NORTHERN IRELAND FORUM

FOR

POLITICAL DIALOGUE

_____________________

INVESTIGATION INTO

CANCER CARE

IN NORTHERN IRELAND

by

STANDING COMMITTEE C

HEALTH ISSUES

7 February 1997

CR6

ACKNOWLEDGEMENT

The Committee wishes to express its sincere thanks to all of the

individuals who gave evidence or contributed in any other way to its

investigation into Cancer Care.

The willing help offered by all concerned and their enthusiasm is

testimony to the dedication and commitment of both voluntary and

statutory sectors in this most laudable common cause.

CONTENTS

PAGE

1. INTRODUCTION 1

Background 1

Reasons for Increase in Cancer Levels 2

Initiatives on Cancer 3

Brief Summary of Present Position 4

Oncology 5

World Health Organisation Model 5

2. METHOD OF APPROACH 6

3. THE EVIDENCE 7

Health Promotion 7

Northern Ireland Cancer Registry 8

Voluntary Organisations 8

Palliative Care and the Hospice Movement 10

Belvoir Park and the Regional Centre 11

4. THE ISSUES 12

The Campbell Report: I 12

Radiotherapy 13

Environment 13

City Hospital 14

The Campbell Report: II 15

Some Further Notes of Caution 16

Concerns about Belvoir Park 17

5. SUMMARY OF KEY RECOMMENDATIONS 19

Recommendations from 'Cautionary' Section 20

Recommendations relating to Concerns about

Belvoir Park 21

APPENDICES

Appendix A Principles and Recommendations of

Calman/Hine Report

Appendix B Recommendations of Campbell Report

Appendix C European Code Against Cancer

Appendix D Committee Membership

Appendix E Committee Remit

Appendix F Compendium of Oral Evidence

1.0 INTRODUCTION

1.1 Background

The Health Committee (Committee C) of the Northern Ireland Forum for

Political Dialogue carried out an inquiry into the future of cancer care in

Northern Ireland between 3 October 1996 and 16 January 1997. The

background to the inquiry and its raison d'être will become evident in the

following paragraphs.

1.2 Black's Medical Dictionary defines cancer as:

"...... the general term used to refer to a malignant tumour, irrespective of

the tissue of origin. 'Malignancy' indicates that

(i) the tumour is capable of progressive growth, unrestrained by the

capsule of the parent organ, and/or

(ii) capable of distant spread via lymphatics or the bloodstream resulting

in development of secondary deposits of tumour known as

'metastases'."

"Cancers are classified according to the type of cell from which they are

derived as well as the organ of origin."

"The behaviour of cancers and their response to therapy vary widely

depending on this classification as well as on numerous other factors

such as growth rate, differentiation in cell and characteristics and size at

the time of presentation. It is entirely wrong to see cancer as a single

disease entity with a universally poor prognosis."

1

1.3 The number of deaths due to cancer in Northern Ireland has steadily increased

since 1912 when formal records first became available. The average annual

increase is 1.4% and while cancer accounted for 5.6% of deaths in 1912 the

figure for 1995 shows a four-fold increase.

1.4 In 1995 cancer was responsible for the deaths of 3,491 people in Northern

Ireland (22.8%). (Source: Northern Ireland Cancer Registry). Its toll is

exceeded only by that of heart disease (31.4%).

1.5 Some 5% (20,700) of the province's total hospital admissions in 1995

(411,461) were for cancer (Source: Cancer Registry) and there can scarcely be

a family left untouched by the disease.

Reasons for Increase in Cancer Levels

1.6 There are many reasons for the increase in cancer within the Province. The

evidence given points broadly to the following summation:

(a) the population of Northern Ireland has grown over time;

(b) cancer rates increase with the age of a population and the Northern

Ireland population profile shows an increasing number of older people.

Deaths due to cancer rise rapidly after the age of 40, peaking in the

70-80 age group. Half of cancers occur in people over 70;

(c) cancer detection has improved due to advances in technique and in

diagnostic facilities;

(d) there is now a more accurate recording of the cause of death; and,

2

(e) there have been changes in exposure to risk factors, such as smoking

and diet.

3

Initiatives on Cancer

1.7 Following acceptance in Great Britain (England and Wales) of the report of the

Expert Advisory Group on Cancer, styled "A Policy Framework for

Commissioning Cancer Services", hereafter referred to as the Calman/Hine

Report, the Department of Health and Social Services in Northern Ireland

established a working group to consider the ramifications for the province. The

general principles and recommendations of Calman/Hine are summarised at

Appendix A. Calman/Hine itself is but the latest of a chain of initiatives on

cancer in the developed world begun as far back as 1973 with the American

'War on Cancer'.

