The aim of national cancer screening programme is to reduce cancer morbidity and mortality through early detection. The NCSS provides population based screening through its BreastCheck and CervicalCheck programmes and is currently in the pre-implementation phase for colorectal screening which will begin in 2012. These programmes are consistent with Government policy and international best practice on cancer control.
High Level Objectives for screening programmes in 2011 are:
BreastCheck: Screening target for an effective national programme is 140,000 women between the ages 50 – 64 .
CervicalCheck: Screening target for an effective national programme of 240,000 women between the ages 25 – 60.
Colorectal: Pre-implementation phase for colorectal screening programme.
Appoint 20 Advanced Nurse Practitioners, designate candidate colonoscopy screening units, and set quality standards for all elements of the programme.
10.3.2 Programme Effectiveness
Cancer screening programmes are proven to be cost effective. Early detection of cancer through population based screening can reduce the overall costs of cancer treatment. Irish survival rates for breast and colorectal cancer are lower than the EU average. As cancer is a disease associated with ageing, early detection through screening services will reduce the curative costs associated with cancer control.
10.3.3 Programme Efficiency
BreastCheck: Over 122,000 women were screened in 2009 while 119,000 were screened in 2010, against an annual target of 140,000 for an effective national programme. The average detection rate of the programme is around 7 cancers per 1,000 women screened, so one could extrapolate that the programme therefore potentially failed to detect up to 140 cancers in the 20,000 unscreened women.
Even though adequate funding has been provided to run an effective national programme, the NCSS reports that a shortage of radiographers made the national target impossible to achieve. In 2009 it required an additional 30 WTE radiographer posts to complete national expansion. The situation was further compounded in 2010 by the effects of the
Employment Control Framework. A screening target of 140,000 women has been set for 2011, but it is unlikely that this target will be achieved.
The Programme for Government specifies that BreastCheck should be extended to women aged 65–69 in keeping with best international practice. The NCCP will undertake further assessment of how efficiencies within the BreastCheck model may result in savings that could be assigned towards extending the programme. Areas such as the call/recall model and better integration with symptomatic services at surgical stage have been suggested. It will use the findings in HIQA’s 2009 “Report of the evaluation of the use of resources in the national population based cancer screening programmes and associated services” to assist in this process. There is an urgency on completing this review in order to identify how BreastCheck may be extended as quickly as possible.
Table 10.3: Numbers of Women Screened and the Cost of BreastCheck 2007-2010.
Year 2007 2008 2009 2010
Women screened 66,527 90, 834 122,000 119,000
Expenditure €m 16.5 22.1 21.7 22.4
The utilisation of separate databases and call/recall systems for CervicalCheck and BreastCheck must result in inefficiencies. However, because these programmes were
‘inherited’ from existing HSE programmes and there is no national database or unique identifier to streamline databases, it is difficult to see how this can be addressed in the short - term. The Health Information Bill, being drafted by the Department, will provide for a unique health identifier.
CervicalCheck: The number of women screened in 2009 was 281,202 and the provisional figure for 2010 is 329,541. While these figures include some repeats the number screened is well above the target for an effective programme of 240,000 per annum. (Figures for 3 years are required to provide an accurate average detection rate).
Table 10.4: Cervical Check Activity & Expenditure 2009-2010
Year Women Smeartaker fees
(€m)
Total Prog Cost (€m)
2009 281,202 15.17 37,685
2010 329,541 15.879 41,547
The NCSS intends to use the CervicalCheck database system as the IT platform for the national colorectal screening programme and the HSE will also use this for a diabetic retinopathy screening programme (i.e. added value for another non-cancer programme).
Reductions in professional fees under the FEMPI Act have reduced the cost of CervicalCheck by 12.6% of the original fee payable (8% in 2009 and 5% of the fee in 2010), but these savings were returned to the Exchequer rather than assigned to other screening programmes. Because such a large proportion of costs in this programme relate to fees to GPs, it is felt that it would be difficult to find significant savings in other areas of the programme. In the next few years CervicalCheck will introduce a system of HPV testing for women who have had excisional treatment for CIN under the programme (approximately 6,000 per annum). At present these women must return annually for 10 years following this procedure. If the HPV test is negative they will not require the annual cervical smear. No details have yet been provided about the costs or potential savings that this initiative will yield.
The 2009 review by HIQA highlighted the potential for a number of efficiencies and cost savings. On assessing its resources, the NCSS was able to fund the pre-implementation
phase of the colorectal programme from existing resources. HIQA also recommended that the NCSS should:
Carry out a full analysis of non-pay spend to identify areas where further savings were possible;
Implement a year on year cost improvement programme to deliver at least 2% per year efficiencies in costs;
Use existing managerial and administrative staff in the development of the new colorectal programme.
Colorectal cancer screening: A Health Technology Assessment by HIQA (2009) reported that “internationally, screening for colorectal cancer has been considered to be cost effective and occasionally cost-saving in most of the settings in which it has been evaluated”. The HTA estimated that a reduction in mortality would be expected from year two of the programme onwards, with approximately 270 deaths from colorectal cancer avoided in year 10.
