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Critically review recent public health policy developments

This assignment will critically review recent public health policy developments in the field of Cancer in England also it will evaluate its effectiveness and implications for public health and health promotion practice. This assignment will first briefly review the recent public health policies of England starting from ‘Health of the Nation’ white paper (1992), ‘Saving lives’ white paper (1999), ‘Cancer Plan’ (2000) ‘Choosing health’ white paper (2004) and the most recent public health policy for Cancer ‘Cancer Reform Strategy’ (2007). After reviewing the recent public health policy developments for cancer in England, evaluation and implications of these policies will be discussed.

From 1992 to 1997, the Health of the Nation (HOTN) strategy was the central plank of health policy in England and formed the context for the planning of services provided by the National Health Services (NHS). The HOTN policy focused on five key areas: coronary heart disease and stroke; cancer; mental illness; HIV/AIDS and sexual health; and accidents. Each area had a statement of main objectives attached to it, together with twenty seven targets across the areas. Cancer targets of the HOTN policy were to, reduce death rate for breast cancer in women invited for screening by more than 25% by 2000, reduce incidence of invasive cervical cancer by 20% by 2000, reduce death rate for lung cancer in those aged less than 75 by 30% (men) and 15% (women) by 2010, halt year on year increase in incidence of skin cancer by 2005 (Department of Health 1992).

Health of the Nation white paper’s importance lay in the fact that it represented the first explicit attempt by government to provide a strategic approach to improve the overall health of the population. But according to the review of the HOTN’s policy commissioned by Department of Health 2000, HOTN’s policy failed over its five year lifespan to recognize its full potential and was handicapped from the outset by numerous flaws of both a conceptual and process type nature. Its impact on policy documents peaked as early as 1993; and, by 1997, its impact on local health policy making was negligible. The HOTN’s policy was regarded as a Department of Health initiative which lacked cross-departmental commitment and ownership. At local level, it was seen as principally a health service document and lacked local government ownership. (The Health of the Nation - a policy assessed 2000).

The White Paper ‘Saving Lives’ Our Healthier Nation was published on 6 July 1999 together with Reducing Health Inequalities: an Action Report. These two documents set out the Government’s strategy for health for the next 10 years. They brought a new and important focus to the promotion of health and the prevention of ill-health. The health strategy set out in the White Paper was centred on four priority areas (cancer, coronary heart disease and stroke, accidents and mental health). Action to tackle these important areas of ill-health was set in the context of both a Government-wide agenda to address the underlying causes (through, for example, measures to combat poverty, to improve education and work opportunities, and to improve the environment including the quality of the housing stock); also through the wider public health agenda, specifically action to tackle smoking (DH 2000)

The NHS Cancer Plan (2000) was the first comprehensive National cancer programme for England. It had four aims: to save more lives, to ensure people with cancer get the right professional support and care as well as the best treatments, to tackle the inequalities in health that mean unskilled workers are, twice as likely to die from cancer as professionals, to build for the future through investment in the cancer workforce, through strong research and through preparation for the genetics, revolution, so that the NHS never falls behind in cancer care again (NHS Cancer Plan 2000) . According to Department of Health (2000), for the first time this plan provided a comprehensive strategy for bringing together prevention, screening, diagnosis, treatment and care for cancer and the investment needed to deliver these services in terms of improved staffing, equipment, drugs, treatments and information systems. At the heart of the Plan there were three new commitments. 1) In addition to the existing (‘Smoking Kills’ white paper 1998) target of reducing smoking in adults from 28% to 24% by 2010, new national and local targets to address the gap between socio-economic groups in smoking rates and the resulting risks of cancer and heart disease. 2) New goals and targets was set to reduce waiting times for diagnosis and treatment of cancer so that no one should wait longer than one month from an urgent referral for suspected cancer to the beginning of treatment except for a good clinical reason or through patient choice. 3) An extra £50 million NHS investment a year by 2004 in hospices and specialist palliative care, to improve access to these services across the country. For the first time ever, NHS investment in specialist palliative care services will match that of the voluntary sector (Cancer Plan DH 2000).

