ADVISORY GROUP REPORT ON CANCER SERVICES

In April 1995 a report by the expert advisory group on cancer to the Chief Medical Officers of England and Wales was published, entitled "A Policy Framework for Commissioning Cancer Services".(1)

This has widely become known as the Calman Report. (This report needs to be distinguished from the Calman Report concerning the new training for doctors). The aim of the report is "to create a network of care in England and Wales which will enable a patient wherever he or she lives to be sure the treatment and care is of a uniformly high standard". This is certainly an exciting challenge within the cancer field. However, it remains unclear if there will be added resources to fund further development or reconfiguration of services.

How is this network to be created? It is to be based on establishing different levels of cancer expertise from primary care to tertiary centres.

The cancer unit

It is envisaged that a Cancer Unit would normally be a district hospital and would be integrated into general hospital services. These Cancer Units should be able to manage the more common cancers, for example breast, lung and colorectal cancer. Clinicians and surgeons will become more specialised in one tumour type, thus giving a specialist service. As well as the medical expertise in the Cancer Unit, there is recognition that involvement of the multidisciplinary team in the care of cancer patients is important and nursing care for patients must be planned and led by nurses who have post-registration education in oncology. Nursing expertise must also be available for cytotoxic chemotherapy administration, site specific expertise eg breast care, and also for counselling and symptom control. Each Cancer Unit has to appoint a lead clinician who organises and co-ordinates the whole range of cancer services provided. Cancer Units are identified as playing an important role in education and research.

The cancer centre

The Cancer Centre like the Cancer Unit, it is envisaged, would be part of a large general services hospital, thus integrating with the hospital services and as well as providing the services of a Cancer Unit, will in addition offer a range of specialised services, including the treatment programmes for less common cancers.

It has been recommended that these centres should serve a population of at least 1 million.

A Cancer Centre would provide the following services:

• full range of radiotherapy facilities
• medical oncology, including intensive chemotherapy
• bone marrow transplantation and peripheral blood
• stem cell support
• the assessment and management of rare cancers
• paediatric and adolescent cancer services
• specialist surgical services, including plastic and reconstructive surgery

The Cancer Centres would work in close collaboration with the Cancer Units. Cancer Centres are also identified as being centres which will be involved in education and research playing a focal role for co-ordinating clinical trials.

Primary care

The advisory group recognises the partnership in continuing care between the Cancer Units, Cancer Centres and Primary Care. Important in this are local guidelines for the identification and management of malignancies, what constitutes best care, the establishment of local referral patterns, effective communication and discharge information.

Palliative care

As yet I have not mentioned palliative care in this article, and indeed it should not necessarily stand alone. However we are fortunate that the development of palliative care within the United Kingdom has reached such a high level of effectiveness and acceptance that it features in high profile within this report. It highlights that palliative care should be a seamless service across the Cancer Unit/Cancer Centre and Primary Health Care sectors. It also highlights that palliative care should be associated with patients early in the disease as well as in terminal stages. It outlines that specialist palliative care multidisciplinary teams should be working in Cancer Centres, Cancer Units and in the Primary Health Care setting, giving patients equity of access. It describes the multidisciplinary team as including Medical and Nursing staff, Social Workers, Physiotherapists, Occupational Therapists and that other disciplines, such as Dietetics and Chaplaincy should be available.

It also recognises the somewhat patchy development of specialist palliative care services, particularly in relation to hospices and urges Health Authorities to avoid duplication of services, as they continue to rationalise and form strategies for specialist palliative care.

I think it is appropriate to highlight at this point in the article the recent publication from the National Council for Hospice and Specialist Palliative Care Services, entitled "Specialist Palliative Care - A Statement of Definitions".(2) In this a distinction is made between The Palliative Care Approach and Specialist Palliative Care. The Palliative Care Approach aims to promote both physical and psychosocial well being, and is an integral part of all clinical practice, whatever the illness or it's stage, informed by knowledge and practice with palliative care principles. Specialist Palliative Care Services are those services with palliative care as their core speciality. Because of the nature of the needs they are designed to meet, they are analogous to secondary or tertiary health care services. They require a high level of professional skills from trained staff and a high staff-patient ratio. They can support the patient wherever that patient may be; at home, in residential care or nursing home, in hospital day centre or in a specialist unit.

This access to specialist palliative care throughout the course of a patient's cancer journey is important if patient's symptoms, psychosocial and spiritual problems are to be fully addressed and managed. It is important that palliative care specialists work in close conjunction with their colleagues in order to provide the maximum quality of life for their patients.

We also need to be aware that increasingly evidence-based medicine demands us to provide more research to back up our practice and that audit regarding outcomes not just of longevity but also of quality will be increasingly required.

Implementation

There is great activity in most health care settings regarding the Calman Report. In the near future Cancer Centres and Cancer Units will be designated throughout the country. These centres and units must demonstrate that palliative care is an integral part of the service.

It is important that people working in palliative care are part of the decision making process regarding the development of cancer services and therefore should be aware who is the lead clinician in their local district general hospital and also of any strategy or working parties that have been formed in the Health Authority around the implementation of the Calman Report.

The opportunity to develop further the specialist palliative care services throughout England and Wales is indeed welcome. Alongside this we need to be sure that the education of health care professionals in the palliative care approach continues and facilitates the work of specialist palliative care professionals.

References

1. A report by the expert advisory group on cancer to the Chief Medical Officers of England and Wales: "A policy framework for Commissioning Cancer Services", April 1995. HMSO.
2. National Council for Hospice and Specialist Palliative Care Services: Specialist Palliative Care - A Statement of Definitions 1995. NCHSPCS.