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Necessary Health System Trade-offs Should Be Unnecessary

The National Bowel Screening Programme (NSBP), which began in 2017 following a pilot that started at Waitemata District Health Board five years earlier, is a welcome initiative long in its gestation and implementation. The screening programme is for people without symptoms in the 60-74 age range.

Early detection wherever possible goes a long way to protecting identifiable vulnerable population groups making for many death avoidable providing, of course, diagnosis is followed by prompt treatment.

The Labour led government elected in 2017 increased the national implementation tempo with 14 DHBs now in the programme (the most recent being the largest, Auckland). The Ministry of Health expects that the remaining six (Bay of Plenty, Capital & Coast, Northland, Taranaki, Waikato and West Coast) to have joined up by next November. While many people, including health professionals, would have hoped for both an earlier commencement than 2017 and pathway to national implementation, at least there is light at the end of the long tunnel.

According to the Health Ministry, since it began the screening programme has detected cancer in 771 people. Many of these cancers will have been found early and with timely treatment the people concerned should make a full recovery. Indicative of an unintended consequence the Ministry notes that colonoscopy demand has risen close to 30%, higher than the predicted increase of 20%.

Bolt of lightning

But suddenly, although not from left field, a bolt of lightning has been unleashed by Christchurch surgeon Phil Bagshaw and University of Otago cancer epidemiologist Brian Cox. They have just had published a joint medical editorial in the New Zealand Medical Journal identifying harmful trade-offs. Characteristically of both authors they don’t pull their punches.

Bagshaw and Cox argue that the implementation DHB-by-DHB of NSBP has been slow and dogged by having insufficient colonoscopy facilities and too few staff who can perform the procedures. They attribute most of the problems with colonoscopy access to inadequate planning, training and resourcing. While there has been longstanding awareness of the needed workforce expansion, the work done to meet this demand has been too little, too late and largely left to DHBs. In other words, there has been a health system leadership failure.

Competing essentials

This situation has led to some DHBs trading off colonoscopy availability for the investigation of symptomatic cases with the colonoscopy needs of population screening. Bagshaw and Cox rightly observe that this is harmful. Both investigating symptomatic cases and population screening are essential and should not be required to compete against each other.

But they are required to compete. The response of the Cancer Control Agency of the Health Ministry is to recommend that access to colonoscopy for the assessment of screen-positive patients take precedence over access for many symptomatic patients except those graded in the urgent category.

Bagshaw and Cox reject this. They authors make the hard call that screening should be provided only if sufficient resources are available to ensure it doesn’t impinge on assessment of those with symptoms.

If a choice has to be made then necessity suggests that the identified (symptomatic) should take precedence over the unknown. The surgeon and cancer epidemiologist are right.

Let’s not normalise poor health system leadership

But there is a much more important issue. The necessary hard choice should not be necessary in a health system as developed as New Zealand’s. National health system planning, especially workforce in such a labour intensive sector, is weak. Funding, as the authors point out, is important but there could be more fiscal robustness to funding if we had more effective workforce planning.

Unless we accept that poor health system leadership should be ‘normalised’ there is no excuse for allowing a situation to develop where there has to be a trade-off between the health and mortality of those who are symptomatic and those in a population group more susceptible than other groups to bowel cancer.

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