What are the challenges, barriers and solutions to equitable access of cancer treatments?
Another year, another International Women’s Day (IWD)was celebrated on March 8th 2021. I was humbled to be invited to stand with fellow leaders at the Health & Care Network celebrations pledging my commitment in choosing to challenge the barriers to health inequalities in cancer care.
Consultations and calls for evidence alone are not enough as the COVID pandemic has served as a stark signal, highlighting and exacerbating the truth about inequalities within our healthcare system. This truth has stressed the urgent need for effective population health efforts that strongly focus on tackling barriers preventing access to treatments.
It should go without saying that the number one priority of the National Health System (NHS) should always be to improve patient outcomes across the UK. While leaders across the health system no doubt understand this, there are reasons to think that workforce culture and some management approaches do not always working in the best interests of patients or improve patient outcomes.
The starting point is to recognise that, whatever role you are in, you can make a difference. In this blog I will demonstrate how individuals, communities, and organisations can work collaboratively to make a step change in tackling health inequalities, with particular respect to access to cancer care and treatments.
What are health inequalities in cancer care?
Health inequalities are avoidable, unfair and systematic differences in cancer care between different groups of people. There are many types of health inequalities.
The COVID-19 pandemic has brought healthcare and health inequalities into sharp focus. It has been clear from the early stages of the pandemic that some groups are more affected than others.
The research from all-party parliamentary group on cancer (APPGC) into inequalities identified 8 priorities for action relating to barriers of access to treatments including social economic status. For most types of cancer, survival rates are worse for the most disadvantaged groups [source: CRUK]. From the evidence socio-economic status is a fundamental determinant of inequalities in cancer outcomes.
This issue is related to the way the healthcare system is fragmented in the UK. Different and disconnected approaches in each geographical location precludes equitable access to cancer treatments.
The focus on local issues is understandable as there are some regional variations but this results in unacceptable levels of variation in the face of a single evidence base as health officials and leaders are incentivised to prioritise their own region, without considering the makeup of the country’s cancer care as a whole.
This tribal attitude to cancer care isn’t just unhelpful; for unlucky patients in areas where access to cancer treatments is limited, it can be deleterious.
Let’s first consider the heart of the problem: studies show that health inequalities in the UK are a real problem despite efforts to level the playing field in recent years.
Data from Cancer Research UK shows that, while survival rates for most types of cancer have been rising for decades, this increase has been seen more among affluent groups, while the gap between outcomes for affluent patients and disadvantaged patients is wider than ever before. National Cancer Equality Initiative (NCEI)evidence suggest that NHS inequalities projects are often engineered around early diagnosis rather than living with cancer or the operational barriers which prevent equitable access to treatments.
By not understanding the root causes of the barriers, any scaling of or service redesign to combat health inequalities will be difficult
What are the barriers to equitable treatment?
There are many reasons why outcomes are worse for people from disadvantaged backgrounds with complex interactions between them. There are, however, some clear conclusions that can be drawn from existing data.
One factor is that different demographic groups seem to have different perceptions of the risks associated with various lifestyle factors, and this creates large disparities in risk factors between groups. For example, 40 per cent of Bangladeshi men smoke, compared with a national average of 24 per cent.
The health care system has struggled to keep pace with changes in treatment paradigms. Geographical variation, consequent on our fragmented, antiquated healthcare system, exacerbates the problem.
The lack of cooperation between regions and health authorities has led to what is described as a ‘Game of Thrones’ mentality, where each leadership team is effectively fighting for success over another. In a country where the health of the entire nation should be made the priority, this approach and culture is clearly damaging and indirectly killing innovation.
Cancer incidence varies geographically, as does stage at presentation. People in rural communities have higher admittance rates to hospital for cancer treatment than those in urban areas [source: Commission for Rural Communities].
The nature of health services in rural communities may increase the chances of cancers being missed during their early stages. Data from Breast Cancer Now shows that the percentage of breast cancers detected at stage 1 or 2 across the country vary from as low as 36.3% in some areas to as high as 88% in others.