Table 10.5: Trend in Expenditure on NCSS Screening Programmes 2008-2011
2008(€) 2009(€) 2010(€) 2011(€)
-budget allocated
Pay 17,538,147 18,857,766 18,918,023 20,709,638
Non-Pay 26,212,184 41,656,842 46,473,904 42,971,394
In 2009, costs rose as a result of the introduction of the CervicalCheck programme and good uptake for the programme. [Department has requested a breakdown of costs by programme in order to identify where possible efficiencies could be made. It appears inconsistent that pay costs are increasing while staff numbers are going down and salaries have been cut.]
Table 10.6: Trend in WTE associated with NCSS Screening Programmes 2008-2011 2008 (at 31.12) 2009 (at 31.12) 2010 (at 31.12) 2011
(budget allocated)
262.68 271.21 258.55 20,709,638
In 2009 the NCSS required an additional approx. 30 WTE radiographer posts as a result of the national expansion of BreastCheck to the South and the West.
Table 10.7: Trend in Administration costs - NCSS Screening Programmes 2008-2011
2008(€) 2009(€) 2010(€) 2011(€)-budget
allocated
13,654,310 14,733,127 15,525,115 12,534,944
Following transfer into the HSE on 1 April 2010, 2011 costs are based on HSE Chart of Accounts (COA). HSE COA requires administration costs to be allocated differently from Exchequer COA and therefore comparison is not possible. Also, costs such as legal, insurance, audit, bank charges are now borne centrally by the HSE and are not directly allocated to the NCSS. This should result in an overall saving to the NCSS. The Department has requested the NCSS to review its projected costs of the colorectal cancer screening programme as the estimate was provided in 2009.
Table 10.8: Trend in Outputs for NCSS Screening Programmes 2008-2011
2008 2009 2010 2011
BreastCheck 92,061 122,000 119,000 140,000
CervicalCheck 281,202 329,541* 240,000
* provisional figure
The NCSS has made a number of changes to the organisation of support functions to manage front line service gaps and deficits suffered as a result of the Employment Control Framework. The NCSS, as part of its operation, regularly reviews service and supply contracts and achieves savings where possible. Any savings achieved allows the NCSS to ensure funding is available to continue to offer screening. Further scrutiny of non-pay spend and of efficiency of BreastCheck model is required. Since the subsuming of the NCSS into the NCCP, the NCSS has provided ICT, HR/IR, facilities, reception and some administrative support to the NCCP from existing resources. The NCSS made the decision to discontinue the National Radiography Training Centre post graduate training programme carried out in conjunction with UCD. The resources allocated for the NRTC (identified as two staff) have been redeployed to the BreastCheck programme’s core activities.
10.3.4 Future Demands
The national colorectal screening programme will be introduced in 2012. As the remit of the NCSS is extending, overall operational costs will also increase. However, as the NCSS manages a number of screening programmes there will be overall savings rather than if the programmes were provided separately. The cost of the pre-implementation phase of the national colorectal cancer screening programme in 2010 was €1.362m. A further spend of
€1m is projected in 2011. This has been found from within existing NCSS resources. The NCSS has estimated that an additional sum of €3.1m is required in 2012 for the implementation of the colorectal cancer screening programme for a 6 month period. The Croke Park Agreement would allow for an extended working day and improved staff mobility. Administrative staff share responsibilities for screening programmes and there is the potential to redeploy administrative staff from the HSE. As set out earlier under Section 10.3.3, the Programme for Government specifies that BreastCheck should be extended to women aged 65–69 in keeping with best international practice.
10.3.5 CONCLUSIONS, SAVINGS AND REFORM
The National Cancer Control Programme has changed how cancer services are being delivered and in doing so it has been successful in providing adequate capacity and timely provision of services, monitoring patient pathways and outcomes and planning for future demands on services.
The NCCP must continue to work with the NCSS to maximise efficiencies in existing programmes. A review of the reduction in fees under the FEMPI Act showed that there was no reduction in smeartakers (GP practices and womens clinics) involved in the programme.
The success of this programme is most likely due to the encouragement of women by their GPs to participate. The introduction of the colorectal cancer screening programme and the age extension of BreastCheck will be challenging in the present economic environment, but each programme must be implemented to ensure early detection and prevention of cancers.
Key Savings:
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• National Cancer Screening Service Funding: Consideration will also be given to funding the NCSS on the basis of number of people screened to incentivise maximum uptake (although it should be noted that the NCSS advises that the numbers screened will not improve until more radiographers are in post/available).
Key Reforms:
Clinical Protocols for Oncology Drugs: Clinical protocols will be developed for prescribing of oncology drugs aimed at ensuring efficiency, evidence based provision and a controlled framework for oncology drug prescribing. This will have the impact of limiting upward pressure on expenditure in this area.
CHAPTER 11
CHILD WELFARE AND PROTECTION