1.8 The Northern Ireland working group was set up in July 1995 under the

chairmanship of Dr Henrietta Campbell, Chief Medical Officer, Department of

Health & Social Services, with a remit to report by 31 March 1996.

1.9 The report of the Northern Ireland working group was in fact published in May

1996 under the title "Cancer Services - Investing for the Future"; it is better

known as the Campbell Report. This report has met with acceptance at

Ministerial level and it is now in the process of implementation. The timeframe

for full implementation is likely to be lengthy and its extent and nature will be

governed up to a point by a process of option appraisal.

1.10 The remit of the Health Committee is a wide one (see Appendix E) and it was

felt that following the publication of the Campbell Report the time was now

opportune to look at cancer care as a matter of some priority.

1.11 A full summary of the recommendations in Campbell is reproduced as

Appendix B. Its principal recommendations however were given in evidence to

the Committee by Dr Campbell herself and are as follows:

4

(i) There should be a team approach to cancer care which should be

centred on the patient and the specialist team - surgeon, oncologist,

radiologist, pathologist, nurse counsellor etc;

(ii) the general practitioner and the public should know where the cancer

specialists are;

(iii) there should be one research-based cancer centre in Northern Ireland

which should provide for the treatment of cancers to a specialist degree -

this would be a 'centre of excellence';

(iv) there should be four cancer units looking after four discrete geographic

populations - one in each Board area looking after the main cancers

(breast, colo-rectal and lung);

(v) radiotherapy and chemotherapy should be relocated in an acute hospital

setting;

(vi) there is an overall requirement for more cancer specialists.

Brief Summary of Present Position

1.12 Currently cancer services in Northern Ireland are dispensed from all of the

province's acute hospitals and virtually all surgeons are involved to some extent

in cancer surgery. The Campbell Report shows that most surgeons operate

on fewer than 10 cancer cases per annum.

1.13 Cancer patients are often still cared for by general physicians or general

surgeons with no special interest in cancer. Early referral to the appropriate

clinician is essential in all cases and this has not always taken place.

5

1.14 The treatment of leukaemia and other diseases of the blood is well organised

by haematologists who have developed a clear system of referrals between the

periphery and the Belfast hospitals.

Oncology

1.15 Oncology is the branch of medicine which is concerned with the management

of cancer and other malignant diseases.

1.16 Belvoir Park Hospital is Northern Ireland's regional centre for oncological

services, providing most chemotherapy treatment and all radiotherapy

treatment within the Province. Oncologists from Belvoir Park also provide

out-patient clinics in most acute hospitals. There is considerable pressure on

consultant services as demand for this rises in the acute hospital setting and

much of the time of the oncologist is spent in transit. There are currently only 8

consultant clinical oncologists at Belvoir Park.

1.17 World Health Organisation Model

It is instructive to reflect at this stage on the World Health Organisation model

for cancer care which has three major phases. The first is curative, the second

is palliative and the last is simply the provision of a 'comfort zone'. The goal in

the first stage is to effect a cure but the reality for the majority is that this will not

be possible. Where life can be lengthened there is a move to the second or

palliative care stage. The conditions for a move to the final stage are obvious.

6

2. METHOD OF APPROACH

2.1 The Committee selected the topic of Cancer Care from a large number of

options open to it. It followed the usual procedure of its enquiries by taking the

evidence of expert or specialist witnesses. The Committee is fortunate in

having the benefit of professional medical expertise within its number and this,

combined with the wider experience within it, facilitated the taking of evidence

from a wide and appropriately representative constituency.

2.2 The Committee is satisfied that all of the key organisations either gave

evidence on behalf of themselves or had the case for their sector or

themselves put by others qualified to do so.

2.3 The Committee itself has a diverse make-up, and proceeded, on the basis of

consensus, to consider the evidence given to it. This report represents the

result of that consensus.

2.4 The structure of the report beyond this point consists of three main sections

covering The Evidence; The Issues; and the Recommendations in summary

form that arise from the earlier sections.

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3. THE EVIDENCE

Health Promotion

3.1 Evidence was given to the Committee on 28 November 1996 by the Health

Promotion Agency. This was of a general nature and may to some degree

have relevance to the future work of the Committee.

3.2 We are concerned here however principally about Health Promotion as it

relates to cancer. Northern Ireland's performance in the field of health care is

amongst the worst in the western world. The Committee was, for example,

dismayed to learn that around 70,000 people had died as a result of disease

brought about by smoking since 1969. This statistic alone dwarfs the death toll

due to terrorism over the same period.

