More money for cancer drugs and a better way to coordinate treatments: what's not to like about the National Party's new cancer plan? Well, it's really not that simple.
On the day after National leader Simon Bridges announced his party's new cancer plan, this newspaper revealed a birthcare unit in Mangere is underused for lack of funds. These things are related.
Bridges got a standing ovation at his party conference last weekend, for his proposal to add $50 million per year to the Pharmac budget, ring-fenced for advanced-stage cancer treatments. He also announced there will be a new national agency to coordinate cancer services and funding.
Patient advocacy groups and funding lobbyists were pleased. The plan was especially welcome from National, Cancer Society medical director Dr Chris Jackson said: "The last National government abolished the Cancer Control Council, so we're pleased to see that they've changed their minds about national cancer leadership."
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But will the plan deliver what they want? And is it what our health services need?
Health funding is not easy. Even if, from a political point of view, it can sometimes be made to look like it is. After all, it's obviously wrong that cancer services are not equitably distributed, nationwide; also wrong that cancer treatments are not better funded.
You'd have a stone cold heart not to want to help people who are dying and whose families are being financially ruined in the process.
But that's not the end of the story. Most health services in this country are inequitably distributed. Most need better funding. The Health Quality & Safety Commission reminded us about this in 2018: "As this report has consistently identified since 2015, New Zealand faces issues of inequity and unwarranted variation in the provision of health care."
This is not about cancer. Inequity and underfunding are embedded throughout our health system. The commission also said: "Our health system's inability to address these issues matters. We cannot continue with current approaches and ignore the lack of progress in these important areas."
Inequity and underfunding are embedded throughout our health system.
It wasn't always this bad. In the years 2003-2009, average real growth in New Zealand's health spending rose by 4.5 per cent. But from 2009, following the global financial crisis (GFC), it's been almost flat.
This is not what happened elsewhere. Everyone took a hit from the GFC, but most countries comparable to ours bounced back after a couple of years. We didn't. We are now $700 million behind Australia in per capita health spending. To catch Norway, we'd have to spend another $3 billion.
An obsession with balancing the budget after 2008 deepened inequities throughout our health system. The last Government created that problem and the present one has maintained it.
Example: Kadcyla, used for advanced-stage breast cancer, is unfunded here even though it is funded in Australia. Example: five-year survival rates for bowel cancer are behind Australia's.
But it's not primarily about cancer. We have high rates of hospital admissions for asthma, bronchitis, diabetes, a whole range of the illnesses of poverty. These admissions rates can be brought down through community-based prevention and early treatment. Why aren't we doing that?
I CONFESS to a vested interest in this debate, because I have prostate cancer. It's not terminal, or not yet, assuming my doctors are telling me the truth. And I don't need expensive drugs because the treatments I'm in line for are funded. A three-month dose of my current therapy cost me $5 at the pharmacy. In theory, this is going to keep me alive in the foreseeable future.
So I'm not in the same position as Tracey Elliott, who has become one of the people fronting the campaign to win funding for more "advanced-stage" cancer drugs. Tracey has breast cancer that has spread to her brain. She and her husband Troy are paying $3000 a week for Kadcyla, and have put their house on the market to pay for it.
Troy was at the National Party conference to give a human face to the new plan. The fact is, though, even if the plan was implemented tomorrow it wouldn't necessarily help Tracey. There isn't enough money. There will never be enough money.
Troy says there are 4500 pages on Givealittle asking for help for cancer treatment. If you distributed National's $50 million per year evenly among them, they'd get a little over $11,000 each. For Tracey, that's less than a month's worth of support.
We can't approach cancer funding, or funding for other diseases with expensive treatment options, on the basis that everything will be paid for. Pharmac spent $220 million on cancer medicines last year. Nearly half of it – $100 million – went on just five drugs.
So if you were designing a nationwide cancer plan, how would you spend the money?
How about something like this. First, put good money into public health programmes, especially promoting healthy food, an active lifestyle, not smoking and taking care in the sun. You can't definitely avoid cancer by living well, but you can reduce the risks. The same recipe works for many other illnesses, too: more on that below.
Second, build up the testing and diagnostic services so they are nationwide, equitable and accessible for everyone. With some cancers, that means screening programmes, but with others it doesn't. For melanoma and prostate cancer, for example, screening might not be best.
Sometimes the key is expensive testing: the best available diagnostic test for prostate cancer costs $2900 a pop and you might need it done a few times. It's not available in the public system.
