up, raised the issue of funding specifically set aside for cancer services, as earmarked in the Cancer Plan, not reaching patients and services at the front line. Following its recommendation for end-of-year accounts for 2000-2001 to be published and pressure from cancer charities, an emergency audit was ordered by Alan Milburn in January to track these funds amounting to over £320 million. If the funding cannot be accounted for, then how far can we expect the new technologies and therapies that constantly make the headlines to become accessible? And if, as a result of this episode, the government has to ringfence certain programmes as has been suggested, then how will a further discrepancy between the services in different regions and the treatment of different cancers be avoided?
However, as Elisabeth Davies, Chief Executive of the UK Breast Cancer Coalition argues, the assessment of cancer services "is not purely a funding issue. We need to ask if government guidance is actually improving access to care". Davies says that the establishment of the National Institute for Clinical Excellence (NICE) in 1999 was welcomed by patient organisations, who hoped it would even out regional inequalities in cancer care. However the low local impact of this guidance disappointed expectations.
As with the currently unaccounted for extra funds allotted to cancer, the monitoring systems required to implement NICE guidelines were not always in place. A survey carried out by the charity CancerBACUP, published in December 2001, found that fewer than half the health authorities in England and Wales had a policy for monitoring local compliance with NICE guidance and the majority were unable to say whether national guidance on cancer treatment was being implemented. Furthermore, while NICE guidance on taxanes for treating breast and ovarian cancer was being implemented almost everywhere, guidance on a wide range of treatments for other types of cancer was not being followed in all parts of the country.
The survey also drew attention to concerns about structural change in the NHS, "with the disappearance of health authorities and the emergence of Strategic Health Authorities, which will have no commissioning function in cancer, and primary care trusts, which have little commissioning experience". It is in the light of this structural change that the UK Breast Cancer Coalition, with support from CancerBACUP, Breast Cancer Care and Breakthrough Breast Cancer, has recently co-ordinated a study on the implementation of NICE guidance, which questioned every PCT in England about the monitoring systems they had in place. The study is focused on breast cancer but should, as Davies points out, provide indicators about the state of treatment for other cancers.
The findings of the survey should be published by April, by which time the information about the additional investment in cancer services should also have been made available. Both are likely to prompt a rethinking of how cancer services across the country are not only implemented but also monitored. There is no single cancer, no single cause and no single treatment, and each of the advances we read about each week present an undeniably significant, yet small, step forward in one particular area of an inevitably multilayered and multifaceted process. In attempting to manage the disease, our first priority should surely be to establish manageable networks and an appropriate balance between local and national control. The restructuring of the health service, and the evident lack of transparency in the transfer of funds and guidance from national to local establishments that this is bringing about, clearly demands greater attention than it is at present given.
