President's Oration
By Dr David Kerr, NZMA President (speech delivered at NZMA AGM 6 May 2008)
The general theme that I wish to present today is that there currently exists a wonderful opportunity for those in power to make a significant contribution to the New Zealand health service.
I am talking here with respect to cancer care.
The funding of cancer care is a challenge for all countries but when we consider the New Zealand situation it is note worthy that statistics from several years ago show over 16,000 people in New Zealand develop cancer each year and by 2011 this number is expected to reach 22,000.
Also, over 7,500 New Zealanders were dying annually several years ago from
cancer and by 2011 that is expected to be in excess of 9,000 deaths per year.
Not surprisingly, when you study those statistics you will also see that Maori
and Pacific Islanders are markedly over represented as with so many other health
statistics.
You also see that 70% of cancer patients will occupy a hospital bed at some stage and that of all deaths in New Zealand 30% are now directly related to cancer.
Clearly the efforts that have been made already in managing this collection of diseases have been enormous and we have seen some improved survival rates.
Nevertheless the burden of this particular disease on our health services is obviously going to increase dramatically over the next few years and beyond.
My strong impression is that our Health Service is already stretched to near breaking point in terms of meeting its obligations to our patients and many would argue we are not even truly achieving their expectations at this time.
So how will we cope with this increase?
A start was made by the commissioning of the New Zealand Cancer Control
Strategy in 2003 and then in 2005 the Cancer Control Action Plan.
This Action Plan describes the objectives that are to be achieved by 2005 and
then by 2010.
With the development of the action plan the actions were divided in to those that would occur in the first 2 years by 2007 and the actions that would generally occur between 3 and 5 years, by 2010.
I need hardly remind you we are mid way through 2008.
In terms of the overall priorities for the early phase, they included
ensuring timely and acceptable access to cancer services by establishing
standards
developing a work force plan for cancer control and
developing a plan for capital expenditure on cancer control, including
equipment, drugs and new initiatives.
If we look at the individual goals of the strategy the first goal is to reduce the incidence of cancer through primary prevention.
This is clearly sensible and involves reducing tobacco related cancer, reducing cancers that are related to physical inactivity or to nutrition, and reducing cancers related to ultraviolet exposure and to infectious disease.
Great progress has been achieved with respect to tobacco related cancer for
both active and passive smokers.
Considerably less clarity exists around the achievements relating to cancers
consequent on nutrition and physical inactivity.
With respect to ultraviolet exposure it is interesting that effective
sunscreens for high risk patients are still not yet part of the prescription
list for general practitioners.
Agreed, there is no certainty that avoiding UV exposure will have a major effect
on the incidence of melanoma, but it would certainly seem prudent to avoid
excessive sun exposure, just as it is prudent to be aware of the familial
tendency that exists with melanoma.
Currently there is no funding for follow up skin assessments after the diagnosis
of melanoma or for familial screening after diagnosis of melanoma.
The situation with respect infectious diseases such as cervical cancer is also interesting as the strategies include promoting safe sex which is clearly prudent and there is also the rather optimistic prospect of delaying the onset of sexual activity.
There is also the commentary that there would be "monitoring and assessment
of the development of human papilloma virus screening and the potential benefits
of vaccination".
Some years down the track now and we have only just had the approval to start in
September an immunisation programme.
I suggest these benefits have been well known and yet only now do we get
approval for a programme that starts in September.
Also, as a General Practitioner, one wonders why is there no financial
support for those patients who attend for cervical cancer screening or follow up
of abnormal cancer smears?
It is interesting that the shining of x-rays is fully funded for mammography but
not the shining of light rays for cervical smear taking.
The second goal relates to ensuring effective screening and early detection of cancer.
Part of this is to ensure that culturally appropriate cancer screening
services exist including the assessment and surveillance of those with familial
risk.
In the action table we see reference to Breast Screen Aotearoa strategies but
little else apart from words such as "ensure effective processes for providing
high level strategic oversight of existing and potential cancer screening, and
of assessment and surveillance of those with familial risk".
Seems a bit like a series of "watching and waiting" words, rather than "doing" words.
I suggest that little progress has been achieved in terms of achieving this
goal except with respect breast cancer.
Even in the case of breast cancer I note that the US Preventive Services task
Force has been recommending for several years good access to genetic screening
for BRCA 1 or BRCA 2 after access to appropriate counselling.
In the general population approximately 2 % of women meet the criteria for this service.
I seriously doubt that this 2% of women are receiving this very important and quite sophisticated advice, and most women are actually unaware of the value it can confer.
Why are we not advertising the value of discussing your family history of
breast cancer with your General practitioner?
Interestingly, the same respected US taskforce also recommends that clinicians
screen men and women 50 years of age and over for colorectal cancer.
