Published: 16/06/2005, Volume II5, No. 5960 Page 19
In February, the Department of Health formally announced that two new cancer targets would be introduced from December.
These targets would be incorporated into Healthcare Commission ratings for 2005-06, although data would only be included from the end of the last financial quarter. The targets specify that there should be a maximum 62day wait for all cancers from urgent GP referral to first definitive treatment and a maximum 31-day wait from the decision to treat to first definitive treatment.
While I think we all agree that faster treatment for patients with suspected or known cancer is a good thing, I am not so sure these targets are the best way of ensuring it. We may be in danger again of hitting a target but missing the point.
This would be a tremendous shame as early indications show that our current endeavours are making a real difference to treatment and outcome results alike. It is, however, perhaps further evidence that targets set from the centre may cause significant operational problems for clinicians, patients and managers.
First, let me make clear what is good about the targets. They are stretching and encourage trusts to do at least four things differently. For the first time, they will be expected to have a clear and explicit personal treatment plan for each patient diagnosed with cancer.
Once a plan has been agreed (in itself this poses interesting questions for multi-disciplinary team meetings), systematic tracking of patient progress will be needed.
Second, new targets will call for investment in areas that have been ignored by 'monitored waiting times' stipulations, such as imaging and pathology.
Third, trusts will need to do a lot of operational clinical process re-engineering.
Fourth, a substantial amount of process control and pathway remodelling across, and within, cancer networks will also be required.
This is no doubt why the targets have been set. Arguably, they pose an even greater challenge than the 98 per cent accident and emergency target that has stretched even the most able trusts financially and logistically.
My concerns can almost be mirrored against the benefits.
First, because of the lack of software sophisticated enough to track patients and their treatment, a new army of administrators and co-ordinators will need to be created to chronicle, log, monitor and track decisions taken by clinicians at the multi-disciplinary team meetings. For large cancer centres that have to track approximately 520 cancers per quarter, this will be a significant cost - naturally, this will not be reflected in payment by results.
Second, extra investment in diagnostic facilities is welcome but, arguably, unaffordable. The financial position of many trusts is worrying and there will be further debate within trusts about the opportunity cost of additional investment at a time when a£1bn contract for the private sector has been advertised by the Department of Health.
While imaging bottlenecks may have been over-emphasised in parts of England, interesting clinical governance issues will arise as suspected cancers are reported from the independent sector back to the NHS.
Given the recent furore surrounding private sector MRI scans, what level of criticism is the DoH prepared for as suspected cancers or non-cancer work (which is more likely as routine cases get further de-prioritised) are dealt with by the private sector? Will NHS consultants work for these independent firms, and what is the legal position of NHS employers if their staff start actively working for organisations that can now be considered legitimate competitors?
Third, good teamwork within and between trusts, will become even more important. Large cancer centres will start to become accountable for the performance of clinical and managerial colleagues in other trusts and cancer units (and vice versa).
In other words, cancer centres will inherit patient cases that have been initiated in other trusts.
In my own organisation, we have modelled seven different scenarios that illustrate that it is possible to achieve one of the two cancer targets without actually achieving the other part of the new standard.
Hypothetically, a patient could be referred by a GP to a consultant at a local district general hospital who suspects prostate cancer. A clinic appointment is arranged for day 10 (52 days remaining) where further investigations are requested.
These prove inconclusive and on day 45 (17 days remaining) the patient is referred to a cancer centre for a second opinion. A treatment plan is agreed, but cannot be begun for another three weeks (day 66). In this instance, the receiving trust has easily met its 31-day target but narrowly failed on the inherited 62day one.
The permutations on success and failure for the 31 and 62-day targets vary depending on the referral route to cancer units and centres.
But trusts will take a dim view on process control in other parts of the cancer network if it affects their Healthcare Commission rating.
Setting a rating at individual trust level is absurd if the objective is to assess the performance of pathway collaboration in a cancer network. It can only act as a catalyst for argument, incrimination and confusion.
More importantly, the name and shame culture will reappear and trusts will wonder why they are tracking individual parts of individual treatment plans.
It is important that we see where - and why - performance is hindered. I hope those that have power to establish national targets take a more considered and mature view of what we are all trying to achieve - process improvement for patient benefit at optimal cost and outcome.
Mark Britnell is chief executive of University Hospital Birmingham foundation trust.