3.3 The Health Promotion Agency is described as an "independent, regionally

based organisation" whose role is "to initiate, develop and support health

promotion in Northern Ireland". Because of the major health problems in this

community a lot of the Agency's work is centred around the various high risk

factors and naturally the issue of cancer is close to the top of its agenda.

3.4 There is now a general awareness that most cancers (a figure of 80% has

been mentioned) are preventable or can be cured if detected and treated early

enough. It is therefore crucial that this message is conveyed in an effective way

to the public at large. An example of the general import of such a message

might be along the lines of what is contained in the European Code Against

Cancer (see Appendix C).

3.5 We were concerned to learn of the relatively small budget allocation of the

Health Promotion Agency and feel that more emphasis and resources should

8

be put into education and programmes that will change lifestyles and reduce

the various factors that are known to increase cancer.

9

Northern Ireland Cancer Registry

3.6 Evidence was given to the Committee on behalf of the Northern Ireland Cancer

Registry. This is an organisation whose purpose is to provide a "mechanism

for collecting and analysing information about cancer". The Registry is not

primarily a research organisation - it exists to provide information for people to

use in relation to decision-making or in research concerned with cancer.

3.7 Information is collected from a number of sources including the Office of the

Registrar General, screening programmes and regional laboratories which

examine specimens of malignant growths.

3.8 The Cancer Registry plays a vital part in identifying the patterns of disease in

our community thus aiding efforts at prevention. It is important that it is

adequately resourced. The prime responsibility for this must lie with

government. Much of the funding and initiative in the area of the Cancer

Registry in Northern Ireland has come from the voluntary sector and the Ulster

Cancer Foundation in particular is to be commended in this regard.

3.9 The Committee would wish to see that the valuable work of the Cancer Registry

is built upon with a far more detailed and formal documentation of cancer

patients. Linking present and previous postcodes, occupations, and other

significant data would help identify causes of cancer and greatly assist

prevention in the future. It would also help to resolve the anxieties felt by many

communities where it appears that there is a very high incidence of cancer. All

of this, we believe, could be done at minimal cost.

Voluntary Organisations

3.10 Northern Ireland is probably quite unique within Europe in having an

exceptionally strong voluntary sector. This is cross-community in nature and it

10

provides significant employment across the Province. Its work deserves great

credit.

3.11 This inquiry has taken evidence from a number of organisations within the

Voluntary Sector that are mainly concerned with specialist cancer service

provision and/or palliative care. These organisations included Action Cancer,

The Ulster Cancer Foundation, and a number of organisations from the

Hospice movement. This latter category is dealt with in the next section.

3.12 Voluntary Organisations, building on some of the evidence given by the Health

Promotion Agency, strongly advocated the extension of screening programmes

in a number of areas which have hitherto received little attention. Northern

Ireland has the highest incidence of breast cancer in the world and the present

screening effort goes some way to recognise this. There are official National

Health Service screening programmes but these need to be extended where

feasible. They noted the plans of Action Cancer to extend screening into the

area of men's cancers and strengthen their counselling provision. All of this

will be achieved without one penny of public funding.

3.13 The Ulster Cancer Foundation has recently conducted a survey of women who

had suffered from breast cancer. The results of this point up a need for people

to be able to unburden themselves of psycho-social problems and to have

someone who can listen to them, console them and accept their emotions.

The charities offer such a counselling service. The Ulster Cancer Foundation

also provides a network of support groups across the Province. The

Foundation funds, in addition, 50% of the salaries of the Northern Ireland

Cancer Registry, described earlier.

3.14 There was a feeling that government had tended to see charities as an

alternative means of funding activities that should in fact be publicly funded.

Experience had apparently shown that the more that was done by charities the

more was expected of them by central government in the Province.

11

12

Palliative Care and the Hospice Movement

3.15 Another important ingredient of the voluntary sector is the Hospice movement

which offers palliative and other care to patients.

3.16 The World Health Organisation has defined palliative care as "the act of total

care of patients whose disease is not responsive to curative treatment".

3.17 The aim of the Hospice movement is to help terminally ill patients lead as

normal, independent and dignified lives as possible and to make the last days

of life days that are worth living. This involves the control of pain, of other

symptoms, and of psychological, social and spiritual problems; in short the

treatment and approach is holistic.

3.18 The Province has 4 voluntary hospices. They are the Northern Ireland Hospice,

the Marie Curie Beaconsfield Centre and 2 smaller hospices located in Newry

and Londonderry.

