Poor old bowel cancer has struggled to grab headlines for many years. Great news then that a screening trial in Waitemata picked up 129 cases of bowel cancer that could have gone undiagnosed. The earlier the bowel cancer is found the easier it is to treat successfully, so these are potentially saved lives.
Great stuff! If it saves lives we should do it, right? So when can you book your appointment for a doc to have a squiz where the sun doesn’t shine? Unfortunately it isn’t quite that simple. It is now more than four years since we wrote Health Cheque, but the same old issues dog our health system, and bowel cancer is a good example of all of these.
Higher profile cancers like breast and prostate cancer get all the limelight, but bowel cancer is actually New Zealand’s biggest cancer killer, knocking over 2700 Kiwis a year. And the irony is that unlike other cancers, it is almost totally preventable.
The story of dealing to colon cancer is the story of our health system. Decisions should be made on cost-effectiveness, but instead they are down to a complex set of interactions between doctors, interest groups and politicians. Essentially who bleats the loudest gets the dosh, and no one wants to put their hand up for colons.
First up, the bad news: our health budget is limited. It is currently sitting at 7c of every dollar our country earns, and that is just the money the Government spends; we shell out another 3c through ACC, insurance and co-payments. But health spending is on a relentless upward trend, and the Government share alone is on its way to 11c in every dollar. That doesn’t even include any new services to keep old fogies alive for longer, it is just the cost of keeping the current system running, as is where is. Our health system is no Rolls-Royce, but it certainly chugs through the gas.
In a world of limited resources, we have to ask whether funding colonoscopies is cost-effective. That describes Health Minister Tony Ryall’s luke warm response to the trial – let’s wait and see how cost- effective it is. This is a pretty fair response. What we do know, though, is that this procedure has been shown as cost- effective overseas so why wouldn’t it be here?
A colonoscopy certainly isn’t going to be less effective here, given our high rates of bowel cancer. The most obvious difference between New Zealand and other places is bound to be on the cost side. And unfortunately this is where we are being held to ransom by the doctors. Ever wary of patch protection, our docs have held on to their sole right to do colonoscopies. This has kept the private cost of the procedure at an eye-watering $1400, and the procedure itself isn’t any more comfortable.
Forget Countdown, Shane Jones, this is an open and shut case for trust-busting. Overseas, trained nurses and technicians do the procedure, not highly paid docs, and if we are to have a nationwide colonoscopy programme we will have to do the same thing. So sad for the docs but it it’s hardly likely they will be idle – there is plenty to do. This is why Tony Ryall has called for a “rethink” of the colonoscopy workforce before we get a national roll-out.
Assuming we can make colonoscopies cost-effective enough to offer checks for everyone over 50, we’re still likely to have to get the money from somewhere, the direct savings from moving to technicians won’t be sufficient. Docs of course will always say we should just spend more on the health system, because they can’t see past the hospital wall into the real world. In reality we have to find the money from within the health system. And it is there, for sure.
There is plenty of money tied up in procedures that don’t add much value to our lives. Good luck getting the money out, though. As soon as the health system tries to pull back from offering a service it has offered previously it is front-page news. No matter how expensive the procedure, no matter how little health benefit it gives, what the alternative is, change will be resisted by all and sundry – doctors, patients and of course the media thrive on the beat-up. No politician will want to make a hard call under that spotlight. Welcome to a health system where money goes to oil the squeaky wheel.
That is why back in 2009 we called for an independent, arms-length body to make these public sector funding calls much in the way Pharmac does for drugs. If you didn’t like the public offer and wanted more, you would be free to purchase insurance to cover the difference. Much better than the current system when the public sector tries to cover everything poorly, and the insurance industry lurks around the fringes picking up business where it can.
Such a body would be able to make a call about bowel cancer screening, and have it in place tomorrow. It may come at the expense of another, less effective procedure, but overall we would be saving more lives. Isn’t that the point of a health system? If on the other hand bowel cancer screening didn’t make the cut, it would become a clear and unambiguous part of the private sector offer – an add-on for those prepared to pay extra – which we can get down by breaking the doctors’ closed shop.
Gareth Morgan & Geoff Simmons are of the Morgan Foundation and are authors of Health Cheque.