Some of the reasons for the disparity between care for people with secondary breast cancer have been identified by The Cancer Taskforce, who note that some teams do not routinely discuss secondary breast cancer patients, while others do not have access to a dedicated secondary breast cancer Clinical Nurse Specialist. In some areas, information for patients is not always provided, and psychosocial needs are also not always met.
What role does workforce culture play in this?
Improving health outcomes is a joint responsibility and requires collaboration amongst all stakeholders in cancer care. We must act now to ensure that health inequalities between regions do not become bigger in the future.
Evidence suggests there are considerable challenges in spread and focus of the workforce in deprived regions. The quality of care that patients receive depends first and foremost on the skill, compassion, and dedication of staff. The more engaged staff are, the better the outcomes for patients and the organisation generally.
With increased pressures being placed on clinical bodies to deliver patient centered services, with limited supportive teams, strategies for many trusts many are not operationalized effectively. This compounded with limited diversity across the executive boards and CEO’s in our health system may be killing our ability to be innovative, build partnerships and access new ways of working.
Innovation involves taking a step back and looking at what you have and adopting changes that make it better. Only by being open to seeing the flaws and issues in our current system can we innovate a better one.
It can be further argued that over a period of time, leaders can become institutionalised making it difficult to take an objective view on regional services and the effectiveness of those services as the inequality gap between affluent and non-affluent, urban and rural, is allowed to continue to grow. In an article by the Guardian published 2014, it is suggested NHS leaders have a disproportionately large effect on the system, where behaviours create the conditions that either hinder or aid innovation.
To halt and reverse this widening gap in access to treatments we must take a critical view of the failings of our regional system and have the courage to make appropriate changes even if these are radical.
One radical and necessary step taken by Prof Andrew Wardley, has been through the formation of Outreach Research & Innovation Group (ORIG)
About Outreach Research & Innovation Group (ORIG)
In a 30-year journey, devising and implementing service improvements to provide equitable access to cutting edge cancer treatments, Prof Andrew Wardley recognises that good health depends very much on to what extent health and healthcare are a priorities for NHS Leaders, The Government and Society.
As CEO and Medical Director for Outreach Research & Innovation Group, Prof Wardley’s, motivation and determination stems from his passion to provide equitable access to treatments since his graduation in 1989. Unfortunately, due to various workforce and cultural challenges, his vision did not see the upscale or fully developed version of his patient-centred continuous improvement integrated model of care.
Sustainability and transformation partnerships (STPs), especially in integrated care systems (ICSs), require strong relationships borne out of the recognition of need for improvement, and a shared motivation to improve patient care. In the absence of this motivation, patient service will not improve.
Outreach Research & Innovation Group provides healthcare service solutions which complement the growth, sustainability and access to treatments through the development of clinical sites in primary and secondary care.
Through combining a multi-disciplinary approach with deep, practical industry knowledge, Andrew Wardley and his team have helped partners meet challenges across the health services by optimising standard of care delivery and systemic anti-cancer therapy research opportunities.
In less than 12 months, Outreach Research & Innovation Group has identified opportunities to expand the number of clinical sites across Scotland and Wales offering systemic anti-cancer therapy trials, allowing: more patients to access innovative new treatments as they are developed; give oncology teams more treatment options for patients and confidence to use these once approved; accelerate the time for new treatments to enter practice and elevate the standards across the NHS, not to mention economic benefits for all of those involved.
By taking an integrated system approach to cancer care in the UK, Outreach Research & Innovation Group plugs the gaps currently present in the healthcare system, by bringing cancer specialists and transformation strategists together to improve patient care and outcomes while lifting innovation and research.
Those leading deep-reaching and meaningful change efforts often report that it is the relationship with the communities themselves that matter in tackling health inequalities – the notion of not ‘doing to’ but ‘leading with’ and being ‘led by’ staff and communities is pivotal to transformational change. Regardless of the methods, the key to getting to the heart of the community will be collaboration, respect and humility.