3.19 There is a steadily increasing demand for hospice care. The most recent

figures for the funding of the hospice movement show that it costs well in

excess of £4m per annum to maintain. There is some government funding of

this but it is patchy and dependent on attitudes within the various Boards. It

amounts to about 30% of the total funding, although according to the

Department of Health and Social Services guidance, it should be around 50%.

3.20 Under the Health and Social Services, Northern Ireland, Order 1972 there is an

onus of responsibility on Boards and Trusts to provide and fund a range of

services for people who require continuing health care. Although this may be

open to some interpretation it appears that up to the present they are failing to

carry out what seems to be a statutory requirement.

13

3.21 There may be some light at the end of the tunnel however as the Chief Medical

Officer has recommended a review of the palliative services in Northern Ireland.

The Committee endorses this recommendation and is confident that any

fair-minded assessment must result in the application of substantial funds to

the hospice area. Such an assessment will also recognise the recent scandal,

given prominence in the press, of a major hospice having to face an

embarrassing cash crisis.

Belvoir Park and the Regional Centre

3.22 The Committee recognises the inestimable contribution by Belvoir Park

Hospital to cancer care in Northern Ireland. It is clear from the evidence given

to it that the services offered at Belvoir Park are held in high public regard. The

most telling testimony of this came from those who gave very personal and

touching accounts of their sometimes harrowing experiences and of how

"Belvoir" helped them through their trials and grief.

3.23 Evidence given by a group known as the Friends of Montgomery House gave

expression to a suspicion that the centre of excellence promised in the

Campbell Report (referred to earlier) was simply a device to slot the facilities at

Belvoir Park on to the under-utilised facility at the Belfast City Hospital.

14

4. THE ISSUES

The Campbell Report : I

4.1 The first and most important point at issue is whether or not a full or partial

implementation of the Campbell Report indicates a desirable way forward. The

Campbell Report in many respects is a practical on-the-ground extension of

Calman/Hine to Northern Ireland. Comparison of Appendices A and B which

list the principles and recommendations of the two reports emphasises this

and it is made clear in the Northern Ireland Report that the working group here

had endorsed Calman/Hine fully .

4.2 The Expert Advisory Group had the benefit of being able to evaluate in detail the

published evidence on Cancer Care and this is a point we will return to later.

The evidence in question points to the substantial benefits of specialist

expertise and of the bringing together of the needed mix of that expertise within

teams. Needs will vary with the problems and so likewise with the make-up of

teams. Campbell puts it thus:

"High quality patient-focused care will be best achieved through a

collaborative effort involving a full multi-disciplinary, multi-professional

team. Doctors, nurses, clinical pharmacists, physiotherapists,

dieticians, speech and language therapists, diagnostic and therapeutic

radiographers, occupational therapists and social workers will all have a

part to play in the provision of a comprehensive cancer service.

Provision of seamless care requires effective communication between

health and social care professionals with expertise in cancer care."

4.3 This concept is gone into in greater depth in a complementary publication: "A

Framework for the Multi-Professional Contribution to Cancer Care in Northern

15

Ireland". It is now necessary to look at some other issues before returning to

the Campbell Report.

Radiotherapy

4.4 One of the arguments in favour of the retention of Belvoir Park as a regional

centre for chemotherapy and more particularly for radiotherapy is the capital

investment that has been made there. Cost therefore is a major issue and this

will be at the centre of the considerations of the Option Appraisal.

4.5 Evidence has been given however to show that there is another significant

factor at play here. It is the fact that techniques, and machines are being

developed in the field of radiotherapy that will allow better targeting of radiation

and reduce the cell damage to surrounding tissue. In effect, it is envisaged that

not only will there be changes to radiotherapy but also that chemotherapy will

grow in importance and that there will be an armoury of other new techniques,

for example, in the areas of vaccine therapy and molecular biology. The

combination of these factors could at some point provide both the window and

the justification for relocation.

Environment

4.6 Among the arguments advanced by witnesses on behalf of Belvoir Park was its

kind environment and its high standard of patient care. This included good car

parking facilities. Clearly the City Hospital would be hard pressed to match this

but if the argument turns mainly on the proposition that the regional centre

should be sited in an acute hospital then, at the extremes, either Belvoir Park

must become an acute hospital or the City must be transformed to provide

facilities that the public deserves and has come to expect.

16

4.7 The former is almost certainly not likely but there may be a series of options

between the two extremes that will have to be appraised. As to the prospect of

transforming the City site, evidence was given that points to this being possible

and certainly the Chief Medical Officer sees it as desirable.

