Madam, – I note with interest Mr Fintan O’Toole’s report in which he states that the degree of failure to meet minimum standards (with respect to breast cancer care) at Waterford’s cancer centre would surprise even critics of “centres of excellence” (April 24th). One was led to believe that no cancer services were to have been moved to any so-called centres of excellence until the new service would surpass care already being delivered in local hospitals.
While I have no evidence one way or another as to standards of care previously on offer in hospitals in the south east, it is alarming that transfer of services has taken place when 36 of 48 national minimum standards for quality and safety were deficient. This report is most surprising and flies in the face of assurances from Prof Tom Keane that services would only be transferred when improved services were guaranteed to be available. In fact it appears that centralisation in this area has not thus far resulted in achieving the quality promised by proponents of the centralisation model.
Is this a breach of trust? In the subsequent media coverage, the Minister for Health was quick to come on radio in defence of the strategy, clearly indicating her unease at the potential scandal brewing. In the course of discussion she volunteered that breast care services in Sligo would have to close because “volume equals quality”. I would disagree fundamentally with such a simplistic assessment of a multifactorial problem, namely the diagnosis and management of breast disease.
Such patients require technical expertise which should ideally be provided as close to home as possible. For those who receive a diagnosis of breast cancer, the distress that goes with it can be alleviated if they have the support of family and loved ones close at hand. It adds the burden of distance to people who are distressed both physically and emotionally is nothing short of cruelty, as a number of experienced general practitioners recently reported to me.
The closest “centre of excellence” to Sligo, namely Galway, represents a 170-mile round trip. Given the lack of road and rail infrastructure this represents a considerable challenge to all patients and perhaps an insurmountable one to some, such as the elderly, those already infirm, and the unemployed. This contrasts sharply with patients based in Dublin, for example, where I suspect proximity to any one of the four cancer centres would not be an issue.
In the north west a functioning specialist breast service has been in place since February 2001, as advised by the original report on symptomatic breast disease services (Prof Niall O’Higgins, 2000). This includes a fully functioning multidisciplinary team with all relevant specialities meeting on a weekly basis, thus ensuring that the highest standards of care are delivered to all patients. Attendance at this meeting is recorded, ensuring that all relevant opinions are canvassed and incorporated into individual patient treatment plans. A dedicated one-stop breast clinic with immediate triple assessment (ie clinical, imaging and biopsy service) operates on a weekly basis ensuring speedy and accurate diagnosis for all urgent cases, thus allowing progression to treatment within a rapid timeframe. In contrast to the south east (as reported on radio), no patient has had to leave Sligo to obtain a stereotactic guided biopsy as this complete service has been available locally since 2001.
The outcomes for patients with breast cancer treated in Sligo are of the highest standard, a fact that is all the more commendable when one appreciates that the national breast screening programme(Breast Check) has not, to date, been fully rolled out to the catchment area served.
In terms of compliance with the National Minimum Standards Assessment (Non-Designated Hospitals: Health Information and Quality Authority, June 2008), the Sligo unit scored very highly in all 12 areas of assessment (minimum score 87.6 per cent, with seven of the remaining 11 scores above 95 per cent). This illustrates clearly that high quality standards of care and excellent outcomes can be delivered in smaller units, where almost 100 breast cancer patients were treated in 2008 close to their families and friends.
In my opinion this supports the view that case load volume is not a proxy for the skill and commitment that a dedicated team of professionals can offer and deliver. The size of such a team is open to debate and, as the patient should be at the centre of all healthcare issues (not politicians or medical/nursing professionals), such debate must take into account patient access.
The cancer strategy as proposed completely ignores access issues for the people of the north west, and threatens to worsen outcomes for breast cancer in the area, with risks of non-attendance at distant clinics and minimisation/non-reporting of symptoms etc.
I fully support the goal of obtaining the highest standards of medical care (including cancer care) for all the people of Ireland who are entitled to expect this of the public health system. I am personally committed to this goal and make no apology for advocating for it on behalf of the people of the north west. I ask for nothing more or special for this area, but the public should not have to accept anything less. – Yours, etc,
TIM O’HANRAHAN FRCSI,
Consultant surgeon with special interest in breast care,
Sligo General Hospital,
Sligo.