CANCER CARE

Published: 03/02/2005, Volume II4, No. 5941 Page 14 15

Despite huge investment in cancer services and the disease being one of the government's top three health priorities, a report by the public accounts committee makes depressing reading for ministers. But how fair are MPs' claims that the promised improvements haven't been delivered? Alison Moore reports

Reducing health inequalities has been one of the foundation stones of Labour's health policy. And improving cancer services is a major priority in achieving this.

So the government must have been doubly disappointed when a report from the public accounts committee last week, Tackling Cancer in England: saving more lives, came to the bleak conclusion that there are still 'clear and unacceptable inequalities in outcome'.

Put more bluntly, if you live in Manchester you are nearly twice as likely to die from cancer as you are if you live in Kensington, Chelsea or Westminster. Deprived areas - many of which are in the North - tend to have higher mortality rates than affluent areas, leading to headlines about the 'North-South divide'.

Labour can justifiably claim that there was little it could have done to influence mortality rates in 19982000, which are cited in the report, given that it was elected in 1997.

But potentially more damaging is the identification of continuing problems which the government has been committed to eliminating.

Eight years into Labour's reign, 'postcode prescribing' still exists and some conditions are still being treated by teams without sufficient expertise. Prostatectomies, for example, should ideally be managed by teams seeing 50 or more cases a year, according to guidance from the National Institute for Clinical Excellence. But only 12 out of 133 trusts doing them see that number.

While there has been great investment in cancer services and more equipment, some patients still face unacceptable waits for treatment and diagnostic tests once they have been referred. Waits for radiotherapy often exceed recommended safe limits.

The report also points to gaps in our knowledge of what happens to patients with cancer and what preventative or educational methods are successful. Smoking-cessation schemes, for example, have widely varying levels of success in persuading people to give up smoking: but on average two-thirds of 'stoppers' will go back to smoking within a year.

Cancer services managers point to enormous improvements taking place, but concede they will take time to show in top-line figures such as five-year survival rates.

'The whole cancer agenda is predicated on us being more consistent across the country, ' says Susan Gibbin, interim executive director of Kent and Medway cancer network. 'All networks will be working to that, but whether it actually tackles the inherent population difficulties I do not know.

Hopefully, it will tackle the issue of getting fair treatment.' So why are there still variations in service - such as patients in some areas having limited access to modern and expensive cancer drugs? The PAC report specifically highlights Herceptin, a drug used in breast cancer which can cost£6,000 for a 12-week course.

June Tulley, director of cancer service development for the Teesside, South Durham and North Yorkshire Cancer Network, says: 'There was a big push from the centre to ensure there was equity right across England. There will be little blips nationally, but people have been working hard to make sure they do it. The whole purpose of cancer networks is to prevent that sort of inequality.' But a review carried out last year for national cancer director Professor Mike Richards showed variations in use of many cancer drugs which had been assessed by NICE - and some evidence that certain cancer networks had a higher usage than others across a range of drugs.

The review also suggested that issues such as capacity to deliver chemotherapy and doctors' prescribing habits were the causes of these variations, rather than funding per se.

Cancer Bacup chief executive Joanna Rule says the organisation's research backs this up: funding is no longer seen as the main barrier.

'When we did a survey a year ago we found 14 per cent of women in the Midlands who could benefit from Herceptin were getting it and 61 per cent in the South West.

'I think the funding around NICE guidance is a factor, but the evidence does suggest that just to say it is a funding issue is not true. There are capacity issues, clinician issues and so on.' She would like to see the Healthcare Commission monitoring implementation of NICE guidance by trusts, and publishing the results.

The commission is already looking at whether trusts are following NICE guidelines for drugs and surgery in its core standards for the new performance rating system.

It is also bringing in national improvement reviews to look at particular healthcare areas where there are problems - but there are none on cancer currently planned.

A Healthcare Commission spokesperson adds: 'NICE guidance is very important. Trusts need to weigh the guidance alongside local conditions to determine what to do.' NICE itself has strengthened its implementation team and is offering increased assistance to NHS bodies in adopting its guidelines. It is developing local costing spreadsheets, templates for care protocols and suggestions on local implementation strategies.

