Lessons from antineoplaston

THE LANCET

SIR—Your March 15 editorial,1 calls for practitioners to recognise patients’ needs for, and rights to, information about complementary as well as conventional cancer treatments. Articulate and literate patients will always succeed in finding information that is in the public domain, whatever the views of their own practitioners. On behalf of all patients, particularly those who are less skilled at handling information, we endorse the call. We would, however, qualify it. Patients need accessible, timely, relevant, and appropriate information about cancer treatments. As a supplement to their interactions with medical teams, patients should have access to a range of texts: print, televisual, and computer-based. They should also be in a position to choose the information that best suits their purposes, skills, and preferences. The quality of such texts should be as carefully researched, and their development and provision as seriously funded as any treatment intervention. For as with orthodox oncology, not everything in cancer information is perfect. *Sally Tweddle, Nicholas James Cancer Research Campaign Institute for Cancer Studies, University of Birmingham, Clinical Research Block, Edgbaston, Birmingham B15 2TT, UK

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Editorial. Lessons from antineoplaston. Lancet 1997; 349: 741.

Health service changes in New Zealand SIR—Your New Zealand correspondent, Sandra Coney, provides a novel and misleading interpretation of the move to more consistent, explicit prioritisation and booking systems (March 22, p 862)1. The omissions are telling. She omitted to say that for 3 years government policy, agreed with the regional health authorities (the purchasers of services), has been to replace waiting lists with booking systems and to assess clinical priority through open, transparent processes. In the past year, NZ$130 million of additional funds have been specifically dedicated to help regional health authorities achieve this policy priority. Nor does Coney say that the clinical priority assessment criteria that assist in this process are a guide only, and clinical judgment is ultimately what determines who is offered what kinds of services. The emphasis is on clinical assessment, not point scores, and this was clearly stated in the central region’s media releases: “We have told hospital doctors that they should not see the

Vol 349 • May 17, 1997

priority access criteria as rigid, and that we expect them to exercise their clinical judgement. We recognise that there are some circumstances where there should be discretion on clinical grounds, regardless of whether or not people meet the threshold. If there is a conflict between a person’s score and generally accepted clinical practice, then generally accepted clinical practice should prevail”. Nowhere in the letters sent to patients in the central region was there mention of not having enough points to qualify for treatment. The letters to general practitioners provided information on the overall assessment processes and context, supported by the clinical priority assessment results and advice on management options. The clinical priority assessment criteria that have been developed by the National Health Committee and the Regional Health Authorities working closely with clinicians and the public give a small weighting to threats to “ability to work, care for dependants, or live independently”, which can be addressed by the treatment under consideration: this is expressly not the same as “extra points are given if an individual is judged a productive member of society” as Coney misleadingly reports. What is clear is that people will no longer languish on waiting lists: those who are accepted for treatment are booked to receive it within 6 months. Those who are assessed as being outside the agreed criteria for treatment, and who do not have extenuating circumstances, are referred back to primary care. Should their condition or circumstance change, or the capacity of the publicly funded sector increase, patients are reassessed and where applicable booked for treatment. All this is open, transparent, and under continual review and refinement in the light of new evidence on effectiveness and greater understanding of communities’ values.2,3 This change represents a major culture shift and it does threaten some of the comfortable patterns that planners and purchasers and providers have settled into—so it would not be reasonable to expect everyone to enthusiastically embrace these changes. Many specialists work in private as well as public medicine, and patients’ uncertainty as to whether and when they will be treated is often cited as the reason that they seek private care: explicit prioritisation and booking systems might reduce private sector demand and therefore specialists’ incomes. The past pattern of provision has not been comfortable for patients, and, quite properly, that is being remedied. Lynette Jones National Health Committee, Ministry of Health, Manatu Hanora, P O Box 5013, Wellington, New Z ealand

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Coney S. New Zealand demands “points” for treatment. Lancet 1997; 349: 862. Hadorn DC, Holmes AC. The New Zealand priority criteria project, part 1: overview. BMJ 1997; 314: 131–34. Hadorn DC, Holmes AC. The New Zealand priority criteria project, part 2: coronary artery bypass graft surgery. BMJ 1997; 314: 135–38.

Author’s reply SIR—The National Health Committee (formerly the Core Services Committee) is naturally defensive about its creation, the booking system—but there are inherent contradictions in what it says. Jones writes that one regional health authority (what about the other three?) told hospital doctors that clinical judgment must not be set aside in implementing the points system, yet the NHC’s seven criteria for assessing patient priority do not include clinical judgment. The NHC’s latest annual report acknowledges that clinicians argue that the threshold for accessing coronary artery bypass graft (35 points or more) is too high. In the words of the NHC, “the preferred clinical threshold is 25 points”. However, says the committee, the threshold has been set on the basis of “existing levels of funding”. Thus level of funding, rather than clinical assessment, is determining who gets treatment. Jones accuses specialists of selfinterest for objecting to aspects of the booking system, since many work in both the public and private sectors. I am not sure how she can claim that taking thousands of people off waiting lists will reduce private sector demand—I would have thought it would produce a bonanza for the private sector. Is she suggesting that those removed from waiting lists do not need or want treatment? As Geoffrey Horne, professor of surgery at Wellington Clinical School, said recently: “I am not aware of anyone on my waiting list who is there for some kind of recreation”. In any case, the critics include general practitioners and academics who have no such pecuniary interest in the new system. Jones labours the point that patients want explicitness and certainty. I would have thought that what patients actually want is treatment. By contrast with this call for transparency, Jones says that patients in the central region were not told they did not have enough points to qualify for treatment, rather, their general practitioners were told: this is not in keeping with the provisions of the recently enacted Code of Health and Disability Services Consumers’ Rights which says that consumers have a “right to be fully informed”. Ironically, in last year’s annual report, the NHC cited the Code as reinforcing the need for

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