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A question of quality: Radiotherapy resources and waiting time outcomes for cancer patients
Clinical Oncology (1998) 10:210-211 © 1998 The Royal College of Radiologists
Clinical Oncology
Editorial A Question of Quality: Radiotherapy Resources and Waiting Time Outcomes for Cancer Patients J. A. Bullimore Bristol Oncology Centre, Bristol, UK
Since the publication in 1995 of the Calman/Hine report, A Policy Framework for Commissioning Cancer Services, [1], the energies of those who treat cancer and of the NHS regional offices have been focused on developing a network of care comprising a cancer centre hub linked to cancer units and to primary care. The structure is well under way in most parts of the country and site-specialist multidisciplinary groups have developed, or are developing, their own protocols for the management and treatment of patients. These clinical management plans have taken into consideration the few national guidelines that are available, and other evidence gleaned from published clinical trials and recommendations of authoritative bodies such as the Royal Colleges. Regional health authorities and district health authorities have set up accreditation bodies to inspect the service provided by cancer units and cancer centres. The accreditation systems developed have been as numerous and varied as the number of regions and districts that have developed them. The time has come to assess the quality of the care provided across the UK. Outcome measures such as survival and incidence of long term morbidity will take time to assess and it will be many years before these will show improvement as a result of the Calmanfl-tine structure. It is not too early, however, to start measuring the quality of some of the care that is given. The publication in June 1998 of Equipment,
Workload and Staffing for Radiotherapy in the UK 1992-1997 [2] and A National Audit of Waiting Times for Radiotherapy [3] by the Royal College of Radiologists is timely and important. When the first survey was undertaken in 1992 [2], it was with the intention of obtaining factual evidence regarding the provision of radiotherapy services for cancer treatment, and to identify areas of inequality and underprovision. Until that time, in spite of the recognition of the inequality of provision across the UK, this factual evidence was missing. It was recognized by the Faculty of Clinical Oncology that, if the purchasers of health care and the hospital trusts were to be influenced to identify areas of underprovision and to take steps to rectify these, hard data would be needed. Correspondence and offprint requests to: J. A. Bullimore, Bristol Oncology Centre, Horfield Road, Bristol, BS2 8ED, UK.
That first survey, which was undertaken before the Calman/Hine report was written, revealed an unevenness of resources across the UK, resulting in unacceptable variation in access to treatment. The number of megavoltage machines per million population served showed great diversity. This variation was repeated in the number of clinical oncologists and therapy radiographers in relation to the population serviced. This first set of data has helped some oncology centres in their efforts to increase the number of megavoltage units in their departments and to replace old cobalt machines with linear accelerators, but this has been far from universal. The second survey, carried out in 1997 [2], has shown little improvement. Radiotherapy machine capacity, measured in linear accelerator equivalents, has changed from a range of 1.5-4.4 linear accelerators per million population in 1992 to 1.0-5.0 in 1997. The number of new patients in the UK who were treated with radiotherapy in 1997 increased by 8.6% compared with 1992. At the same time, there has been an increase of 18% in the total number of radiation exposures delivered, reflecting the increased complexity of treatment for each patient. The total numbers of new patients per million population served who receive radiotherapy each year show alarming countrywide variations. In some areas, as few as 24% of patients with cancer receive radiotherapy, whereas in others 64% benefit. More than 50% of patients with cancer will require radiotherapy at some stage of their illness, but this report [2] makes clear that 20 of the 57 radiotherapy departments in the UK treat 33% or less of the patients with cancer in their catchment area. This equates to a population of 17 million for whom proper provision is not available. These figures are shocking and measures must be taken to correct them. In addition to highlighting the paucity of linear accelerators in the UK, the report details the problems caused by the ageing national megavoltage stock and its heavy workload, leading to frequent machine breakdown and interruption of patients' treatment. Unplanned breaks in treatment reduce cure rates [4]. A target of four linear accelerators per million population is suggested, based on the Department of Health's 1993 publication Independent Review of Specialist Services in London [5]. The provision of extra linear accelerators alone would not solve the
Radiotherapy Resources and Waiting Time Outcomes for Cancer Patients
