The plan to centralise cancer services in eight facilities around the State has met a mixed reaction, writes Theresa Judge.
Leading cancer expert Prof Niall O'Higgins has warned that adequate resources must be provided if a plan unveiled last week to centralise cancer services in eight hospitals is to work.
He says "nobody should be under any illusion but that the programme will be very expensive" - in terms of buildings, new equipment and "a lot of medical expertise".
However, a senior HSE manager who drew up the implementation plan, Tony O'Brien, says "much of the cost will not be new cost" as the programme is "not about creating an enormous amount of new capacity, but of providing capacity in different places".
Additional money will have to be provided "to handle the transition", he says, but in the long term, investment in cancer care will be "more strategic".
It is now seven years since O'Higgins and a team of specialists drew up a report recommending that smaller breast cancer units be closed. This week he welcomes the fact that eight hospitals have been designated, saying there is no doubt that patient care will improve.
He also welcomes the appointment of Prof Tom Keane who will take charge of implementing the national cancer control programme over the next two years as cancer services are transferred from some 30 hospitals to eight specialist centres, in addition to an outreach service in Letterkenny. Thirteen smaller units are to close immediately.
O'Higgins says "everybody should support and get behind" Keane, who is taking a two-year secondment from his post with the British Columbia Cancer Agency. While there was a broad welcome for the plan unveiled last Wednesday from organisations such as the Irish Cancer Society and the Irish Nurses Organisation - because of the widely accepted view that patient outcomes are better in specialist centres - concerns have been expressed about the long journeys some rural patients will face.
Four of the eight designated centres are in Dublin (Beaumont, the Mater, St James's and St Vincent's) with the other four in Cork, Waterford, Limerick and Galway. A multidisciplinary team will work in each centre deciding on the best treatment for each patient.
Surgery and radiotherapy will take place in the specialist centres but some chemotherapy will be provided in smaller, local hospitals. Breast and bowel cancer will be treated at all eight centres but less common cancers will be treated at specific centres to be decided in the new year.
O'Higgins says the issue of resources for the eight designated cancer centres is crucial. "It would be a travesty of good care to close down places and not build up the eight centres - they must be built up and developed with all speed.
"It would be extraordinarily unfair to ask a person to move from service A to service B if service B is not as good as it should be - if it is not excellent - so a lot of work is needed to develop that excellence," O'Higgins says.
"It is a huge programme and we are just at the starting point - we now have a mountain to climb," he says, adding that the designation of the eight centres is just "the end of the beginning" and that there has been "an inordinate delay" in designating these.
O'Brien stresses that services at the specialist centres will not suffer from having the additional patients.
He says it is "essential" both for quality control and for the "credibility of the process" that no change will be made "that cannot be sustained by the receiving centre". He says the transfer of services will be done "in a carefully planned way" with some 60 per cent of the programme implemented by the end of 2008 and 90 per cent by the end of 2009.
In 2005 there were 32 centres providing cancer services, he says. Of the 13 centres to close immediately, the highest caseload is about 20 new patients a year, so the closure of these will not have a "dramatic impact". With the remaining centres, where the caseload is up to 50 new patients a year, the transfer will be "progressive and managed", O'Brien says.
"The pace will be governed by the ability of the bigger centres to accommodate the workload," he adds.
The eight hospitals designated as cancer centres will, in the future, "place a higher priority on cancer cases" and "dispose of some non-cancer work". O'Brien says he can not at this stage give examples of services that might move from the eight cancer hospitals to hospitals which are having cancer services closed.
He says that while the process is "not about creating an enormous amount of new capacity" there will be "significant change" within each of the eight cancer centres.
He acknowledges that there will be a greater demand on services as the population grows and ages, but says there will be "better use of resources".
The question of adequate resources for the specialist centres and transport provision are two of the key issues that will determine the success of the plan, according to others.
The chief executive of the Irish Cancer Society, John McCormack, says the eight centres will have to insist on getting the resources they need. He agrees that in the past there were examples of smaller units closing and larger centres not getting the necessary resources to meet the increased demand.
This occurred, he says, when the mammography unit in Ennis closed but Limerick regional hospital did not get a corresponding increase in staff.
The provision of transport will be crucial, McCormack says, particularly as 50 per cent of people with cancer are aged over 65.
"The plan will simply not work unless transport is provided because people simply won't be able to travel," he says.
On this question of providing transport, O'Brien says the HSE is currently conducting a review of transport services and that the needs of cancer patients and the new designation of cancer centres will be taken into account.
One of the most critical of the plan is the Irish Medical Organisation (IMO), which criticises the closure of 13 units "ahead of the introduction of phantom facilities not due to be completed until 2011".
IMO president Paula Gilvarry says that "given the HSE's track record to date, these facilities will probably be delayed for a further two to three years, adding further severe stress and unconscionable concern to patients and their families".
She also says it is unacceptable that the HSE has failed to recognise the further trauma patients face by having to travel long distances "with no transport arrangements in place". Cancer patients in Co Donegal will continue to face the longest journeys for surgery and radiotherapy, to either Galway or Belfast.
However, patient groups, which have run high-profile campaigns for better cancer services over recent years, are determined to keep pressing for a radiotherapy service in either Letterkenny or Donegal.
It is pointed out that the requisite 500,000 population for a specialist cancer centre exists in the northwestern section of the island. "You can't ignore half a million people and say you are going to have to travel because there is a border there," says Noelle Duddy, of Co-operating for Cancer Care Northwest.
The group is planning further meetings with authorities on both sides of the Border to press for a radiotherapy service.
She stresses, however, that she welcomes the plan unveiled last week because Letterkenny is to retain its services, as an outreach service from Galway. Donegal's "unique position" due to geographical location has been recognised, she says.
If it's any consolation to people in Donegal, Keane, who is to implement this plan, pointed out at a press conference last Wednesday that there are just four cancer centres in British Columbia, which is the size of France and Germany combined.
"Patients actually understand that they have to travel," he says.
What is being established in Ireland now "is standard in most countries that have well-developed cancer programmes", he says, as "a critical mass of specialists" is needed to provide the necessary expertise. He believes most Irish people understand why change is necessary.
"There will never be 100 per cent of people who will buy into any idea, but certainly I think most Irish people would understand that if you had cancer and you have an opportunity to get a 20 per cent better chance of survival by having your treatment in a hospital remote from your home, I believe virtually every Irish person would choose to do so," says Keane, who takes up his new post in November.