4.8 A secondary argument which is being deployed to support the case for the City

is that cancer treatment in the future is in any event less likely to involve the

same levels of in-patient treatments as have applied in the past. More

substantive evidence for the City's case is discussed later.

City Hospital

4.9 Evidence was given to the Committee by Professor Patrick Johnston, Professor

of Oncology at The Queen's University who is based at the City Hospital. He

painted a bleak picture whereby by the year 2005 one in two males and one in

three females can expect to develop cancer in their lifetimes. There are

approximately 7,500 new cases of cancer per year in Northern Ireland and the

main cancers are: Lung, Breast, Colo-Rectal, Gastric, Prostate, Carcinoma of

the Cervix, Ovarian, Melanoma and Lymphomas.

4.10 Dr Johnston's view was that the goals in dealing with cancer must relate to

excellence in patient care, the core of which must be state-of-the-art modes of

clinical research. It is his intention to develop a clinical trials infrastructure

within Queen's University and the City Hospital. Creativity is a key word and this

will come from outstanding investigators, both scientific and clinical, who

develop new ideas based on rational and laboratory work and by utilising what

has been done elsewhere.

4.11 The clinical setting for this vision will be an in-patient unit and a day hospital

serviced by multi-disciplinary teams. Professor Johnston, speaking on the

question of a possible upgrading of the facilities at Belvoir Park, felt that the

17

issue was not a simple either/or. Cancer services are now developing around

acute hospitals (indeed they have been doing so far a long time) and Belvoir

Park would in essence have to change in nature to meet this key requirement.

The extra costs of this would need to be taken account of in any appraisal.

4.12 There was also an efficiency question: many oncologists are spending much

of their working time in motor cars as they travel the Province and this was not a

good use of a scare resource.

4.13 Centralisation and co-ordination, as outlined in Campbell, will develop a more

uniform service and will yield improvements across the board.

The Campbell Report: II

4.14 Whilst the Committee endorses and welcomes the general thrust of the

Campbell Report and recognises its achievement in charting a course through

very difficult waters, it must also be mindful of the impressive track record of

Belvoir Park Hospital.

4.15 The Committee is confident that the recommendations of the Campbell Report

and the recognition of Belvoir Park Hospital as a still valuable asset need not

be, and indeed are not, mutually exclusive.

4.16 There are many options that now need to be looked at in implementing

"Campbell" and we would hope that some solution might be found that will

include what Belvoir has to offer, insofar as this is possible, in a final outcome.

4.17 This outcome will be determined rationally within the rigorous disciplines of the

Option Appraisal and that is how it should be. The Board carrying out the

appraisal will include representatives of Belvoir Park Hospital: the process is

therefore designed to be both objective and inclusive.

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4.18 The Committee also recognises that there are numerous permutations to be

considered and that any ultimate radical change from the present position will

have to be brought about only very gradually. As treatments for cancers have

changed and continue to change it is only to be expected that this must be

reflected in some way in how we organise ourselves to combat the threat, the

scale of which in Northern Ireland terms is truly daunting.

4.19 The Campbell Report claims very significant improvements in survival rates,

and even if this calculation were only to be half fulfilled it would be a marked

improvement on the present situation. This Committee must act in the

interests of the people of the Province as a whole and the case for change as

outlined in the Campbell Report is a compelling one. We believe therefore that

matters should now be allowed to take their course through and beyond the

appraisal process.

4.20 The change is necessary and has, in any case, begun but we are hopeful that it

will proceed with caution and care so that we do not lose that which is good

and valuable in what we already have.

4.21 As indicated earlier we are at one with Campbell at the general level; there is

however one plea we would wish to make: it is that there should be five Cancer

Units and not four as recommended in Campbell.

4.22 We feel that Units should be set up geographically where needed, irrespective

of Board boundaries or other considerations, and the geography and

population of the Province calls for a fifth unit. This would cover the more

isolated areas of counties Fermanagh and Tyrone and might be best located at

Enniskillen.

Some further notes of caution

19

4.23 At the present time the received wisdom seems to favour the themes of the

Campbell Report. However we need to be very careful that we do not deceive

ourselves into thinking that this is a complete panacea for the problems of

cancer.

4.24 The Committee is aware that recent research tends to show that there is no

general relationship between volume and health care outcomes and there is

also evidence that shows that utilisation of some health services is lower for

patients living further away from centres of treatment.