problem of providing an adequate service. There is a need, nationally, for the recruitment and training of all types of radiotherapy staff. The urgent need to increase the numbers of consultant staff in clinical oncology has already been highlighted in the 1998 College document Consultant Workload in Clinical Oncology [6]. Equally, more therapy radiographers, physicists and other supporting staff are required. The companion report, A National Audit of Waiting Times for Radiotherapy, [3] has revealed serious delays in waiting times when measured against the targets defined by the Joint Council for Clinical Oncology (JCCO) in 1993 [7]. The government's White Paper on The New NHS [8] pledges a reduction in waiting times for cancer patients. For patients requiring radiotherapy, the relevant waiting time is for therapy to start. The JCCO waiting time targets were derived in order to provide national standards against which individual departments could audit their own performance and allow national audit to take place. Waiting time for radiotherapy was defined as being that time between when a course of radiotherapy was first recommended by a clinical oncologist and it actually starting. The alarming statistics of the audit echo those revealed in the survey of equipment, workload and staffing. [2]. Overall, 28% of patients wait longer than the maximum times advised by the JCCO. The regional variation and inequality of service provided are strikingly illustrated. It can hardly be coincidental that the North West region is the worst in the waiting time ranking and also the worst in megavoltage ranking. With only 1.88 megavoltage units per million population, it is at the bottom of the pile and compares badly with the other extreme of 3.08 linear accelerators provided per million population in Wales. It is a matter of concern that the UK lags 5%-6% behind most other European countries in 5-year survival rates for many cancers [9]. These two reports [2,3] illustrate forcibly the underprovision to a large part of the UK population of a major player in the cure of patients with cancer. This alone might account for the deficit. Add to this the effect of delays in the start of potentially curative radiotherapy and it is surprising that the UK does not lag further behind Europe. The outcome of cancer treatment should not be measured in cure rates alone, important as these are. If the morbidity and psychological distress caused by the illness is added to the anxiety of a prolonged waiting time for radiotherapy, the burden becomes intolerable. It goes without saying that those patients requiring palliative treatment for the relief of severe symptoms need it as quickly as possible, delivered by the most effective means. Radiotherapy is a cost effective palliative treatment and should be promptly and easily accessible in a good cancer service.
211
In setting the targets for waiting times for radiotherapy, the JCCO strove to make them realistic and achievable. That the targets are failing to be reached, for some patients in all the regions and for so many in some, is a cause for professional concern and should be one of national shame. The two reports [2,3] identify a major reason why the UK fails to equal the cure rates obtained in other developed countries. Without a major influx of additional money to purchase expensive items of equipment and to fund the necessary increase in the training of staff to support radiotherapy, the aims of the government's Green Paper Our Healthier Nation [10], seeking a reduction in cancer mortality in those aged under 65 by the year 2010, will not be achieved. Each Regional Office of the NHS Executive must examine its position in the radiotherapy provision league tables, and the Government must take ultimate responsibility to ensure improvement in poor regions. These regional league tables should be widely disseminated, to the NHS Executive centrally and to its regional outposts, and to local MPs, community health councils and the media. The scale of funding to equalize the number of linear accelerators per million population across the country is so great that central resources must be provided. Part of the government's pledge of additional billions for the NHS could not be better spent.
References
1. Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales. A policy framework for commissioning cancer services. London: Department of Health and Welsh Office, 1995. 2. Royal College of Radiologists. Equipment, workload and staffing for radiotherapy in the UK 1992-1997. London: Royal College of Radiologists, 1998. 3. Royal College of Radiologists. A national audit of waiting times for radiotherapy. London: Royal College of Radiologists, 1998. 4. Fowler J, Lindstrom MJ. Loss of control with prolongation in radiotherapy. Int J Radiat Oncol Biol Phys 1992;23:457-67. 5. Department of Health. Independent Review of Specialist Services in London: HMSO 1993. 6. Royal College of Radiologists. Consultant workload in clinical oncology. London: Royal College of Radiologists, 1998. 7. Joint Council for Clinical Oncology. Reducing delays in cancer treatment: some targets. London: Royal College of Physicians, 1993. 8. The new NHS: modem, dependable. UK Government White Paper, 1998. 9. Berrino F, Sant M, Verdecchia A, et al. Survival of cancer patients in Europe - the Eurocare Study (International Agency for Research on Cancer Scientific Publications no. 132). Lyon: IARC, 1996. 10. Our healthier nation - a contract for health. UK Government Green Paper, 1998.
