This month's COVER Think Tank debates the emotive issue of medical treatment for cancer in the UK. Lucy Quinton reports.
Lucy Quinton:What is the current state of cancer care in thiscountry?
Karol Sikora:If you take Europe as the benchmark, in termsof the amount spent on healthcare and theamount spent on cancer, we get far less for ourpound. The reasons for this are complex and goback several years.
Lucy Quinton:A study a few years ago showed wealthycountries such as Germany, France, Italy andSweden have a higher number of cancersufferers but also have the best survival rates.In contrast, Britain had a relatively lowincidence of cancer compared with its Europeanneighbours but more in common with theformer Eastern bloc in terms of survival. Whydo you think Britain is failing its cancersufferers in comparison with these othercountries?
Paula Franklin:I think there have been some failings butthrowing money at it is not the answer.
Lucy Quinton:How will cancer care be funded in future?
Teresa Tate:Patients will have more impact on the nature ofcancer care because they will start to exercisetheir own choice. It is only a matter of timebefore the current situation is challenged wherepatients cannot top up their treatments. It isalmost inevitable people will start adding to the cost of their care without having to vote whetherthey have their treatment entirely in the privatesector or entirely in the NHS. Somebody isprobably going to get together and challenge thesituation. It will become a much more mixedeconomy. I am a trustee of Breakthrough BreastCancer and we do a lot of work in terms ofeducating patients and facilitating them tochallenge their local services to see how theycan be improved. But there is an Englishtendency to want to have treatments locally. Ifyou feel you are getting the equivalent treatment,most people will want to go down theroad rather than travel for half an hour.However, if we start to get more transparencyand share data, it will be a question of educatingthe public to understand the differences interms of access to treatments, whether a centredoes clinical trials and its outcomes.
Karol Sikora:The interesting thing is the voluntary sector hasreally triumphed with palliative medicine andcare. And that has come from outside the NHS -;it would not have happened within the NHS.Radiotherapy, chemotherapy is within the NHSonly and there is no outside provider orchampion.
Hilary Thomas:There is another step too and this concernspublic education and people understanding theearly signs of disease and risk factors in theirlifestyle. We are far behind European countriesin that aspect.
Alex Bennett:There has been a shift in emphasis towardsbetter education and understanding of wellnessissues generally -; for the right clinical reasonsor not.
Elliott Hurst:I agree and there are one or two things to add tothis. There are issues around screening, notnecessarily specifi c to cancer alone. But ingeneral, when it comes to providing healthscreening, we need to be mindful of whatpotentially may come out of the Her Majesty'sRevenue and Customs. That may be somewhatcontrary to a general ethos saying we would liketo have access to broad health screening thatmay or may not detect certain conditionsincluding cancer. One of the potential failingsand downsides of health screening is that it istoo generic. There is a question that needs to beaddressed about whether employees take up thehealth screening options available to them. Thestatistics we look at vary wildly according toindustry sector, gender, age mix and location.Therefore, even if employers want to becomemore involved in the health screening activity,there is a question mark over how effective itmay be in terms of take up and the directivenature of the screening.
Karol Sikora:I think there is a greater awareness of lifestylehealth risks among UK employees. There ispotential for health screening to be grasped byemployers who do not already do so, by thosethat do but do not actively promote it aseffectively as they could and by employeesseeking to understand what health risks theymay face.
Lucy Quinton:What support is offered to people with cancer?
Hilary Thomas:If you were to look at individual's experiences,they would vary and that may be down simply tothe team and consultant whose care they areunder. Regarding communication, to an extentsome patients make this happen for themselvesby testing the system and asking questions andtrying to fi nd out more. Some of those patientsgo for second opinions and will be prepared tomove and be difficult. A patient may fi nd theyare in a multi-disciplinary team -; they have aspecialist and a nurse in that area and they haveaccess to palliative care support from day one.But in other parts of the country, in other teamsor hospitals, a patient may have to fight for that.
Lucy Quinton:At what stage should people be educated on this?
Teresa Tate:People need information when they need it -; youdo not know beforehand and there is only somuch general education people will take onboard. People do not want to think abouthealthcare until they need it. It is a balance andneeds, as Hilary said, to be easily available at thestart so it should be available for them as theyneed it. Information needs to be available in a lotof different media so it can be accessed indifferent ways.
Chris Oakland:It is important to have a system that providesmore education and more information.Employers have a direct interest in making surestaff have access to information and encouragingthem to engage in making healthy lifestyledecisions because then they can cover a lot ofthis at the outset.