4.25 Because of this the Committee is of the view that festinate lente applies and

implementation should proceed with the utmost caution and with constant

reference to the latest and best research.

4.26 The Committee supports the recommendation in Campbell that a Cancer

Forum be established. We recommend that this Forum should have the widest

possible representation including respected independent researchers, and

most importantly, it should have democratically elected representatives of the

people sitting on it. For it is only by this means that the interests of the people

can be protected.

4.27 It is most important to get the balance of the Forum right so that it is not seen

simply as a creature of one or other interest.

4.28 The Committee felt that it was right to be concerned and suspicious about the

motivation of government and its enthusiastic support for the Campbell Report.

The Committee was concerned that saving money may be playing too great a

role in the scheme of things, and that the dramatic building of a new cancer

centre could be seen as a means of building reputations and creating

impressions, whilst more "mundane" needs were being neglected.

20

4.29 For instance, it was conscious that at the moment, after a cancer had been

diagnosed, NHS patients have to wait for up to 2 months for treatments that

should be started immediately. The investment in additional staff and in other

facilities that would eliminate this waiting list would be minimal in proportion to

the money that government is proposing to spend on relocation of cancer

services.

Concerns about Belvoir Park

4.30 A major advantage of the Belvoir Park site is the pleasant surroundings and the

convenience of parking. The Committee was of the view that if in the final

analysis, it was intended to go ahead with the favoured plan to move cancer

treatment to the City Hospital, there must be a pledge by Government to provide

free, adequate, and convenient parking and other facilities for patients and

visitors.

4.31 Cancer treatment has many differences from other health care treatments and

requires humanity and flexibility, including facilities and surroundings to allow

patients, and their friends and families, to cope with the emotional strains and

traumas.

4.32 The Committee felt that Belvoir Park had achieved an excellent balance in the

above areas as a result of its situation and the skills and patience of its staff.

The Committee is concerned that this dimension be maintained by

Government. We would not wish to see only minimal investment in a hi-tec

set-up that did not also take account of the human and personal side of cancer

treatment. The Committee would like to see written proposals to equal or

improve upon the environmental and humanitarian features of the present

services.

21

4.33 The Committee is concerned to ensure that any proposed relocation of cancer

treatment should deal fairly with all concerned. This should of course include

primarily the patients but also the staff involved in their welfare.

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5. SUMMARY OF RECOMMENDATIONS

5.1 There needs to be a greater effort in Health Promotion. A wide-ranging

preventative policy should be introduced that would include public education

about the main risk areas. Funding should be increased significantly (3.5).

5.2 The vital role played by the NI Cancer Registry must be recognised. This

organisation should attract full government funding and its work should be built

upon (3.8, 3.9).

5.3 The Committee felt that the existing early diagnosis programmes for breast

and cervical cancer should be extended into other areas. For example,

programmes of early diagnosis should be considered for prostate, bowel and

lung cancers (3.12).

5.4 The Committee was concerned to discover that government has failed to

reasonably support the Hospice movement and its extension to all parts of

Northern Ireland. We recommend that the Hospice movement be given an

adequate and guaranteed budget (3.18, 3.19).

5.5 The Committee supports the Chief Medical Officer's proposed review of

palliative services (3.20).

5.6 The Committee felt that there should be greater investment in research into the

causes of cancers considering specifically the situation in NI (general

conclusion).

5.7 General Conclusions and Recommendations on the Campbell Report drawn

from throughout the report

i. The Committee heard disturbing evidence on the level to which cancer

has become a major and increasing cause of death and suffering.

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ii. The Committee expressed serious concern that the average survival

rate for patients with all types of cancer in NI is significantly less than for

other advanced countries and regions.

iii. The Committee was convinced by the argument that NI would be better

served by having a modern central cancer unit, linked to an acute

hospital. It appears that the introduction of such units has played an

important part in improving treatment results in other countries and

parts of the UK. A specialised unit would deal with, and supervise the

continuing treatment of, the vast majority of cancer patients. It would

become a centre of excellence and it would also facilitate the

development of research and new methods of treatment, prevention

and early diagnosis.

iv. It also appears to be sensible that some treatments, such as

chemotherapy, should be devolved to hospitals that are nearer to

patients' homes. This would make day care more practical and ease

pressures on patients and their families.

v. A final decision on where the main centre should be cannot be taken

until an evaluation of the various options has been completed. The

Committee did not feel that it was possible for it to make a precise

recommendation on this issue.

vi. It would be much more appropriate to have five cancer units as

opposed to four.

5.8 Recommendations from 'Cautionary' Section:

i. Implementation of Campbell should proceed with great caution.

