The method of financing the national radiotherapy network raises questions of accountability, writes Dr Muiris Houston, Medical Correspondent.
The Hollywood report on radiotherapy services in Ireland, published almost two years ago, found the Republic had the weakest radiation oncology service in Europe. It said we had the lowest number of radiation specialists and the highest number of cases per consultant in the EU.
This stark conclusion is reflected in figures which show that only 35 per cent of cancer patients receive radiation therapy in the State. International experience suggests that close to 60 per cent of people with tumours require radiotherapy as part of a multi-treatment approach to eradicating cancer.
Surgery, chemotherapy and radiation therapy are used in varying combinations and sequences in the treatment of cancer. It has been shown that patients who avail of all appropriate treatment modalities within an accepted timeframe have a much better chance of surviving cancer.
It is against this background that Minister for Health Mary Harney has launched a national network for radiation oncology services, relying on the expert advice of the Hollywood group and on an international panel of cancer experts who visited a number of potential sites before issuing their recommendations.
But she also had to contend with intense lobbying from medical and hospital interests, as well as a vociferous campaign from residents of the south-east, who were not happy at the Hollywood group's decision to focus on a core spine of radiation oncology facilities in Dublin, Cork and Galway.
What emerged on Monday was essentially a modified version of Hollywood, complete with funding proposals that demonstrated the Minister's particular fondness for private investment as the way forward for our health service. Coming just after the publication of a plan to add 1,000 extra hospital beds by building private hospitals on the grounds of existing public facilities, there can be no doubt that under Ms Harney's stewardship, it will be the influence of Boston rather than Berlin that will hold sway.
The big winner in this shake-up of cancer services is St James's Hospital, Dublin. As the premier cancer centre in the Republic, it will house 13 linear accelerators (the machines that administer radiation therapy), with the existing St Luke's facility moving onto the St James's campus. The south Dublin cancer hospital, which for many years shouldered the burden of providing treatment for patients from all corners of the Republic, was given a number of guarantees as to its future in Ms Harney's statement.
On Dublin's northside, Beaumont hospital, which treats 4,000 cancer patients a year, saw off the challenge of the Mater hospital, which had been seen as the favoured location. It is understood that the Taoiseach, in whose constituency the Mater is located, was lobbied in recent months, with a view to reversing the expert group's recommendation that Beaumont be the site for a super regional cancer centre. But Beaumont carried the day.
There was no controversy about expanding facilities in Cork, nor of locating a radiotherapy centre in Galway. A cross-border arrangement will eventually provide for patients in Donegal. However, when it came to the south-east and south- west of the country, Ms Harney responded to local campaigners, going against the Hollywood group's recommendation that no cancer centre operate with a capacity of less than four linear accelerators. There are quality of care issues at stake, with evidence that a critical mass of staffing, workload and ancillary services are required to ensure best survival rates for patients.
Despite this clear advice, the Minister has sanctioned satellite units, each with two basic treatment machines, in Limerick and Waterford. In an attempt to shore up the quality of care in these units, she has stipulated that they work under the guidance of the major centres in Galway and Cork respectively.
Ironically, at least one of these units may be up and running more quickly than additional facilities elsewhere, simply because the private sector has outpaced the slow pace of Government reform and has already built radiotherapy units in Limerick and Galway.
But the method of financing the national radiotherapy network is also significant. At over €400 million, it is a major infrastructural investment. Some three quarters of this money will come from the private sector under a public-private partnership (PPP). "The PPP will be a single design, build, finance, manage and partially operate project. Clinical staff will continue to be recruited under public sector arrangements", Ms Harney stated. But she made no specific reference to governance issues. How will "partially operate" work in practice for both the private investors and the public hospital managers?
If we have learnt nothing else from our ailing health service, it is how difficult it can be to link investment money with service outcome using a single public investment stream. How will accountability be achieved in a complex PPP model?
Undoubtedly Ms Harney will set off to the sun this weekend with a sense of achievement. Should her initiative help deliver a comprehensive cancer treatment service for all patients in the Republic, with improved survival rates, it has the potential to match the success of her predecessor's tobacco ban in its impact on public health.