Its research suggests that although some of its recommendations are underimplemented, others are 'bang on' and some are even overimplemented, says a spokeswoman.

In some areas, risk-sharing between primary care trusts is being used to deal with expensive drugs which could blow apart prescribing budgets.

PCTs in Kent assess the likely cost of such drugs and share it per capita regardless of where patients live. 'It has been a very effective way of getting the PCTs to eradicate postcode prescribing for oncology, ' says Ms Gibbin.

But can a devolved system of 300 PCTs, each commissioning their own cancer services, result in an optimal service pattern? Ms Rule argues it can't in all cases. While surgery for some major cancers has been appropriately concentrated, the PAC report showed this was not the case for all cancers.

'Some of the money should be fast-tracked through cancer networks, ' she says. 'It is the big picture guidance which will not be picked up by very local commissioning.' Improving the referral patterns of GPs so that fewer patients who turn out to have cancer are dealt with as 'non-urgents' is another priority.

Last year the all-party parliamentary group on cancer warned that the two-week target for urgent referrals was 'causing a delay elsewhere in the system and creating a divide between urgent and non-urgent referrals which is not always justified by the subsequent diagnosis' (Meeting national targets: setting local priorities, October 2004).

Guidance on GP referral is expected from NICE in the spring and local initiatives are underway - such as conferences between cancer specialists and GPs and an audit of non-urgent pathways being carried out in Kent.

Unfortunately, there are signs that cancer incidence will continue to increase over the next few decades - putting additional strain on hospital services and soaking up some of the extra capacity.

Lung cancer can take years to develop and reduced smoking rates now, however desirable, will not have much effect on cancer incidence for many years.

Increased smoking rates among women from several decades ago is still feeding through in terms of lung cancers.

Smoking patterns alone can explain some of the regional variations in cancer incidence. In the Greater Manchester and Cheshire cancer network area, smoking is thought to be a major factor in the substantially higher than average incidence of several cancers - lung, larynx, lip and pharynx.

An ageing population nationally also means that many cancers which are age related will become more prevalent.

And redesigning services and increasing capacity looks easy compared with influencing some of the causes of cancer, especially those linked to deprivation or social class.

Not only are some common cancers more common in deprived areas, they are more likely to lead to the patient's death. Patients from more deprived areas are less likely to receive radical treatments, although the reasons for this are unclear.

Ms Rule points out that cancer has a high public profile and there is widespread support for improvements, including in preventative services. 'The inequalities are going to last a long time because they are complex and we have not teased out all of the factors, ' she says.

Education aimed at lifestyle changes and getting people to present earlier with suspicious symptoms will also require changes in attitude and knowledge.

'We are not getting into schools and colleges early enough, ' says Ms Tulley. 'Everyone in the North East is working hard on the awareness campaign, but we are talking about 30, 40, 50 years down the line to see the full effects.' Ms Gibbin points to work being done by community development teams on some of the estates in Kent which may ultimately empower local people to be more challenging and demanding of bodies such as the NHS or local authorities.

Kent and Medway cancer network has won awards for its patient information leaflets, but like most patient information campaigns and services they are aimed at those who are newly diagnosed, she points out.

Getting through to people who may be ignoring a cancer symptom is a greater challenge.

WHAT THE PUBLIC ACCOUNTS COMMITTEE IS CALLING FOR

The Department of Health should publicise simple guidelines to help people spot symptoms of major cancers.

More work to identify areas where cancers are found at later stages and work out why.

Help for GPs in identifying symptomatic patients and quicker treatment for patients with urgent referrals.

Patients and the public should be given more information to help them press for better cancer services.

A deadline for the end of wide variations in cancer drug prescribing, and NICE recommendations should have a timetable.

PCTs should use their commissioning powers to concentrate cancer surgery in hospitals with a high volume of such cases.

Research into the impact and effectiveness of smoking-cessation services.

The government should set a timescale to ensure equality of provision, bearing in mind the current unequal distribution of specialist staff.

www. publications.parliament. uk/pa/cm/ cmpubacc. htm