As advisers draw up a blueprint for cancer care, they would do well to take into account public opinion, says Martin Wall.
When the members of the National Cancer Forum met at Government Buildings in mid-July, one of the documents up for discussion was a report on communications which emphasised how important it would be for the advisory body to sell the controversial recommendations contained in its forthcoming blueprint on cancer care.
The history of Irish medico-politics is littered with expert group reports which ran into trouble in the face of public hostility.
From the Fitzgerald report on hospital reform in 1968 to its distant off-spring - the Hanly report last year - their recommendations may have made good medical practice but were extremely dangerous politically.
What the National Cancer Forum will have to do when its new strategy is published in the autumn is to sell it to a somewhat sceptical public that it would be in their long-term interest if cancer surgery services were centralised in regional or supra-regional centres.
The report cites the medical literature as indicating that the outcome for patients with common cancers is better where large numbers of people are treated under multi-disciplinary teams of doctors and other healthcare professionals.
The message coming from the forum appears to be that the era of virtually every hospital in the State doing a bit of everything in the area of cancer surgery would have to come to an end.
Around 20,000 people in Ireland are diagnosed with cancer every year and about 7,500 people die from the disease annually.
However, cancer services in Ireland are improving - albeit coming from a low base. Since 1996 the Government has invested heavily in this area, appointing up to 60 additional consultants, and the return has been a significant reduction of more than 15 per cent in the mortality rates in persons aged under 65.
While the Government's first national cancer strategy concentrated largely on establishing oncology services around the State, the second one, due later in the year, will, in essence, examine structures.
And it is precisely here that the potential trouble lies. For while nobody could object to the appointment of dozens of additional cancer specialists and the investment of millions in improving services, decisions on the organisation and indeed the re-organisation of these services could be more problematical.
However, in its confidential internal discussion document, revealed in The Irish Times last week, the forum is adamant that the current fragmented structure has to change.
It notes that two-thirds of surgeons providing breast cancer services carry out fewer than 10 procedures annually. It also highlights significant variations in treatment patterns and survival rates depending on where patients live. The report maintains, for example, that patients with breast cancer in the south of the State have a significantly lower survival rate compared with their counterparts in the east.
Similarly, women with colorectal cancer in the mid-west have a significantly lower survival rate than those with the condition in Dublin, Wicklow and Kildare.
"The current arrangements for the delivery of cancer services are not generally in accordance with best practice.There is insufficient case volume to support the number of consultants and hospitals engaged in oncology surgery," the report states.
The document also contains a comment from Comhairle na nOspideal, the State body that regulates consultant appointments in hospitals, which is even more stark.
"Comhairle accepts that there are a significant number of consultants doing small numbers of certain procedures and this may lead to worse patient outcomes," the document states.
The cancer care reforms as envisaged by the forum would see the establishment of a small number of expert cancer centres delivering or directly leading the delivery of care to those with cancer.
Each of these proposed centres would deal with a minimum population and the report makes clear that the level and type of equipment made available to each would depend on the type of activity being carried out there.
When the forum meets again next month it will have two separate models from which to choose.
One model would see the development of four cancer networks - mirroring the division of the State into four administrative units as part of the Government's broader healthcare reforms.
The second model would see specific hospitals which believed they had the appropriate staff, facilities and expertise seeking accreditation for the treatment of certain types of cancer.
For example, one hospital in Dublin could specialise in lung cancer, another in breast and a third in brain or pancreas, etc.
The downside would be that small hospitals with relatively low numbers of patients would lose surgery services for some cancers.
However, senior figures on the forum have stressed that these hospitals could take a lead role in the network in the provision of some medical oncology services - largely the administration of chemotherapy - or by carrying some other kind of cancer surgery.
But local communities have traditionally guarded their local hospital services jealously. Under Hanly, for example, smaller hospitals would lose full-time accident and emergency and maternity facilities but would gain from the appointment of additional consultants and the provision of additional elective or non-urgent medical services. Local community groups that opposed the plans were sceptical that once the cuts were made that the investment promised in return would ever materialise.
Already the opposition to the National Cancer Forum proposals are growing.
Independent Mayo deputy Dr Jerry Cowley told The Irish Times that if centralisation and large numbers of patients were required to maintain services, the Government should close down all hospitals and send everyone to London.
He said the centralisation plans did not take account of the human factor and the remoteness of some parts of the State. He said it was virtually the same distance for some of his constituents in north west Mayo to travel to Galway as it was for people in Dublin to travel to Galway.
The communications strategy given to members of the forum last month said that one of the challenges facing it was to create an understanding among the public of the need for the proposed centres of excellence in delivering care to patients.
It said the potential pitfalls were that the strategy could be seen to withdraw services from areas without just cause and that the forum itself be viewed as a group that didn't take into consideration what the public wanted.
It seems like the forum members will need to take this advice to heart when promoting the new strategy in the months ahead.