Lucy Quinton:How much do you think cancer care costs in theUK each year?
Karol Sikora:£4.25bn is the Department of Health fi gure,which is just for England and does not includethe private sector which is more expensive. Soon a total cost per capita, it is probably around200 euros per person, which is about the sameas most Western European countries. TheDepartment of Health denies this: it says in theCancer Reform Strategy that it is slightly less,more like 180 euros per person. In reality whatis inexplicable is why access to certain things ismuch poorer in Britain on average. The paradoxis it is possible to get the best and the worst carein the world here.
Hilary Thomas:We know from drug spend that cancer therapiesare at the cutting edge in terms of new treatmentsand costs. We have treatments comingthrough that will become much more widelyavailable but may cost tens of thousands a year.And sadly we continue to spend a vast majorityof that money in the last six months of people'slives. This is not a good investment to UKcompanies and getting some of that investmentupfront to ensure people live longer would bewiser.
Lucy Quinton:How do we ensure people can afford cancercare?
Karol Sikora:The problem we have is that cancer is a diseaseof retired people, just as taking your pension isa disease of being retired by defi nition. Peoplehave to make an investment at an earlier ageand that costs more than they think. It doesn'tmatter how it is delivered - by the State, byprivate insurance. In the end we simply have tospend more on healthcare.
Lucy Quinton:What support is available on the corporate side?
Elliott Hurst:Right now, there is a fair amount of support.Employers can begin to grasp more fully thanthey do at the moment the support out therefrom the different sectors. There is an understandingthat all this information can bebrought together for employers. This would be amethod to facilitate a greater level of healtheducation and awareness in a more cost andinformation effective manner going forward.
Alex Bennett:Employers have not really done anythingdifferent with their benefi t designs for years. Itis inevitable some things are going to changesoon. Though quite what that will be is difficultto tell. But some of the themes that come outwhen you start to ask that question are obvious:only 12% of the population have private healthinsurance to begin with and probably 6% or 7%through a corporate healthcare arrangement. Sofor everyone that has private health insurance,there is another employee who has nothing.
Elliott Hurst:From some research we have undertakenrecently with employers and specifi cally in thearea of cancer benefi ts, looking at the employerbenefi t plan, most of them do not know whatlevel of cancer benefi ts they may have withintheir employee medical plan. The only time theystart to understand it is when they have a verybig claim that has come through on it andobviously there is then a signifi cant cost in theoverall programme budget.
Chris Oakland:Employers have a real conundrum and theirviewpoints change with experience. I had aconversation last week with an HR director whosaid two years ago they would have been lookingat how to save costs. And now that they havehad a big terminal cancer case, they areexamining their whole stance and asking if wereally want to cut somebody's treatment offafter a period of time, because the terms andconditions of their contract say they onlyprovide some cover and access to somechemotherapy drugs for a limited period oftime. People's perceptions are being shaped bytheir own experiences and there is a realproblem of where to draw the line.
Paula Franklin:It is about general ethical challenges allowingpatient choice. We have to remember what theNHS was intended to achieve when it was put inplace.
Karol Sikora:One way forward is to make it more efficient.The other factor is that the NHS is a far fromequitable service.
Hilary Thomas:There is nothing worse than to relapse - and Ihave treated patients in this situation who haverelapsed with their cancer and found theirprivate medical insurance (PMI) has dried up.So while they are adapting to the fact that theyare now terminally ill, they are also transferringto the NHS. Fortunately, thanks to NationalInstitute of Health and Clinical Excellence(Nice) and others, many drugs which perhaps 10years ago were only available to private patientsare now offered on the NHS. But they do not getthe same personalised care, access to a room ontheir own and access to that same space. So justat the time a patient is ill, it is diffi cult for themto go through the last months of their lifeknowing the company they worked for over thepast 15 years had a policy for them that did nothelp them at the end of the day. We need toeducate the public and expect insurers to bemore explicit about what they are offering.
Paula Franklin:That is an interesting point. Certainly whereBupa is concerned, our default position on allour policies is to provide full cover and onindividual policies we do that. Sometimes costmanagement is an issue. In some of those cases,it is a very big issue for the individual who issuffering from the cancer and we are keen to dowhat we can to support them. But the fact oof thematter is the way in which the finances are constructed, the impact of the claim on the costof the policy is very transparent to the employer.
Paula Franklin:It depends who the claimant is. In somecircumstances, depending on the position in theorganisation, we have been requested that it isstopped.
Elliott Hurst:Inconsistent behaviour of employers is only onestep away from discrimination.
