Phase 5 Case Study: Delivery of the Second National Cancer Strategy 2006

With some exceptions, such as paediatric cancer, Ireland was performing poorly by international standards in relation to cancer risks, incidence, and survival. The fragmented delivery of cancer services was out of sync with best practice. Cancer services were spread across 36 hospitals and many with treating a small number of people and lacking full multidisciplinary teams. There was poor access as well as inequity in the provision, availability, and performance of cancer services when examined by region, gender, and by social class. The aim was to develop a cancer control system with the potential to achieve population and individual outcomes on a par with the highest international standards.

The HSE published a plan which specified that eight hospitals were to be designated as cancer centres. These would provide primary curative surgery with full multidisciplinary care. The National Cancer Control Programme, led by Professor Tom Keane, was established. Its remit was to lead and implement the reorganisation of cancer services and set up a system of quality assurance designed to improve the care and outcomes for cancer patients. (15)

(15) NCPP (2014) Report on the Implementation of ‘A Strategy for Cancer Control in Ireland 2006. Available at https://www.drugsandalcohol.ie/23368/1/NCCPHSE%20strategy%20cancer%202006.pdf

In a later testimony to the Oireachtas (16), where the implementation of the cancer strategy was described as one of the most successful examples of reform in the health service, Professor Keane described the delivery process as comprising three vital elements; communication, legitimacy through evidence, and leadership:

Communication: Professor Keane noted that communication took up 50% of his time in a variety of different settings and to different audiences. He stated that communication about change was his first and most important priority and he engaged with the political system, medical professions, and the relevant unions. It is important to note that he set parameters on this dialogue and refused to revisit the strategy’s guiding assumptions lest it delay implementation.

Legitimacy through evidence: A core pillar of the National Cancer Strategy’s success was its reliance on robust evidence. Professor Keane highlighted that a substantial portion, about 80% to 90%, of the strategy’s foundation was built on international literature and experiences from other nations. This evidence conclusively indicated that Ireland’s cancer care practices were suboptimal. By comparing against international benchmarks like the OECD cancer outcome rankings, it was evident that Ireland's cancer outcomes were in the lower quartile. This compelling data-driven analysis underscored the need for major change, eroding any doubts about the legitimacy of the strategy’s objectives.

Leadership: Professor Keane stressed the important of leadership at different levels. Oncologists were a vital community to lead on this initiative. They were receptive to the data analysis underlying the strategy, as were other medical groups such as coloproctology society representing most of the relevant surgeons. Support at ministerial and departmental level was also stressed.

While setting out with a clear plan is crucial to delivery, Professor Keane appreciated the need for constant engagement with people affected by the proposed decisions. As the above example shows, communication with a variety of affected parties can be vital parts of delivery but should not be an excuse for not implementing policy.

Monitoring and evaluation: One final issue not addressed in the above is the importance of monitoring and evaluation in providing either assurance that interventions are producing the expected results or else signalling that things are not going as planned. The implementation of the cancer strategy was assisted by the monitoring of key performance indicators (KPIs) that would demonstrate whether it was being successful. For example, you can see in the diagram below that the survival rate for males from cancer in 1994 – 1999 was just over 40% (41.5%: 4 out of 10 people). However, the survival rate for males in 2005 – 2009 increased significantly. It was almost 60% (59.6% or about 6 in 10 people). (17)

(17) National Cancer Control Programme (2014) Report on the Implementation of A Strategy for Cancer Control in Ireland 2006. Available at https://www.drugsandalcohol.ie/23368/1/NCCPHSE%20strategy%20cancer%202006.pdf