There were enormous achievements since the NHS Cancer Plan 2000, like action on tobacco and the smoking ban had led to a fall in smoking rates (from 28% of the population in 1998 to 24% in 2005), amounting to 1.6 million fewer smokers.

More cancers were detected through screening by National Cancer Screening Programmes for breast, bowel and cervical cancers. New screening programmes were introduced as and when they were proven to be both clinically and cost effective. Waiting times for cancer care have reduced dramatically. There had been a major increase in the use of drugs approved by the National Institute for Health and Clinical Excellence (NICE), to treat cancer with less variation between cancer networks. Since April 1 2009, patients undergoing treatment for cancer, including the effects of past cancer treatment, have been able to apply for a medical exemption certificate. It is expected that the new scheme will benefit up to 150,000 people already diagnosed with cancer, who might pay £100 or more each year in prescription charges (NHS Cancer Plan DH, 2010)

Although there are tremendous improvements of ‘NHS Cancer Plan’ according to Department of health but according to the ‘The Lancet Oncology’ editorial 2009 the NHS cancer plan for England was set up, at least in part, in reaction to data from the EUROCARE project, which showed that England cancer survival rates was lagging behind the rest of the Europe. The stated aim of the plan was: “By 2010, England’s five year survival rates for cancer will compare with the best in Europe.” Despite all the caveats that must be borne in mind when extrapolating from available data, and when comparing across European countries, the evidence available suggests that England is at best keeping track with improvements elsewhere, rather than closing the gap, and that the 2010 cancer target looks optimistic. Solutions to the problems of cancer are not easy, but perhaps the time has come to consider rather more fundamental changes to the NHS than are offered in the cancer plan if England is to truly offer world class healthcare (The Lancet Oncology 2009). According to Bosanquet et al (2008) huge amounts of money have been thrown at cancer in NHS cancer plan. The exact sum is opaque but the investment in cancer care has more than tripled over the past decade and now have approached European levels but improvements in cancer survival rates is not comparable with other European countries (Bosanquet et al, 2008).

The Choosing Health White Paper was published in November 2004.  Choosing Health identified six key priority areas: - tackling health inequalities, reducing the numbers of people who smoke, tackling obesity, improving sexual health, improving mental health and well-being, reducing harm and encouraging sensible drinking (Choosing Health, Department of Health 2004). Choosing health policy was particularly successful in banning the smoking in public places (Department of Health 2010).

Before reviewing the most recent public health policy development for Cancer in England it is important to look at the current and past statistics of Cancer in the England. Also according to the Parkin (2006) accurate statistics on cancer occurrence and outcome are essential both for the purposes of research (into causes, prevention and treatment of cancer) and for the planning and evaluation of programmes for cancer control. According to the Office for National Statistics (ONS) 2010 UK the four most common cancers, breast, lung, colorectal and prostate accounted for more than half of the 245,300 new cases of malignant cancer (excluding non-melanoma skin cancer) registered in England in 2007. Of the total number of new cases in 2007 in England, 123,100 were in males and 122,200 in females, breast cancer accounted for 31 per cent of all cases of cancers in England among women and prostate cancer accounted for 25 per cent of all cases of cancers in England among men. Cancer is predominantly a disease of older people as only 0.5 per cent of cases registered in 2007 in England were in children (age under 15) and 25 per cent were in people aged under 60. Between 1971 and 2007, the age-standardised incidence of cancer increased by around 21 per cent in males and 45 per cent in females in England. In each year in England over one in four people die from cancer. In England cancer accounts for 30 per cent of all deaths in males and 25 per cent of all deaths in females (ONS UK, 2010). Survival rates of cancer patients in England varies by type of cancer and, for each cancer, by a number of factors including sex, age and socio-economic status. Five-year relative survival is very low (in the range 3–16 per cent) for cancers of the pancreas, lung, oesophagus, stomach and brain for patients diagnosed in England in 2001–06, compared with ovarian cancer (39 per cent), cancers of the bladder, colon and cervix (47–64 per cent), and cancers of the prostate and breast (77–82 per cent). In England for the majority of cancers, a higher proportion of women than men usually survives for at least five years after diagnosis. Among adults, the younger the age at diagnosis, the higher the survival for almost every cancer. In England five year survival rates for patients diagnosed between 2001–06 have improved slightly or stayed stable for 16 of the 21 most common cancers compared to the period 2000–04 (Cancer Research UK, ONS UK 2010).