This is currently far from routine here in New Zealand and certainly not
resourced by any one other than the individual patient.
Progress with colorectal screening has been very poor, despite the fact that
many international groups have agreed the value and the specific processes that
should be undertaken.
There is now high quality evidence that screening with faecal occult blood
testing reduces the mortality from colorectal cancer.
Why then are we in New Zealand undertaking a feasibility study of colorectal
screening using faecal occult blood testing?
What could possibly be different about us New Zealanders?
Could this be in truth a deferral of real action?
Maybe the availability of screening is more related to the ability of the DHBs
to fund the screening, rather than reflecting the risk.
How acceptable is this?
The third goal refers to ensuring the presence of effective diagnosis and treatment to reduce morbidity and mortality.
Under this heading it is noted that in previous years (prior to 2005) the
increased resources devoted to cancer treatment had not matched the increase in
demand… leading to undesirable and distressing delays in treatment.
It is also noted at that time that our overall cancer survival might be inferior
to that of Australia and that our current treatment outcomes could be worsening
in comparison to similar societies.
Recent commentators have suggested that there are up to 800 excess deaths
annually in New Zealand compared to the outcomes achieved by Australia.
Despite these observations the Action Plan actions in the short term, to be
completed by 2007, included
seeing that waiting times were monitored and reported,
seeing that referral guidelines were available, and
seeing that a plan for the provision of diagnostic and treatment services was
developed.
Again, these would appear to be “watching and waiting” type words.
During those 2 years between 2005 to 2007, while these particular actions were being achieved, we must not lose sight of the fact that 15,000 New Zealanders died of cancer.
A further component of the action plan under this third goal relates to the
introduction of effective processes for the assessment and prompt introduction
of proven new pharmaceutical cancer treatments.
This was a goal to be achieved between 2007 and 2010.
Clearly a significant proportion of the concerns that surround cancer
treatment relate to the high cost of cancer drug treatments. But it must not be
forgotten that there are other costs incurred with the use of these agents apart
from the pure pharmaceutical costs.
The administration of these pharmaceutical agents will often require significant
medical work force input as well as hospital services and hospital beds.
The cancer drug treatments that are currently being developed tend to reflect the tailored approach that the pharmaceutical industry is taking to particular types of cancers and the understandable consequence of this approach is that the drugs fit in to what could be deemed the “high cost – low volume” category.
There is no reliable way of determining of what should be the cost effectiveness threshold for these drugs but New Zealand, like similar countries, has used for some time cost utility analysis and the calculation of a cost per quality life year gained.
This tends to be the international metric that is applied when considering
the newer high cost pharmaceuticals.
So, in effect the measure is available, and has routinely been part of the
assessment undertaken by Pharmac but I am not aware of any progress being made
in New Zealand with respect clarifying what the actual cost per quality adjusted
life year gained should be the actual threshold for utilisation.
All of this has been of concern to many within the profession.
However, I was moved to make these observations when reading the recent Med
Speak newsletter.
In it I see a commentary on our profession’s repeated and enduring involvement
in the work force debate.
We have been advising of the looming crisis for over 10 years and precious
little has been done in response. Each month there is yet another article in the
lay press expressing surprise at our very significant work force issues.
As you all well know, we have had various tasks forces and plans but no sign of
any commitment to truly addressing the challenges that have been so clearly
enunciated.
Work force issues are inextricably entwined with the health sectors ability
to deliver on such worthy aspirations as the Cancer Control Strategy and the
Cancer Control Action plan.
I am aware that there is talk again of Canterbury needing to send patients to
Australia for radiotherapy, and most will be well aware of the difficulties that
have existed in Wellington with respect providing a Cancer Service for young
people. In short, they cannot, because of workforce shortages.
It has also been observed that the breast cancer workforce is under immense
pressure with the recent extension of the age groups for the Breast Screen
Aotearoa programme.
In other countries the shortages have been openly acknowledged, and it is certainly interesting that Australia has seen fit to double the number of it’s medical trainees in recent years. This is of course despite many commentators suggesting that the grass is already greener for medical professionals in Australia compared to here in New Zealand.
So my point, put simply, is this.
At this time there exists, and even more so during an election year, a
wonderful opportunity for our representatives in parliament to
grasp the challenge of cancer care in New Zealand now, and
and to truly make a difference for those 22,000 people who will get cancer in
2011 and for those 9,000 New Zealanders who will succumb to the disease in that
year.
The time for action and resourcing is now if we are to make a difference over
the next few years.
Let’s not have the indecision and lack of action we have seen with Workforce
management over the last decade.
We have a plan, a good plan, and what we need is now is commitment and adequate
resourcing.