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ii. The Committee supports the idea of a Cancer Forum that would inspire

public confidence. It should include public representatives and

independent experts.

iii. The Committee is perturbed to find that patients are having to wait for up

to 2 months for treatment that should be begun immediately and

strongly recommends that this state of affairs be attended to without

delay.

5.9 Recommendations relating to concerns about Belvoir Park

i. The Committee feels that if the favoured plan is to be implemented

Government should make pledges on parking and other facilities and

there should be no diminution in the high standards set by Belvoir Park.

ii. Any relocation must deal fairly with all concerned.

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DA52.WM

26

APPENDICES

27

APPENDIX A

"A POLICY FRAMEWORK FOR COMMISSIONING CANCER SERVICES"

REPORT BY THE EXPERT ADVISORY GROUP ON CANCER TO THE CHIEF MEDICAL

OFFICERS OF ENGLAND AND WALES (CALMAN/HINE)

General Principles

The principles which should govern the provision of cancer care are:

i. All patients should have access to a uniformly high quality of care in the

community or hospital wherever they may live to ensure the maximum

possible cure rates and best quality of life. Care should be provided as

close to the patient's home as is compatible with high quality, safe and

effective treatment.

ii. Public and professional education to help early recognition of symptoms of

cancer and the availability of national screening programmes are vital parts

of any comprehensive programme for cancer care.

iii. Patients, families and carers should be given clear information and

assistance in a form they can understand about treatment options and

outcomes available to them at all stages of treatment from diagnosis

onwards.

iv. The development of cancer services should be patient centred and should

take account of patients', families and carers' views and preferences as well

as those of professionals involved in cancer care. Individuals' perceptions

of their needs may differ from those of the professional. Good

communication between professionals and patients is especially important.

v. The primary care team is a central and continuing element in cancer care

for both the patient and his or her family from primary prevention,

pre-symptomatic screening, initial diagnosis, through to care and follow-up,

or, in some cases, death and bereavement. Effective communication

between sectors is imperative in achieving the best possible care.

vi. In recognition of the impact that screening, diagnosis and treatment of

cancer have on patients, families and their carers, psychological aspects of

cancer care should be considered at all stages.

vii. Cancer registration and careful monitoring of treatment and outcomes are

essential.

28

Summary of Recommendations (Calman/Hine)

i. All cancer patients should have access to a uniformly high standard of care.

ii. The needs of patients and their carers should be the primary concern of

purchasers, planners and professionals involved in cancer.

iii. Cancer Centres and Cancer Units should be established to provide an

integrated network of cancer care. Effective communications between

components, including communication between Cancer Centres, are vital.

iv. There should be a clear understanding of appropriate referral and follow up

patterns between General Practitioners, Cancer Units and Cancer Centres.

These should be based on agreed guidelines and information on quality

and outcome of care and should involve patient groups.

v. Cancer Units should appoint a lead clinician to co-ordinate services for

cancer patients in a Unit. The lead clinician should be closely involved in

negotiating service agreements with purchasers.

vi. Professional bodies should urgently develop guidance on the level of

expertise and support required to manage the commoner cancers.

vii. The Health Departments should work with professional bodies in

developing the role of Primary Health Care Teams in the management of

cancer.

viii. Each Cancer Unit will need to have input from non-surgical oncology.

Development of appropriately trained staff will take several years. We

welcome and encourage the collaboration between medical and clinical

oncologists.

ix. There are manpower implications for all specialities and professions

involved in cancer care. Discussions should be held with appropriate

professional bodies.

x. Radiotherapy should normally be provided in a Cancer Centre. In

exceptional circumstances it may be necessary to continue to provide

radiotherapy in Cancer Units closely linked to Cancer Centres for existing

quality assurance and audit purposes.

xi. Palliative care and symptom control should be available at all stages of a

patient's illness. Hospitals, primary care, social services and the voluntary

sector should be involved.

xii. Education, audit, research into cancer care and the entry of patients into

trials are important parts of the programme.

29

xiii. The full changes in the organisation and provision of cancer services

recommended in this report will take several years to implement. There is

however much that can be done now by better organisation and improved

communication between patients, purchasers, providers and professionals

and the voluntary sector to enhance the quality of cancer care and the

utilisation of staff already trained. Specialist training of an oncologist takes

up to five years and this assumes there are sufficient numbers of qualified

doctors wishing to enter training and sufficient trainers available.

xiv. It is vital to monitor outcomes of treatment and the implementation of

changes in services. The Expert Advisory Group on Cancer should be in

association with the NHS Executive and the Welsh Office Health

Department monitor the implementation of these recommendations and

report regularly to Ministers.

