ANALYSIS:The degree of failure to meet minimum standards at Waterford's cancer centre would surprise even critics of 'centres of excellence', writes FINTAN O'TOOLE
OVER THE past two years, as the health system was rocked by repeated misdiagnosis of breast cancer, Minister for Health Mary Harney repeated the same reassuring line.
The official response to revelations of serious errors in the cases of Rebecca O’Malley and of women seeking treatment at Portlaoise and Barrington’s hospitals was to push ahead with the strategy of centralising diagnosis and treatment in eight specialist centres.
Mary Harney described this policy as “the best and only realistic assurance to patients that cancer diagnosis and care will be of the highest quality”.
Breast cancer diagnosis and surgery is being stopped at 25 smaller centres and concentrated in the eight flagship hospitals.
The damning review by the Health Information and Quality Authority (Hiqa) of one of those centres, Waterford Regional Hospital, raises very serious questions about the implementation of this strategy. While much of the opposition to the “centres of excellence” plan was fuelled by resentment at the loss of local services, there have also been fears that overcrowding and lack of staff at some of the designated hospitals may undermine the policy.
The review of Waterford Regional suggests those fears have been well grounded. While the results are particularly stark, they are not thought to be grossly out of line with similar reviews at the other seven hospitals.
Waterford Regional became, by last October, the sole centre for its own patients and also for those currently treated in St Luke’s Hospital, Kilkenny, South Tipperary General Hospital in Clonmel and Wexford General Hospital.
The assessment benchmarks the breast cancer services at Waterford Regional against the national quality assurance standards for symptomatic breast disease services, which were launched in May 2007. These “minimum standards for quality and safety”, the review says, define “the features of a well-functioning specialist breast disease centre”.
The aim of the assessment process, according to the authority’s chief executive Dr Tracey Cooper, speaking in February 2008, is to highlight “key issues needing to be addressed in advance of the HSE plan of transition from multiple diagnostic centres to eight specialist centres”.
The intention, in other words, was for the services at the relevant hospitals to be brought up to scratch before treatment was discontinued at smaller breast cancer clinics. Instead, as the Waterford report reveals, those key issues were very far from being addressed even as patients were being directed to the new centres.
A spokesman for the authority told The Irish Times yesterday that the review process across the eight hospitals has shown that while “there are different levels of compliance across the eight centres”, “no one is 100 per cent compliant”. He declined to give further details in advance of the planned publication of the assessment reports “in the latter part of this year”.
It may not be surprising that none of the centres is able to meet all the minimum requirements for safety and quality, but the degree of failure highlighted in the Waterford review is far greater than even most critics of the policy would have expected. Of particular concern is the evidence that the fundamental benefits of the policy – medical staff performing a critical mass of procedures and fully integrated multidisciplinary teams – are not being delivered.
On the first issue, it is clear from the report that key members of the Waterford medical team were not performing the required number of procedures. Of the need for all relevant surgeons to perform at least 50 breast operations a year, the report says that Waterford was not even measuring whether this was happening.
It adds that a “snap-shot audit” that was conducted within the hospital “did not provide adequate evidence to demonstrate that the centre was meeting the standard”.
Likewise, radiographers are supposed to do a minimum of 20 mammograms a week. Waterford was found to have no routine measurement of compliance with this standard, but a “snap-shot” audit for the first nine months of 2008 found that “the centre was not meeting the standard for that period”.
On the question of fully integrated multidisciplinary teams, the review found that Waterford was again not meeting standards. Instead of having two consultant radiologists “fully trained and with continuing expertise in all aspects of breast disease”, Waterford had one specialist breast radiologist who also “does general radiology on call”.
While the standards demand “one whole-time equivalent radiation oncologist dedicated to the specialist breast centre”, Waterford had no dedicated radiation oncologist post and instead of being integrated in a team, these services were provided by an external third party. Instead of having one specialist breast cancer nurse per 50 patients, Waterford and the other hospitals in the region had three for 218 patients – a ratio of one for 72.
The functioning of the multi-disciplinary team (MDT) also fell short of the standards. There was no “adequate evidence to demonstrate that each MDT member attends all weekly meetings”.
While consultant surgeons are meant to attend at least one diagnostic clinic a week, “the centre did not provide any evidence to illustrate compliance with the standard”.
Perhaps most critically of all, Hiqa found that Waterford Regional was unable to ensure timely access for urgently referred patients. The standards require that in at least 95 per cent of cases, “an urgent triaged patient referred by a GP should be offered an appointment to attend the specialist breast centre within two weeks”.
A date for a surgical operation is supposed to be given to a patient within three weeks of the decision to operate. Urgent patients should have all their radiography images done within six weeks, and routine patients within 12 weeks. None of these standards was being met.
A spokeswoman for the National Cancer Control Programme, which is implementing the cancer strategy, told The Irish Times: “Additional radiology, histopathology, nursing, radiography and medical laboratory scientist staff have been appointed, augmenting the staff who were already in place and those who moved to Waterford Regional Hospital to support the transfer of breast services.
“All new patients are seen by a multi-disciplinary team with a specific interest in breast disease. The target of 95 per cent of urgent cases to be seen within a two-week period has therefore been surpassed. All women deemed clinically urgent have their required triple assessment diagnostic procedures at first attendance.”
The NCCP was satisfied, she said, “a high quality, safe service is being delivered” at Waterford, while recognising that further progress is needed in some areas.