Clinical Oncology
Editorial A Question of Quality: Radiotherapy Resources and Waiting Time Outcomes for Cancer Patients J. A. Bullimore Bristol Oncology Centre, Bristol, UK
Since the publication in 1995 of the Calman/Hine report, A Policy Framework for Commissioning Cancer Services, [1], the energies of those who treat cancer and of the NHS regional offices have been focused on developing a network of care comprising a cancer centre hub linked to cancer units and to primary care. The structure is well under way in most parts of the country and site-specialist multidisciplinary groups have developed, or are developing, their own protocols for the management and treatment of patients. These clinical management plans have taken into consideration the few national guidelines that are available, and other evidence gleaned from published clinical trials and recommendations of authoritative bodies such as the Royal Colleges. Regional health authorities and district health authorities have set up accreditation bodies to inspect the service provided by cancer units and cancer centres. The accreditation systems developed have been as numerous and varied as the number of regions and districts that have developed them. The time has come to assess the quality of the care provided across the UK. Outcome measures such as survival and incidence of long term morbidity will take time to assess and it will be many years before these will show improvement as a result of the Calmanfl-tine structure. It is not too early, however, to start measuring the quality of some of the care that is given. The publication in June 1998 of Equipment,
Workload and Staffing for Radiotherapy in the UK 1992-1997 [2] and A National Audit of Waiting Times for Radiotherapy [3] by the Royal College of Radiologists is timely and important. When the first survey was undertaken in 1992 [2], it was with the intention of obtaining factual evidence regarding the provision of radiotherapy services for cancer treatment, and to identify areas of inequality and underprovision. Until that time, in spite of the recognition of the inequality of provision across the UK, this factual evidence was missing. It was recognized by the Faculty of Clinical Oncology that, if the purchasers of health care and the hospital trusts were to be influenced to identify areas of underprovision and to take steps to rectify these, hard data would be needed. Correspondence and offprint requests to: J. A. Bullimore, Bristol Oncology Centre, Horfield Road, Bristol, BS2 8ED, UK.
That first survey, which was undertaken before the Calman/Hine report was written, revealed an unevenness of resources across the UK, resulting in unacceptable variation in access to treatment. The number of megavoltage machines per million population served showed great diversity. This variation was repeated in the number of clinical oncologists and therapy radiographers in relation to the population serviced. This first set of data has helped some oncology centres in their efforts to increase the number of megavoltage units in their departments and to replace old cobalt machines with linear accelerators, but this has been far from universal. The second survey, carried out in 1997 [2], has shown little improvement. Radiotherapy machine capacity, measured in linear accelerator equivalents, has changed from a range of 1.5-4.4 linear accelerators per million population in 1992 to 1.0-5.0 in 1997. The number of new patients in the UK who were treated with radiotherapy in 1997 increased by 8.6% compared with 1992. At the same time, there has been an increase of 18% in the total number of radiation exposures delivered, reflecting the increased complexity of treatment for each patient. The total numbers of new patients per million population served who receive radiotherapy each year show alarming countrywide variations. In some areas, as few as 24% of patients with cancer receive radiotherapy, whereas in others 64% benefit. More than 50% of patients with cancer will require radiotherapy at some stage of their illness, but this report [2] makes clear that 20 of the 57 radiotherapy departments in the UK treat 33% or less of the patients with cancer in their catchment area. This equates to a population of 17 million for whom proper provision is not available. These figures are shocking and measures must be taken to correct them. In addition to highlighting the paucity of linear accelerators in the UK, the report details the problems caused by the ageing national megavoltage stock and its heavy workload, leading to frequent machine breakdown and interruption of patients' treatment. Unplanned breaks in treatment reduce cure rates [4]. A target of four linear accelerators per million population is suggested, based on the Department of Health's 1993 publication Independent Review of Specialist Services in London [5]. The provision of extra linear accelerators alone would not solve the
Radiotherapy Resources and Waiting Time Outcomes for Cancer Patients
