Five years after its inception, England's National Cancer Plan has been placed under intense scrutiny by two different groupsthat have reached near opposite conclusions about the progress made in cancer care since 2000.
The most recent report, by the National Audit Office (NAO), concluded that 4 years into the 10-year plan, "substantial progress" had been made in meeting targets. "This should contribute to the downward trend in cancer mortality and continue to bring significant benefits to patients," said NAO head John Bourn, Ph.D.
The report says that the cancer plan was a "good model from which other countries have taken inspiration." It resulted in the development of 34 cancer networks that bring together health service commissioners and providers, local authorities, and the charity/voluntary sector, which includes patient groups and fund-raising bodies. A network typically serves a population of between 1 million and 2 million people.
But a second report by a group called Reform, which describes itself as an independent nonparty "think tank," says that the plan is giving "poor value for money." Comprising almost 1,000 doctors, Reform concludes that the cancer plan is based on an "outdated, traditional public-sector model" that relies predominately on public funding.
This traditional model is consistent with the principle of the state-run National Health Service (NHS) that medical care should be determined by medical need rather than the ability to payby state, not private funding. The more contemporary philosophy that encourages publicprivate partnerships has been shown to ease pressure on public fundingbut not, according to the Reform report, in cancer care.
"While other areas of health care are benefiting from greater pluralism, cancer services are in the era of a complete NHS monopoly within which cancer networks are promoting cartels to block out competition," the report states.
The authors of the report are two of Britain's best known oncologists, Karol Sikora, M.B.Chir., Ph.D., formerly chief of the World Health Organization Cancer Program, and Maurice Slevin, M.D., chairman of CancerBACUP, a prominent cancer information charity.
The report echoes concern from other organizations and individuals about the state of U.K. cancer care. It quotes a Royal College of Radiologists report that found "appalling delays in access to curative radiotherapy," with 72% of patients in 2003 being treated outside the "maximum acceptable delay" time of 4 weeks for patients due to receive radical radiotherapy with curative intent, compared with 32% in 1998. Many new machines, says the Reform report, are lying unopened in boxes because of staff shortages.
"Patients often have to wait 3 months, and some up to 6 months, because of a shortage of radiographers," the Reform report continues. "A study from Glasgow found that 21% of lung cancer patients became unsuitable for curative treatment during the long wait for radiotherapy."
But Mike Leahy, M.D., senior lecturer and honorary consultant in medical oncology at the Cancer Research U.K. Clinical Center at St. James University Hospital, Leeds, said that the report is using cancer services as political ammunition to attack the Labor Party government.
"While the report may have some support ..., I think most NHS doctors and nurses would not identify with it," Leahy added. "The shortfalls it highlights are undeniable, but these are neither due to a lack of commitment or investment. It is true that waiting lists for radiotherapy are scandalous and new equipment is not being used, but this is the result of staffing shortages that cannot be corrected in a matter of a few years."
Reform's attack against the development of new multidisciplinary cancer care teams has also generated vehement criticism. It complains that multidisciplinary meetings "take up many hours in the week which could otherwise be devoted to patient care." The new multidisciplinary approach includes large teams of up to 20 doctors, nurses, social workers, pharmacists, and dieticiansin addition to patients themselves.
The Reform allegations that the new cancer networks are promoting cartels to block out private competition and that 30% of diagnostics, radiotherapy, and chemotherapy should be handled by the private sector have provoked further protest. "I don't think there would be much support for fragmenting care by moving 30% into the private sector," Leahy said.
Mike Richards, M.D., England's first national cancer director and author of the National Cancer Plan, dismisses the Reform report as "very old and out of date."
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Survival data quoted by Reform comparing Europe and the United Kingdom were based on diagnoses between 1990 and 1994more than 5 years before the publication of the National Cancer Plan. "In fact, these data were one of the main drivers behind the development of a cancer plan," Richards said.
The Reform report, he added, also "ignored" the marked increase in use of new cancer drugs. Moreover, he said, improvements to the breast cancer screening program had resulted in detection rates increasing by almost 25% in the last 2 years.
An additional £50 million (about US $96 million) has been invested in specialist palliative care services, said Richards, and accrual to clinical trials had doubled since the formation of the National Cancer Research Institute, which was founded in 2001 to coordinate all research funded by government, charities, and industry and to promote greater collaboration across Europe. It aimed to double the number of patients recruited to trials within 3 years (see News, Vol. 93, No. 9, p. 670, "New Cancer Institute Sets Out to Coordinate, Promote Research").
Radiotherapy was a problem, Richards conceded, but he added: "The [Reform] report failed to acknowledge what is being done. Unprecedented numbers of linear accelerators have been installed over the past 5 years, replacing obsolete equipment and expanding capacity. The number of training places for therapy radiographers has been doubledand this should start to yield dividends from this summer onwards."
But Sikora and Slevin remain firmly committed to the idea that the private sector should provide cancer carethat the NHS should pay for. Slevin said that the NHS is overbureaucratic, weighed down by managers who wanted to "stop things happeningto save money." In contrast, he said, private-sector managers were driven by the idea of "making things happen."
This sentiment will strike a strong chord with many U.K. oncologistsand even the NAO acknowledges that there is room for improvement. "Cancer networks have achieved much, but there is much more to be done if they are all to become fully effective, including better planning, more coordinated commissioning of cancer services, proper resourcing, and effective cooperation between constituent organizations," Bourn said.
Forward planning was a particular concern. The NAO report gave an example of poor planning: "Networks were required to prepare 3-year delivery plans by 2001, underpinned by workforce, education, and training strategies. Three of the 10 networks we spoke to did not have a current delivery plan, and although at a national level workforce development was seen as a priority in the plan, by late 2003, only a third of the networks had produced a workforce strategy, and just over a third had developed an education and training strategy."
But Richards remains optimistic about the cancer plan. "I come into contact with a large number of cancer doctors, nurses, managers, patient groups and charitiesand they tell me that considerable progress is being made," he said.
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