The national sport of demanding that every cancer service be available everywhere must end, writes Tony O'Brien
The current controversy enveloping symptomatic breast services serves to underline the pressing need for a fundamental rethink of our collective national approach to the question of medical specialisim and quality assurance. Campaign groups, local communities and some public representatives will seek routinely and on principle to "defend" services that are "local" merely because they are local, and all too often without any reference to the true value or quality of such services.
BreastCheck, the multi-disciplinary and quality assured national breast screening programme has, on the other hand, faced and had to resist many demands to extend its services in ways which would have not been quality assured and which would have undermined the basis of its quality control systems.
Such demands have been advanced on the supposed notion that something is better than nothing. The success to date of the centralised model of BreastCheck, shortly to be extended nationwide, has proven that specialisation combined with systematic quality audit is the key to client confidence and quality outcomes. There can be no safe short cuts in the development of population screening programmes.
Across a wide range of cancer and other specialities, there is solid evidence of the relationship between specialisation and multi-disciplinary team working and patient outcomes.
Specialisation, multi-disciplinary team working and case volume are the vital attributes of any cancer service at both diagnostic and treatment stages. The proximity of a cancer service to your home address is not a quality indicator. The size of our population and the incidence of cancer will determine the total number of centres that can provide high quality services.
For each cancer the number of centres which can sustain quality assured services will vary, and there is international evidence which can guide us in this. This is not an issue of cost or economics, but of required case volume.
Symptomatic breast services have provided some stark recent examples of the problems that can arise at the diagnostic level. It is important to stress that arriving at any diagnosis requires the application of well-developed clinical judgment. Whether looking at an X-ray or a tissue sample, as patients we rely on judgment calls by the professionals involved.
In all such situations we must accept that there will be a margin of error. There will also be some instances of missed diagnosis that are not the result of error on anybody's part. We cannot expect any individual to get it right 100 per cent of the time.
This is why it is so essential to provide integrated multi-disciplinary team environments in which all cases, and borderline cases in particular, can have the benefit of collective experience and judgment.
The team environment also provides support to the individual clinician and provides a good platform for quality assurance that can support ongoing audit and improvement initiatives. In what might loosely be termed the "post-Neary" era we are, happily, now living in a time when possible errors will be readily surfaced and then speedily audited.
The impact on the individual women at the centre of reviews in Limerick and the midlands, even where the original findings are quickly confirmed, will be significant and should never be minimised. However, such exercises are likely to become more commonplace in an environment that encourages review and transparency.
The approach taken by some sections of the media to reviews that are currently under way will not have served to encourage such an open environment. That the health system now moves more quickly than in the past to address quality issues deserves some credit and encouragement. The clinicians at the centre of any review should not face premature judgment or the unpleasant ordeal of implied trial by media, even before the reviews have been completed. We need to develop a more mature and measured approach to the review process in order to sustain support and co-operation with it.
But we do already know, in advance of any review reporting its findings, that for a number of cancers we have too many centres assessing and treating too few cases. We have far too many self-styled cancer services in public and private settings without suitable specialisation or multi-disciplinary teams. We must now build on past improvements and begin the process in earnest of significantly reducing the number of locations and individual clinicians applying their trade in sub-optimal circumstances.
We need this process to begin now and be completed over a reasonable timeframe. There will be some relationship between public support for change and the pace at which it occurs.
We must now all accept our responsibility to bite the bullet. We have to stop using and defending local services that cannot meet the quality criteria; we have to accept the end of some local services in order to ensure that we have cancer services that can produce the best possible outcomes. No parent would hesitate to travel the length and breadth of the country to get the best care available for our children. Our approach to cancer care must apply the same principles.
If your local hospital offers a breast cancer service but does not have a specialised multidisciplinary team and does not treat a minimum of 150 new cases per annum then you should just drive past and continue to the next specialist centre that does. If you find that a local private hospital can see you tomorrow but doesn't have a full team or a sufficient volume of cases, it is worth waiting a bit longer to access the public centre that does.
There may be a good reason why the private hospital has immediate next day appointments available while the specialist centre down the road does not. Many of us judge restaurants and hairdressers by such criteria - why would we not be equally discriminating about cancer care?
Changing the way we provide cancer care will be a process and not an event. It will take some time to implement it safely and effectively. We can all help to facilitate and hasten the completion of this process by taking a mature and realistic approach to the number and distribution of specialist centres and ending our national sport of demanding every service, everywhere.
Tony O'Brien is chief executive of the National Cancer Screening Service