One of Ireland's most respected oncologists, John Crown, says the HSE cancer care strategy of concentrating on centres of excellence is the right one but much more needs to be done.
In the aftermath of the most recent cancer tragedy, we find ourselves embroiled yet again in the politics of the last healthcare atrocity. It is, however, important that we attempt to rise above the near-ritual welter of recrimination and finger pointing that attends these apparently perennial disasters, and to focus instead on the substantive problems of our cancer service, and more generally of our hospital service. These problems are inaccessibility, inefficiency, unfairness and uneven quality.
Irish cancer care has improved immeasurably over the last 10 years, but we still lag far behind our European peers. While I have no insight into the specifics of the recent cases beyond that which is in the public domain, there does appear to be a pattern of departure from accepted standards of excellence.
We do know that one hospital was insufficiently resourced to perform its own pathology examinations, and was instead outsourcing them to an institution remote from the clinical decision-making process, that another hospital was delivering cancer care which would have to be considered unorthodox, and that the accuracy of the reports of an entire cohort of mammograms from another institution have been called into question. Such incidents, and the appropriate media focus which they have received will lead many Irish cancer patients to question the quality of the care which they receive in Irish hospitals. Such questions are justified.
It is generally accepted by cancer professionals that the best clinical care takes place in large comprehensive, specialist centres, institutions where a critical mass of multi-speciality expertise is deployed to meet the complex needs of cancer patients. Such centres exist throughout most of the world, and the very best care is delivered in the very best of them, eg Memorial Sloan-Kettering in New York, or the Netherlands Cancer Institute.
It is now obvious that Irish cancer patients receive a very different type of cancer care, care which is delivered in small, poorly resourced, low throughput, non-comprehensive centres. I am not pointing fingers, my own institution has many of these problems. Critically, every single one of our patients are being seen by hugely overworked doctors, doctors who in some cases are practising single-handedly, due to the extraordinary shortage of specialists of all types in this country. This leads to crushing workloads, rushed consultations and high incomes.
I saw more than 90 patients on each of two days this week, and more than 50 on the others (before you ask, yes about half were private). One cannot, I cannot, deliver high quality care to that volume of patients.
This shortage in turn leads to wholly inappropriate delegation of responsibility to trainee doctors. None of our patients is currently being treated in a comprehensive cancer centre. None exists here.
The proposed remedy is the concentration of public cancer care into eight Health Service Executive-run centres of excellence (not comprehensive centres). This will inevitably involve the suspension of cancer care in some local units, and already local forces are mobilising in protest. I would urge them to think their opposition through.
I have no self-interest in seeing rural cancer centres closed down. The dirty little secret that most Irish consultants know is that a disproportionate number of the private patients from these areas come to Dublin anyway. No, the proper way to approach the problem and this was not done, was to get agreement from all concerned on the principle of concentrated care, and then to hammer out the geographical disputes later. I believe that right thinking doctors would have agreed to this plan, and would have attempted to lead their patients, and local community leaders to the truth, which is, that when you have cancer, you want the best chance of cure.
Instead, specialists, many of whom have actually gone to great lengths to build up decent services in their local hospitals despite administrative and political neglect, were informed that they were slated for closure. In some cases they were told to consider themselves closed already. As with so many of our health reforms, this happened precipitately in the aftermath of scandal.
Let me reiterate: I agree with the strategy of concentrating cancer care. Some of the specifics are, however, very strange.
Why four centres in Dublin? It sounds like too many to me. Why was the existing medical school structure in the capital ignored? Who thought of the odd idea of treating the different tumour types (eg bowel, breast) in different Dublin hospitals, guaranteeing by definition that no Dublin centre will be a truly comprehensive cancer centre? I also believe that the northwest and the midlands have sufficient population to justify their own centres. There is another elephant in the room. While size matters, it is not a guarantee of quality. Some large and expertly staffed centres deliver care which is inferior in quality to that which is received by patients in other smaller institutions. Why is it that the UK falls so far behind the other major nations in cancer survival, despite having a superbly organised and highly concentrated cancer service?
Centralisation, while it will address and rectify some quality issues, will if enacted in isolation from a more profound re-engineering of our health service, fail to deliver on the crucial deficiency, which is access, access to the system itself, and access to effective treatments. Centralisation would not have saved Susie Long, but a single tier not-for-profit social insurance model might have. Centralisation did not help the British women who were denied potentially life-prolonging treatments.
Nor will centralisation end the iniquitous public-private split. Indeed, I think that it is virtually certain that our heavily privately insured population will flee a HSE-led and Health Information Quality Authority rationed cancer network to new private cancer centres, including those which our Taoiseach and our Minister for Health have ceremonially opened.
High quality, equitable cancer care will necessitate two reforms, one which the HSE is pursuing (concentration of care into centres of excellence), and one which they are not, which is a true, fundamental health service revolution.
Professor John Crown is a consultant medical oncologist at St Vincent's hospital in Dublin