In this post-devolution era, health is devolved to the constituent countries of the UK and their respective legislative and executive bodies. In Scotland the health of the nation is overseen by the Scottish Executive Health Department (SEHD). At the coalface are the employees of Scotland's health boards and their trusts.
In recent years cancer care has come under the same detailed focus in Scotland as elsewhere in the UK. All of the union was affected by the impetus of the Calman-Hine Report. The nation's minds were collectively concentrated by the cancer survival league tables for Europe that showed the UK was "the sick man of Europe". Scotland has reviewed its cancer care needs and plans in a number of steps, the first being Cancer in Scotland: Action for Change (2001). A further development to aid planning cancer services in Scotland for the first decade of the 21st century was Cancer Scenarios (2001).
One significant result of these reviews and plans has been the establishment of the three Scottish cancer networks: one in the north, one in the southeast and one in the west. They began their work in 2001. Each is guided by a Regional Cancer Advisory Group (RCAG), which oversees and steers the work of its network and the allocation and spending of its extra ring-fenced funds. Each cancer network covers several boards, and one (the north) has three constituent cancer centres.
Funds from the SEHD to each health board are apportioned by the Arbuthnot Formula that takes into account not only population numbers but also other factors including socio-economic deprivation levels. In addition to these general funds, further ring-fenced monies were allocated to the three newly established cancer networks. These additional monies are recurrent and have risen from £10 million in 2001/02 to £25 million in all subsequent years. The ring-fenced allocations will continue into 2005/06 (i.e. for five years in the first instance).
The additional funds have been made available to the cancer networks for agreed programmes, increases in workforce and for equipment. To make good years of under-resourcing, £2 million per annum is top-sliced for the UK's second largest cancer centre at the Beatson Oncology Centre in Glasgow. An additional £700,000 is retained centrally for the Scottish Cancer Research Network, waiting time initiatives in surgery, communication skills training and several other projects and to implement, coordinate and monitor the process.
Cancer networks benefited from additional consultants in many specialities, more nurses, additional pharmacists and extra radiographers, APHs and physicists. Each cancer network and the central secretariat are monitored in two ways. Each networks must monitor its spending and its outcomes. The latter is the role of the managed care networks (MCNs) established within each cancer network. Each RACG must review and monitor its own cancer network and report to SEHD. The SEHD monitors the six monthly reports of the cancer networks and also its own activities. Unspent monies ? "slippage" ? may only be spent on approved, cancer-related activities.
Outcomes such as waiting time targets are included in the monitoring process. Increasingly clinical outcomes will be reported by the site-specific MCNs, which are funded for service improvement, protocol development and, most importantly, audit.
All of these processes ? planning, identifying services to be supported or enhanced, selecting and appointing, monitoring expenditure, auditing outcomes of process and effect ? involve managers and clinicians across the spectrum of care. Those clinicians see the extra investment being spent on the services they deliver. To date, the bureaucracy to oversee this has been minimal. Clinician involvement has been, therefore, generally supportive and enthusiastic. Clinicians do not criticise wastage on administration and do not complain that the money goes elsewhere. In Scottish cancer care there is no "black hole" for the money to disappear into. Nor are there armies of project officers.
Not all activity and funding are ring-fenced. Improved access to clinicians, to clinical trials, to the benefits that result from such trials as they mature and to evidence-based protocols means more patients receive the most appropriate of care. As new therapies are approved, they are integrated into care protocols and clinical pathways. Drug costs and other associated expenditure increases and those increases must be obtained from the general budget: they are not fenced within that additional financial ring. That produces its own problems.
The recent rolling out of the Scottish Cancer Research Network with ring-fenced funds totalling £500,000 per annum is a truly exciting development. Each of the five main Scottish cancer centres has developed, to a variable extent, cancer trials infrastructures. Now each health board has access to extra funds to resource clinical trials. More data managers and research nurses will guarantee increased clinical trial entry ? a benefit for all cancer patients. Already in the west of Scotland 11 per cent of cancer patients enter into clinical trials.
The "sick men of Europe" are clearly improving. Scotland already has the highest participation in breast and cervical cancer screening in the UK. It has also established family cancer clinics in all regions. Outcomes for several cancers (as elsewhere in UK) have improved e.g. the falling mortality for breast cancer and male lung cancer.
There remain many challenges: the dearth of oncologists and radiographers; the need for extensive upgrading of the IT systems across each network; and the rising costs of specialist oncology and palliative care drugs. Nevertheless, in a little over two years Scottish patients and Scottish clinicians have seen benefits that are likely to increase further.
