I thank the Chairman and members of the committee for the opportunity at least to begin to communicate my vision for a cancer control programme for Ireland.
I have provided a background document for members of the committee. I did not feel it would be useful for me to read its contents into the record. Essentially, it outlines the goals and objectives I have set for the two-year period in which I will be in situ. I have lived in British Columbia, Canada, for the duration of my career in oncology. I have maintained strong links with Ireland. My wife and I are the only members of our respective families who live outside Ireland and we have made more than 60 trips here in the past 35 years. I have a great deal of contact with the medical community here.
Many people have asked me why I took on this task, particularly as some of my colleagues view it as a poisoned chalice. The cancer strategy announced in 2006 was circulated to us in British Columbia and we were asked to provide an opinion as to whether it was sound and whether it contained any deficiencies. In the past, we were asked to examine similar strategy documents from other jurisdictions. We found the Irish strategy to be excellent. It clearly reflects the considerable work and consultation carried out, not just within the Irish community but internationally. It is a very good strategy surrounded by an excellent body of work based on international best practice.
Princess Margaret Hospital in Toronto is probably one of the five leading cancer institutes in the world. Its work is primarily focused on cancer treatment and research. I was involved in the major redesign of how care services in Toronto are delivered. Having completed that work, I shortly thereafter took up the chair of the university department in British Columbia and the leadership position, to which the Chairman referred, at the British Columbia Cancer Agency.
The BC Cancer Agency is different to Ontario's in that it was mandated by legislation in the 1930s. That far-seeing legislation gave the Cancer Control Agency of British Columbia, as it was called then, the mandate for cancer control for the population of British Columbia. It has an enviable record; it had the first organised cervical screening programme in the world some 50 years ago and it has had breast screening for more than 20 years. It has been a leader in cancer control on a population basis. As distinct from the way cancer services are organised in many jurisdictions, it is a cancer control organisation. Having not worked in such an organisation previously, I make the distinction. It is responsible for the entire population, namely, the people who do not have cancer, those who are at risk of getting cancer, those with cancer, those who have been treated and those who require ongoing care. It addresses a population's need and integrates all of the components of cancer care, including research, in a single agency.
The agreement of the Government and the HSE to form a separate business unit to execute the strategy was attractive. I was completing my tenure as a professor and leader in the BC Cancer Agency when I was approached and asked whether I would consider taking this position for a two-year period. I told the BC Cancer Agency that I really wanted to do it because there was significant potential for the strategy to be implemented in Ireland and I could bring something back to my home country as a result of the experience I had gleaned abroad. The agency seconded me generously for a two-year period and told me that I must return on 30 November 2009. The university has given me a leave of absence from my professorial position.
My vision for Ireland is reflective of my experience in British Columbia. The goals of the cancer strategy are threefold. The first is to reduce cancer incidence, which is high in respect of a number of cancers on an age-adjusted basis. Ireland has a relatively young population and the real incidence of cancer will grow as the population ages. By 2020, the incidence of cancer will reflect the fact that we have an older population. British Columbia has a similar population to Ireland, but it has approximately 6,000 more cancer cases because it has a relatively old population and cancer is a disease primarily of people beyond the age of 60 years. As people live longer, there will be a higher cancer incidence.
The first goal of any cancer control programme is to reduce cancer incidence. It is a broad strategy concerning cancer prevention and healthy lifestyles. I will not dwell at great length on this point, but it extends way beyond cancer. In the Canadian system, British Columbia has the lowest incidence of cancer in respect of many cancers and a considerably lower incidence than Ireland on an age-adjusted basis. Much of this reflects healthy lifestyles rather than any particular intervention at a population level.
The second obvious goal of a cancer control programme is to reduce cancer mortality and the morbidity inflicted on those unfortunate enough to suffer from cancer. While there has been significant improvement in the past decade as a result of the first cancer strategy, there is some considerable road to travel to be in the upper 25% of European nations in terms of cancer mortality.
The final goal is to improve the quality of life of people living with cancer, a significant issue in respect of many of the cancers that are similar to chronic diseases. It is not uncommon for people with breast or prostate cancer in particular to live with the disease for five years to ten years if they are not cured. Managing the quality of their lives and making decisions based on that is a very important objective. In terms of the vision for Ireland, they are the three big goals.
Obviously, we must look at where we are starting from. On the positive side, Ireland is lucky to have a huge cadre of very well-trained oncologists, clinicians, nurses, technicians and therapists skilled in oncology. Nearly all the oncologists I have met in Ireland have been trained in some of the best centres in the world and have come back here to practise. There is no deficiency of knowledge or skill in Ireland, which is a huge advantage. Many other countries would love to have access to the level of cancer expertise that exists in Ireland. That is the big plus.
The contrast with the experience in British Columbia in Canada is that cancer care is not an organised system in Ireland. Perhaps I should not use the word "disorganised" but it is certainly not organised. It is fragmented; there is significant duplication of services and essentially resources are stretched in many areas because of the failure to concentrate resources to provide the critical mass needed to provide effective cancer services. That is not unique to Ireland but the lesson from the Canadian experience is that concentrating resources and building critical mass of expertise are essential if we are to produce the sort of results in cancer control that are needed.
