NHS RADIOTHERAPY FAILURE

Cancer patients are being systematically let down by the radiotherapy services in England, a damning government report concludes. Lengthy waits and huge variations in service from place to place mean that tens of thousands of patients every year are receiving substandard service, reducing their chances of survival. The report to ministers from a top-level committee, whose broad conclusions were first revealed in The Times last month, calls for urgent action. "Unless action is taken without delay, the Government will lose the opportunity to save lives, and services in this country will fall further behind those of other comparable countries" the National Radiotherapy Advisory Group says.

The NHS delivers 1.5 million courses of treatment every year, when the optimum would be 2.5 million, the report says. Variations between areas are said to be "unacceptable", with the best-served areas delivering two and a half times as many courses as the worst. But it does not specify which areas are bad and which less bad.

Karol Sikora, a cancer specialist, said: "The report shows how bad things really are, but disguises just how bad the local gaps in services are. These areas which have fallen behind must be named too in order to target improvements." Since 1997 the Government has invested more money in radiotherapy, but even this increase has fallen far short. The problems arise from miscalculations made 15 to 20 years ago, when the need for radiotherapy was significantly underestimated.

It was wrongly believed that radiotherapy would not have a key role to play in future cancer treatments and that demand for it would fall. This was a gross misjudgment, as demand has increased and will continue to increase as the population ages. Radiation treatments involve large doses given by linear accelerators, given in a series of smaller doses to reduce injury to healthy tissue. Typically, an entire course might comprise 15 to 40 treatments. The most productive centres deliver more than 10,000 courses per linear accelerator (linac) per year, the least productive only about 5,000.

The report calls for a target of at least 8,000 courses a year immediately, and 8,300 a year by 2010-11. Linacs should be kept running nine hours a day on average, with some running for as long as 11.5 hours a day. They should be operated year-round, including Bank Holidays (with the exception of Christmas Day, Boxing Day, and one day at Easter), and include some treatments on Saturdays. But the report rules out seven-day working because there are insufficient staff and patients may be reluctant.

Michael Williams, Vice-President of the Royal College of Radiologists, and co-chair-man of the advisory group, said: "Radiotherapy is one of the most effective cancer treatments available, but the UK has fallen short in its provision. "This is the main finding of a second report published in the current issue of the journal Clinical Oncology. The research confirms that substantially less radiotherapy is given in the UK than is standard practice elsewhere in Europe and the USA."

Professor Janet Husband, president of the college, said, "The report will be extremely valuable in determining future development and in building on the substantial investment in modern equipment achieved as part of the Cancer Plan."

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NHS DOCTOR-TRAINING MELTDOWN CONTINUES

An emergency review of the appointments system for junior doctors is being dominated by government apparatchiks, leading doctors claim in a letter to The Times today. The system and attempts to rescue it are a fiasco, write Morris Brown, Professor of Clinical Pharmacology at Cambridge, and more than a dozen leading specialists, as doctors prepare to challenge the outcome of the review in court. The hearing, which begins on Wednesday, will seek to have the computer-based Medical Training Application System (MTAS) declared so unfair as to be an abuse of power. It is expected to take two days. Victory for the doctors would leave the Department of Health, which has apologised for the debacle, in confusion.

In their letter to The Times, Professor Brown and colleagues say that MTAS has so far failed every task, and the review set up to rescue it “has become top-heavy with DoH apparatchiks”. The issue, in the Times letter and later today in court, is whether it is fair to allow doctors in England, who have already spent ten years training, a single interview to determine their futures. There are about 32,000 junior doctors applying for about 20,000 posts, which they will take up in August. Nobody knows the exact figures, nor how many of the applicants come from outside the UK. The doctors are mostly in their mid to late20s, and are applying for “run-through” training posts lasting five years, which would end with them ready to apply for jobs as consultants. Hospitals that pick the wrong applicants will be stuck with them for five years, so finding the right ones is crucial.

Applicants who fail to get a run-through post will not necessarily be unemployed but their careers will stall. To get a doctor to this stage costs the state 250,000 pounds in education and training costs. The potential losses would easily exceed 1 billion if, say, 5,000 UK-trained applicants gave up medicine or decided to go abroad. One official, who did wish to be named, blamed the department for a failure to match the expansion of medical schools to an equivalent growth in training posts.

This year, the difficulties are compounded by a failed attempt by the department to exclude foreign graduates. Under European law it cannot exclude EU graduates, but relatively few of them apply. The key is graduates from outside the EU, traditionally one of the mainstays of the NHS. The department attempted to cut off these applicants by saying they would need work permits. A challenge in court by the British Association of Physicians of Indian Origin (BAPIO) was rejected, but leave to appeal was granted. Pending the result of that appeal, the department was forced to allow nonEU doctors to apply in the first round of selection.

Thousands more found another way round, by joining the “highly skilled migrant” programme. They qualified for that by virtue of already working in the NHS as, for example, senior house officers. As a result, it is estimated that between 10,000 and 11,000 of the applicants for the 20,000 posts originate from outside the UK and Europe, maybe half of them through the highly skilled migrants programme. Nobody knows quite how many, nor do the application forms enable hospitals to distinguish home from foreign applicants.

So who is in charge? “Nobody is,” said the official who spoke to The Times. “The system was developed in isolation from workforce planning. So it was impossible to find any one person who would ask: ‘Will this work?’ .” RemedyUK, the pressure group bringing the action, hopes the court will say the process is unlawful, but expects a solution to require negotiation.

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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