30

APPENDIX B

SUMMARY OF RECOMMENDATIONS OF 'CANCER SERVICES: INVESTING FOR THE

FUTURE' (THE CAMPBELL REPORT)

1. The management of patients with cancer should be undertaken by

appropriately trained, organ and disease specific medical specialists.

2. All patients with cancer should be managed by multi-disciplinary,

multi-professional specialist cancer teams.

3. A Cancer Forum should be established involving all key interests in the delivery

of cancer services.

4. Cancer units should, in conjunction with local GPs and other providers, develop

an effective communication strategy.

5. Northern Ireland should have one cancer centre, which in addition to its

regional role, should act as a cancer unit to its local catchment population of

around half a million.

6. There should be four other cancer units, one in each Board area, each serving

a population of around a quarter of a million.

7. Radiotherapy services, together with chemotherapy services, should be moved

as soon as possible to the Belfast City Hospital and become an integral part of

the regional cancer centre.

8. Each cancer unit should develop a chemotherapy service. This service should

be staffed by designated specialist nurses and pharmacists, and should be

overseen by the non-surgical oncologist attached to the unit, with back-up from

a haematologist.

9. There should be a minimum target of 13 consultants in non-surgical oncology

for Northern Ireland by 2005.

10. Any new appointments of trained cancer specialists should be to cancer units

or to the cancer centre.

11. Guidelines should be drawn up and agreed for the appropriate investigation

and management of patients presenting to non-cancer unit hospitals who turn

out to have cancer.

12. The cancer centre and cancer units should each develop a specialist

multi-professional palliative care team.

31

13. There should be a comprehensive review of palliative care services in Northern

Ireland.

14. The Northern Ireland Cancer Registry should be adequately resourced.

32

APPENDIX C

EUROPEAN CODE AGAINST CANCER

Certain cancers may be avoided and general health improved if you adopt a

healthier lifestyle

1. Do not smoke. Smokers, stop as quickly as possible and do not smoke in the

presence of others. If you do not smoke, do not try it.

2. If you drink alcohol, whether beer, wine or spirits, moderate your consumption.

3. Increase your daily intake of vegetables and fresh fruit. Eat cereals with a high

fibre content frequently.

4. Avoid become overweight, increase physical activity and limit intake of fatty

foods.

5. Avoid excessive exposure to the sun and avoid sunburn especially in children.

6. Apply strictly regulations aimed at preventing any exposure to known

cancer-causing substances. Follow all health and safety instructions on

substances which may cause cancer.

More cancers may be cured if detected early

7. See your doctor if you notice a lump, a sore which does not heal (including in

the mouth), a mole which changes in shape, size or colour, or any abnormal

bleeding.

8. See your doctor if you have persistent problems, such as a persistent cough,

persistent hoarseness, a change in bowel or urinary habits or an unexplained

weight loss.

For women

9. Have a cervical smear regularly. Participate in organised screening

programmes for cervical cancer.

10. Check your breasts regularly. Participate in organised mammographic

screening programmes if you are over 50.

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APPENDIX D

STANDING COMMITTEE 'C'

HEALTH ISSUES

Committee Members who attended the Evidence Sessions on Cancer Care:-

Mrs M Beattie DUP

Mr C Calvert DUP

Mr G Campbell DUP

Dr A Evans Labour

Mr S Foster* UUP

Mr S Gardiner UUP

Mr P King UUP

Mrs M Marshall Alliance

Mr F McCoubrey UDP

Mrs J Parkes DUP

Ms G Rice Alliance

Mr T Robinson UUP

Mr H Smyth PUP

Mrs M Steele* UUP

Dr J Wilde Women's Coalition

Mr C Wilson* UKUP

*Not regular members of the Health Committee during period of

investigation.

34

APPENDIX E

REMIT: The Forum has set up a number of Committees. The

Committee to deal with HEALTH ISSUES is among

these.

DESIGNATION: STANDING COMMITTEE C

TERMS OF REFERENCE: To examine the health needs of the community in

Northern Ireland with particular reference to health

care administration; acute hospital services,

community care services and access by the rural

community and report to the Forum.

35

• Investigation into Cancer Care in Northern Ireland: Report (introduced on 1997-01-22 00:00:00 - CREATE - e802947) [This document] [view current proposal at this moment]
  • None (introduced on 1997-01-22 00:00:00 - REPORT_PROPOSAL - e802949) [view current proposal at this moment]