There are significant issues relating to the patient journey, all of which have been addressed in the cancer strategy. The patient journey from presentation to the family physician to diagnosis to treatment is very long. The longest interval is from presentation with symptoms to diagnoses. This is the same in nearly every country. This is vital time that is lost. Clearly, to address this, one needs a system that is accessible and where both patients and general practitioners are highly aware of the risk profiles for cancer so that patients with cancer can be diagnosed as early as possible. It is still a truth that despite all the improvements in technology, chemotherapy, surgery and radiotherapy, early diagnosis underpins all cancer strategy. One can address that through a cancer strategy but there are many facets that need to be addressed.
There are a number of issues that limit and cause hardship in the patient's journey and which relate to the lack of integration across the system. There is no single medical record in Ireland. Patients have medical records at the local hospital and records throughout the system but it is not possible for a patient to go into a cancer centre in Cork and have his or her cancer record from a hospital in Dublin available to them. This creates endless duplication and considerable delay and leads to tests being repeated because the previous results cannot be found, all things I am sure the committee is well aware of.
We have an excellent cancer registry in Cork led by Dr. Harry Comber which does a very good job. However, I was quite surprised to realise that the reporting of the diagnosis of cancer is not mandatory in Ireland. It is something that I wish to bring forward for the attention of the Minister. Nearly every major country has mandatory reporting of cancer diagnosis. It is currently voluntary and is fairly successful but is not 100%. More importantly, there is a paucity of information on cancer outcomes in Ireland. The clinical audit mechanisms, the identification of short-term surrogates for outcome and the feedback of that information so that people can learn from the results being achieved, is a fundamental part of any cancer control system. In many situations in Ireland the clinicians are flying blind, as is the system. There needs to be a significant investment in the turnaround of information so that one knows how one is doing.
The strategy is challenging and will challenge the Irish system to make major changes. Members are aware of this and I see managing change as a major part of my job. I will not minimise the amount of change required at all levels, how institutions manage cancer, how clinicians are integrated into the cancer process and to build a system that is connected, so that we address the current fragmentation.
My desk has a pile of requests from a variety of people across the country seeking to alert me to their need for greater resources. In every case, bar one or two, the request had no supporting information such as a business case or supporting data. It is clear that this information is not available to people. It is difficult to adjudicate on requests for resources unless benchmarks have been established on how resources should be distributed. There has been comment in the media about adding money and resources to the system. Some resources will be required but mobilising the existing resources is the most important part of the strategy. Resources are there but are widely distributed and there is widespread duplication, of which many committee members are aware.
There is an expectation that every initiative, such as a reorganisation of cancer surgery or a reorganisation at any level, requires an injection of new resources. My experience in British Columbia was that the history of the redesign of cancer services was precipitated by a major economic recession in 1997. It was a wealthy province but became a province requiring federal support in 1997. The Government challenged the health care system by saying there would be no additional funding for five years. The system was challenged to find a way to mobilise resources to provide a better service with the existing funding. This was thought to be impossible two or three years previously. As long as money was flowing, the reaction of throwing money at the problem has been shown not to solve the problem. I am a firm believer in that, having seen what happened in Princess Margaret Hospital, Toronto and in British Columbia. I will strive to identify where resources are and how they could be better spent. Practices that do not contribute to better cancer outcomes, but that are embedded in the system, will have to change.
Many of these are physician driven and I hope to engage the clinical and oncology community and leaders to examine how oncology is practised compared with other jurisdictions in terms of effective use of people's time and service to patients.
I will provide an example. There is a widespread belief - it is also a practice - that patients with cancer need to be followed by their oncologists. Patients, even though they have been cured, are sometimes followed for up to 20 years. Under the current system, patients return to see either their original consultant or a registrar and, even though the evidence indicates that they have been cured, they are given an appointment to come back again a year later. Under the system in British Columbia, patients are brought back for follow-up interventions at cancer centres only if there is demonstrable evidence that such interventions are likely to improve their chances of survival. There is significant literature to the effect that routine follow-ups in respect of cancer patients, which involve the deployment of a huge level of resources, represent money poorly spent and that they do not produce better cancer outcomes.
I use this example to highlight the fact that one could have a clinic where there might be four new patients and 40 follow-up patients. In such circumstances, one might not be able to provide new patients with appointments. A clinic of this sort could probably deal with eight new patients and 15 follow-up patients, who would really benefit from access to follow-up interventions.
There will be a need to change certain practices in Ireland. I will be obliged to convince the people who control those practices, which, as in Canada, are deeply embedded and traditional. In British Columbia 20 years ago, we followed everybody for ever until someone asked whether this was achieving anything. For many patients, this type of behaviour creates a dependency and a concern that if we are bringing them back to be seen, we must somehow believe they are at risk of getting cancer again. This is despite the fact that we know the disease will not return or the risk is small.
I see change on a very large scale being an integral part of what I will do. Two years is a very short period in which to take on a task of this magnitude. My goal is to get the fundamental elements of a cancer control programme in place and assist in the recruitment of a permanent director who can carry the job on after I leave.