Third, we need treatment regimes that will allow patients to live with the disease and not die of it. Your illness is chronic and managed, not terminal. Such regimes are getting better all the time. Radiotherapy is far more precise than it used to be. New drugs and developments in genetics are changing everything.
This is a real thing: many, many lives can now be saved that once would have been lost. But the key is early detection.
Fourth, we need reasonable funding for those "advanced-stage" treatments, but let's remember: that's a euphemism. Often, they are end-of-life drugs. According to the manufacturer Roche's own data, Kadcyla has been shown to extend life expectancy by six months. It also has fewer unpleasant side effects.
Fifth, we need good funding for palliative care.
UNDER THIS hierarchy we'd spend a lot more on public health, and on diagnosis, and on early and mid-stage treatment. Patients would not wait a year for consultations, as has been happening, scandalously, in Southland.
We'd also spend more on late-stage treatments. Is National's $50 million the right amount? It might be. But I can't see how we can possibly know that – unless we also know how much more it would spend at those earlier stages. The stages where spending more money will improve the lifespan and quality of life for exponentially more people.
In my view, we should not allow the cancer funding debate to be defined by end-of-life drugs.
There's another reason National's plan might not help people like the Elliotts. Kadcyla might not qualify.
Bridges says the money will go through Pharmac and be allocated by clinical experts, independent of political influence. It will be for "proven" medicines.
Pharmac's panel of experts has given Kadcyla a "medium" status. The agency says the evidence to date for the drug is "weak and of poor quality".
In my view, we should not allow the cancer funding debate to be defined by end-of-life drugs.
Advocates for Kadcyla argue Pharmac should subsidise "all of the drugs listed in the European Society of Medical Oncologists guidelines for the treatment of advanced breast cancer". There are 24, of which Kadcyla is one of six not funded by Pharmac.
Breast Cancer Aotearoa chair Libby Burgess says: "It's appalling that our politicians are standing back and leaving women to die when there are effective medicines available to treat them. This has created a two-tier health system – if you can afford to pay for the latest medicines you'll live a longer, better life."
She calls this a "mean-spirited approach" and blames the Pharmac model, established 25 years ago, which she calls an "out-dated system", long overdue for review.
But Pharmac didn't create our "two-tier" health system. It's always been there. Pharmac actually reduced the disparity, because the deals it does with drug companies allow medical care to be spread more widely than would otherwise be the case.
And the Pharmac model is not out of date. In fact, with fast advances in medicine and very clever public relations from drug companies, Pharmac is more relevant than ever. An independent agency that can sift the competing claims, on the basis of both equity and efficacy, and secure good prices from drug companies, is exactly what we need.
The problem with Pharmac is that it's underfunded. This is not a new problem and it needs addressing, and National's plan helps with that. But it isn't just a cancer issue and it's hard to see why it should be treated as such.
WHICH BRINGS us back to that underused birthcare unit in Mangere.
Mangere is in the catchment of the desperately under-resourced Counties-Manukau District Health Board and its principal health facility, Middlemore Hospital. The population served by the board has high rates of poverty and therefore high rates of the illnesses, medical complications and social dislocation that poverty breeds.
In recent years that population has also had to put up with some remarkably poor standards of management and governance.
It's in crisis. The reason the birthing unit, run by a charity, is underused appears to be that the DHB's own maternity-care services need more money. There isn't anything spare to support the Mangere unit as well.
When we're talking equity and funding in healthcare, let's not forget the communities in great need who do not have well-resourced public campaigns to support them.
Also announced this week: Countdown supermarkets will limit sales of energy drinks to people 16 years and older. Is that a good thing? Or will it simply drive all those kids back to the absurdly cheap Coke and Sprite and Mountain Dew?
The manufacturers won't mind: the same companies make all those drinks.
All these things are related. It's sugar, more than any other food ingredient, that is creating a diabetes epidemic, an obesity epidemic, an epidemic of tooth decay.
But where's the nationwide health action plan to deal with this? Led by the Government, activated by public health and education authorities, supported by community agencies, and supported by manufacturers and retailers too.
And if that industry support is not forthcoming, which it won't be, it needs to be legislated. Sugary drinks: let's treat them like tobacco. Public health: let's make it a real priority.
Is that the biggest single thing we could do to improve the health of New Zealanders?
Will we be hearing an announcement on it at a National Party conference anytime soon? Or at a Labour Party conference?