Paying for cancer care--a new dilemma
Authors: K. Sikora
Journal: Journal of the Royal Society of Medicine (2007)

NHS spending is now at unprecedented levels. Over £90 billion is being spent this year alone and by 2008 this will reach £105 billion. Yet the quality of service provision and access to technology still does not match that of our European neighbours. Increasing the total budget spent on health is one solution. This can either come from increased taxation or by direct payment at the point of care: a co-payment. Another is a radical reform of the entire system from its insurance function through to its delivery system. Stripping away bureaucracy to reduce costs is an essential component of the reform process. A recent report1 suggests that we are heading for a £7 billion deficit in the NHS by 2011—and that's not allowing for step changes in technology. That represents an income tax increase of two pence in the pound for all those at work unless we use some other payment mechanism.

Cancer care costs are spiralling out of control in every healthcare environment. Aging populations with a wide range of medical problems are consuming vastly increasing amounts of care. New technology—drugs, devices and procedures—are powerful inflationary drivers in an information rich, consumer-oriented world.2 Different healthcare systems are using a variety of approaches to dampen demand. Rationing, both overt and covert, inevitably leads to inequity. Britain's NHS is undergoing a slow reform process, but huge variations exist in the way patients access its services, depending on their location, education and socio-economic background. There are also major differences in prioritizing services by those responsible for their payment (the Primary Care Trusts, often advised by the local Cancer Networks). A study in 2006 showed clearly that new cancer drug use in Britain was consistently and significantly well below that of our EU neighbours.3 Similarly, another comparative EU study on the availability of radiotherapy last year ranked the UK near the bottom, on the level with the accession countries of Central Europe, even after the recent purchase of over 100 machines using lottery money.4 An alliance of British cancer charities have successfully lobbied for a second cancer plan to improve services. Whilst this would be beneficial, there is no evidence that any additional tax-based NHS funding will be available for this laudable concept. Cancer is seen as a ticked box in Britain.

There is now evidence of a growing use of co-payments to break through the access barriers in the NHS. This applies to areas as diverse as implanted hearing aid devices, access to diagnostics such as MRI scans and home nursing care services. Politicians of all persuasions seem to be in denial about their existence and are reluctant to get involved in debate. Meanwhile cancer patients are beginning to develop sophisticated approaches to buying extra clinical services either from the NHS directly or through the selective use of the private sector to purchase upgrades to their basic NHS care.

With drugs the economics are relatively straightforward, but with precision radiotherapy the issues are more complex and so far hidden from the political media limelight. There are 61 radiotherapy centres in the UK. Of these, 28 now have equipment to provide intensity modulated radiotherapy, which is now standard in the US and most of Western Europe. Only three British centres, however, provide intensity modulated radiotherapy routinely to significant numbers of patients: Clatterbridge (Liverpool), Ipswich and the Royal Marsden (London). Staff and funding shortages are blamed. Savvy patients are beginning to travel long distances for more precise radical radiotherapy in order to suffer fewer long-term side effects. The imminent publication of the National Radiotherapy Advisory Group report, which shows wide variation in radiotherapy utilization across the country, is clearly going stimulate new models for radiotherapy provision. Furthermore, delays abound, with a three-month waiting time for radiotherapy being common in the UK. In contrast, a centre in Zurich, Switzerland, currently has a working group engaged in re-engineering the time from first contact to radiotherapy delivery from five to three working days.