Chris Oakland:But this goes outside the corporate sector aswell. You get access to care and better access toeducation if you are educated and you comefrom the right area. It is the savvy consumers ofhealthcare who know where to go and how tonavigate their way through the system.
Karol Sikora:Nice is very good if you look at the analyses butthe diffi culty is they are too long and with someof these drugs it is surprising the cost they cometo is so high. The drug companies dispute it andit is a dance that goes on.
Paula Franklin:Cancer care is our second biggest spend. Wespend twice as much on cancer as we do oncardiac conditions. It is among the top threehighest rates of increase of spend. A huge issueis providing complete cover. The question of howwe are going to manage to continue to providethat level of cover and to provide access to newdrugs is very significant.
Lucy Quinton:Doctors for Reform launched a campaign to helppatients who have been prevented from payingextra towards their NHS care in order to receivedrugs and treatments. Why is there such adilemma when it comes to treating people withcancer who can afford the drugs that the NHSwould not provide? How can insurers play arole?
Paula Franklin:There are a couple of issues. I think the fi rst is inthe future, which is less on the funding side andmore on the provision side. If you have mixedfunding, how do you ensure care is co-ordinated?The other area to be clear on is whatinsurers cover. It is important to be transparentand to let people understand.
Hilary Thomas:Cancerbackup did a piece of work some yearsago about insurers and transparency and aboutwhat policies cover. Often the fact that it doesnot cover treatment once somebody has relapsed is buried in weasel words that says the policydoes not cover chronic conditions. And I havehad lots of semantic arguments with insurersover the years where a patient has relapsed and Ipoint out: "Well, actually this is not a chroniccondition, it is a remitting and relapsingcondition". Some people know how to argue fordrugs that may not yet have been approved byNice but are prepared to get their MP on side,prepared to go to the Strategic Health Authorityand make a real noise in the media in order toget access to that drug. And the drug in realitymay give them just a few more weeks or monthsof life and the incremental benefi t may be verysmall. There is a real ethical balance about howmuch the drug will benefi t that individual. Thatis often a judgement call and is not somethingNice can legislate for because it is very muchabout clinical experience. Now for the publicand for patients, they see that as denying themextra life. It is a very emotive area. I think one ofthe most articulate speakers on this subject hasbeen Lisa Jardine who argued why she did notwant to have Herceptin. There were scientificmerits about how she had relatively low riskbreast cancer and therefore the incrementalbenefit of Herceptin was quite small, which iswhy she chose not to have it. We need morechampions like that so we have a more commonsense approach. We need to educate the publicabout that balance as well.
Chris Oakland:It is a risk management issue as well.
Elliott Hurst:It is a diffi cult balance for employers becausetheir costs increase unless they do somethingquite fundamental. So you go back to what themedical plan looks like and start to plug thoserelatively low incidence, as things stand and howthey will increase, of high cost treatments andcancer drugs. You have to ask the employee andsay you are going to have to start financing someof those high frequency, lower cost, less pressingneeds.
Chris Oakland:There is a real problem for employers withinsome categories of workers, particularly inmanufacturing where they provide PMI to getpeople back to work and there is a conflict ofinterest between employees who are quite happyto stay at home and be paid. Some of them maybe afraid of going into hospital, some of themmay be afraid of going back to work and it isdifficult to sometimes distinguish between thosepeople. So yes, there is that aspect and,increasingly, employers will see PMI as a deviceto manage absenteeism and risk as well.
Lucy Quinton:The Choice to Die at Home campaign waslaunched back in 2004. How do you think thishas impacted on care for patients?
Paula Franklin:We are implementing a programme that isfocusing on achieving that.
Hilary Thomas:It is a question of education again. We know thevast majority of people would prefer to die athome, we need to educate people quite early onafter diagnosis to realise they can exercise thatwish. But it requires a degree of co-ordination.
Elliott Hurst:From a medical benefi ts perspective, we face therelative absurdity that if someone has anepisode of surgery and they require regularrecalls, which may be accessed under the NHSbut they have associated their treatment withthe private sector, then at a certain point, thoseongoing consultations and tests should not becovered.
Hilary Thomas:The first is the driver of the care they receiveshould be the clinical situation. So the clinicianshould be deciding with the patient what isappropriate, what level of follow up, how muchsupport they need and so on. And that shoulddictate the point at which it is no longer coveredbecause it is no longer necessary. I think it needsto be joined up in that sense. One of the thingsthis highlights is the difference in people'sexpectations. Individuals' expectations whenthey have private care are that it will pay forwhatever they need, or rather, whatever theywant, regardless of if they need it or not.
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