Diana Sarfati has possibly the toughest job in New Zealand. Back in September, the former public health physician and cancer epidemiologist was appointed by the Government to establish a national cancer agency to work with DHBs to ensure they meet national standards, soon to be introduced – in a bid to save hundreds of lives each year. The Herald speaks exclusively to Sarfati about the hard climb ahead.
Within 10 years Kiwis battling cancer will have the same chance of beating the deadly disease as those who live in Australia – something that would save about 800 lives every year.
That's the goal New Zealand's new interim cancer boss Diana Sarfati has made, telling the Herald by 2030 our country should be providing world-class care regardless of where they live.
Currently, New Zealand ranks bottom of the pile for cancer survival rate of improvement, when compared to other countries with similar health systems. About 800 Kiwi cancer patients who die each year in New Zealand could be saved if they lived in Australia, the Cancer Society has estimated.
It's an issue Sarfati has dedicated much of her life investigating.
In a wide-ranging interview with the Herald, Sarfati outlined how we can not only stop the gap from widening, but close it completely.
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Sarfati, who lives in Wellington, said dramatically improving cancer care in a decade was "absolutely achievable", because countries like Canada and Australia had already done it.
"We know both Australia and Canada have been much more proactive in having national approaches and carefully monitoring what they do and have seen improvement as a result, and we have not tended to do that," said Sarfati, who has advised on international health reforms.
The 51-year-old said ensuring District Health Boards and GPs were held to account was a priority. Currently, there aren't clear national targets or standards so it's difficult to monitor performance effectively, she said.
Changing that would happen by the end of next year, she said – giving poorly performing DHBs no place to hide. Then, both the carrot or the stick might be used.
"There are a number of approaches we can take from softer approaches like pointing out that their services are falling behind and helping them improve, to harsher responses which would include getting the health minister to write a letter of expectation, Sarfati said.
"[At the moment] we don't have the capacity to look at all that stuff and show the minister what it is we are expecting, so we need to start planning and thinking about it."
What can we learn from overseas?
University of Auckland Professor of cancer epidemiology Mark Elwood told the Herald New Zealand had been slipping further and further behind our counterparts for some time.
"We now have got several studies showing that if you compare the outcome of patients diagnosed with cancer in New Zealand to Australia, they do much better than us, as do other countries.
"And we know that the gap is widening because our extent of improvement is the very low."
Rami Rahal leads an agency in Canada similar to what Sarfati will oversee in New Zealand, and has been advising her and Health Minister David Clark. He told the Herald that having good data on how patients were being treated was crucial.
"You need to be able to know where you're going and know if you're getting there.
"It's also important for New Zealanders to know how well their system is doing and the extent to which the plan is making a difference."
Another way places like Canada, the United Kingdom and Europe have improved outcomes is by having specialised centers for highly complex surgeries. Patients needing a specific type of surgery go to whatever city the centre is located in, with travel costs covered.
The Netherlands introduced centralised centres for pancreatic surgery in 2006. Two-year survival rate for pancreatic cancer increased from 40 per cent in 2005 to 55 per cent in 2008.
The Cancer Society of NZ argues the centralised system is why our survival rates for childhood cancers compare well international, because we have two specialised centres – one at Auckland's Starship Hospital and the other at Christchurch Hospital.
Could such an approach be expanded for adult cancer care? Sarfati didn't rule it out, but said the national cancer plan was in its infancy, and other possible approaches were still being considered.
Flying people to a specific place for surgery would only work for highly complex operations, she said, and straightforward procedures like removing a tumour in the breast would always be delivered in local hospitals.
"The biggest issue when you look at centralising cancer services is ensuring people still have access, so building that into the service would be absolutely critical."
Past failures and Pharmac
Establishing a ten year cancer plan is nothing new. There have been previous efforts to fix things, including the first cancer plan in 2003 and major reforms in 2011.
Sarfati said the 2003 plan was an "excellent" strategy, but failed because it allowed different systems and approaches by the country's 20 DHBs. That led to examples of so-called "postcode healthcare".
Differences between DHBs could be a good thing, she said, but treatment outcomes and survival rates needed to be similar.
"There is still room for regional innovation, and we want to hold onto that, but at the same time be identifying the gaps and closing them."
Sarfati's time in the role has already sparked controversy. Patient advocacy groups have been campaigning for an overhaul of the Government drug-buying agency Pharmac, with heartbreaking stories emerging of people unable to afford potentially life-extending drugs.
Shortly after her appointment, Sarfati voiced reservations about greatly expanding the Pharmac budget, telling Stuff that, "We do have limited resources...if we spend massively on drugs, there's something else that we can't spend on."
Advocates including chair of the Breast Cancer Aotearoa Coalition, Libby Burgess, fired back, saying it was extremely disappointing to see improved access to cancer medicines not included in Sarfati's priority list.
"While everyone agrees that cancer prevention is the ideal, it's just not possible for many types of cancer, and it does nothing for the thousands of New Zealanders who are already living with advanced cancer," Burgess said.
The backlash appears to have had an effect. Sarfati made it clear to the Herald that she wouldn't prioritise prevention over life-saving or extending medicines, and said she'd met with Pharmac just two weeks after her appointment, to talk about increasing the spend, transparency and clarity of their decision making.
"Cancer drugs are a really critical part of that cancer care process and for some they are the only treatment available."
The new agency is expected to be officially up and running in about three weeks. Patients, health workers and academics alike are waiting to see how quickly it can help the thousands of Kiwis in the fight of their lives.
For Sarfati, dramatically improving cancer care in New Zealand is a lot more than a day job. Like most, she too has watched loved ones battle the system on top of the deadly disease.
"By in large we have a good health system, we have good health professionals who are working to the best of their patients but that doesn't stop people from missing out on the care that they need."