problem of providing an adequate service. There is a need, nationally, for the recruitment and training of all types of radiotherapy staff. The urgent need to increase the numbers of consultant staff in clinical oncology has already been highlighted in the 1998 College document Consultant Workload in Clinical Oncology [6]. Equally, more therapy radiographers, physicists and other supporting staff are required. The companion report, A National Audit of Waiting Times for Radiotherapy, [3] has revealed serious delays in waiting times when measured against the targets defined by the Joint Council for Clinical Oncology (JCCO) in 1993 [7]. The government's White Paper on The New NHS [8] pledges a reduction in waiting times for cancer patients. For patients requiring radiotherapy, the relevant waiting time is for therapy to start. The JCCO waiting time targets were derived in order to provide national standards against which individual departments could audit their own performance and allow national audit to take place. Waiting time for radiotherapy was defined as being that time between when a course of radiotherapy was first recommended by a clinical oncologist and it actually starting. The alarming statistics of the audit echo those revealed in the survey of equipment, workload and staffing. [2]. Overall, 28% of patients wait longer than the maximum times advised by the JCCO. The regional variation and inequality of service provided are strikingly illustrated. It can hardly be coincidental that the North West region is the worst in the waiting time ranking and also the worst in megavoltage ranking. With only 1.88 megavoltage units per million population, it is at the bottom of the pile and compares badly with the other extreme of 3.08 linear accelerators provided per million population in Wales. It is a matter of concern that the UK lags 5%-6% behind most other European countries in 5-year survival rates for many cancers [9]. These two reports [2,3] illustrate forcibly the underprovision to a large part of the UK population of a major player in the cure of patients with cancer. This alone might account for the deficit. Add to this the effect of delays in the start of potentially curative radiotherapy and it is surprising that the UK does not lag further behind Europe. The outcome of cancer treatment should not be measured in cure rates alone, important as these are. If the morbidity and psychological distress caused by the illness is added to the anxiety of a prolonged waiting time for radiotherapy, the burden becomes intolerable. It goes without saying that those patients requiring palliative treatment for the relief of severe symptoms need it as quickly as possible, delivered by the most effective means. Radiotherapy is a cost effective palliative treatment and should be promptly and easily accessible in a good cancer service.
211
In setting the targets for waiting times for radiotherapy, the JCCO strove to make them realistic and achievable. That the targets are failing to be reached, for some patients in all the regions and for so many in some, is a cause for professional concern and should be one of national shame. The two reports [2,3] identify a major reason why the UK fails to equal the cure rates obtained in other developed countries. Without a major influx of additional money to purchase expensive items of equipment and to fund the necessary increase in the training of staff to support radiotherapy, the aims of the government's Green Paper Our Healthier Nation [10], seeking a reduction in cancer mortality in those aged under 65 by the year 2010, will not be achieved. Each Regional Office of the NHS Executive must examine its position in the radiotherapy provision league tables, and the Government must take ultimate responsibility to ensure improvement in poor regions. These regional league tables should be widely disseminated, to the NHS Executive centrally and to its regional outposts, and to local MPs, community health councils and the media. The scale of funding to equalize the number of linear accelerators per million population across the country is so great that central resources must be provided. Part of the government's pledge of additional billions for the NHS could not be better spent.
References
1. Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales. A policy framework for commissioning cancer services. London: Department of Health and Welsh Office, 1995. 2. Royal College of Radiologists. Equipment, workload and staffing for radiotherapy in the UK 1992-1997. London: Royal College of Radiologists, 1998. 3. Royal College of Radiologists. A national audit of waiting times for radiotherapy. London: Royal College of Radiologists, 1998. 4. Fowler J, Lindstrom MJ. Loss of control with prolongation in radiotherapy. Int J Radiat Oncol Biol Phys 1992;23:457-67. 5. Department of Health. Independent Review of Specialist Services in London: HMSO 1993. 6. Royal College of Radiologists. Consultant workload in clinical oncology. London: Royal College of Radiologists, 1998. 7. Joint Council for Clinical Oncology. Reducing delays in cancer treatment: some targets. London: Royal College of Physicians, 1993. 8. The new NHS: modem, dependable. UK Government White Paper, 1998. 9. Berrino F, Sant M, Verdecchia A, et al. Survival of cancer patients in Europe - the Eurocare Study (International Agency for Research on Cancer Scientific Publications no. 132). Lyon: IARC, 1996. 10. Our healthier nation - a contract for health. UK Government Green Paper, 1998.