The most recent public health policy for cancer in England is the Cancer Reform Strategy (DH 2010). The Cancer Reform Strategy published in December 2007, builds on progress made since publication of the NHS Cancer Plan in 2000 and sets out a clear direction for cancer services. According to the document of Cancer Reform Strategy published by Department of Health (2007), it shows how by 2012 cancer services in England can be among the best in the world. It also launched three new initiatives: 1) The National Awareness and Early Diagnosis Initiative, aimed to raise awareness of cancer symptoms among the public and health professionals and encourage those who may have symptoms to seek early attention. Almost £5 million was allocated to the NHS to support cancer networks and primary care trusts in improving awareness of cancers and promoting early diagnosis. 2) The National Cancer Survivorship Initiative is working to improve support for the 1.63 million people currently living with and beyond cancer in England. 3) The National Equality Initiative is working to reduce inequalities in cancer care. According to the Department of health (2010) the aims of the Cancer Reform Strategy is to build on progress already made and meet remaining challenges, the government has developed this strategy to set out the next steps for delivering cancer services in England, by saving more lives through prevention of cancer whenever possible and through earlier detection and better treatment, by improving patients’ quality of life by ensuring services patient centred and well-coordinated and by offering choice where appropriate, increase public awareness of cancer, reduce inequalities in access to services and in service quality - thereby reducing inequalities in cancer outcomes, build for the future, through education, research and workforce development, and enable cancer care to be delivered in the best place, at the right time.

Prevention of cancer by screening is a most important aspect to tackle cancer. NHS Screening programmes are part of the Cancer reform strategy 2007. According to NHS Screening Programme (2010), over half of all cancers in the past could be prevented if people adopted healthy lifestyles such as: by stopping smoking, avoiding obesity, eating a healthy diet, undertaking a moderate level of physical activity, avoiding too much alcohol, and excessive exposure to sunlight. According to the NHS Cervical Screening Programme (2010), it saves up to 4,500 lives in England every year. Within the NHS Cervical Screening Programme in England, women aged 25 to 49 are invited for free cervical screening every three years, and women aged 50 to 64 are invited every five years. Women over the age of 65 are invited if their previous three tests were not clear or if they have never been screened.

According to the NHS Breast Screening Programme (2010), its breast screening awareness programme regarded as one of the best screening programmes in the world, saving an estimated 1,400 lives each year. 96.4 per cent of women who have had invasive breast cancer detected by screening are alive five years later. Under the NHS Breast Screening Programme, breast screening is provided every three years for all women in England aged 50 and over. Currently, women aged between 50 to 69 years are invited routinely and women over the age of 70 can request free three-yearly screening. The eligible age range for routine breast screening will be extended further to provide nine screening rounds between 47 and 73 years. According to the NHS Bowel Cancer Screening Programme (2010), it is one of the first National bowel screening programmes in the world and the first cancer screening programme in England to include men as well as women. All men and women aged 60 to 69 are expected to be included by December 2010, meaning around 2 million men and women will be screened and an estimated 3,000 cancers detected every year. The programme will be extended from 2010 to include men and women aged 70-75 years.

According to the Lancet Oncology editorial (2009), although the Government's Cancer Plan and Cancer Reform Strategy has had some impact on how long sufferers survive after diagnosis, it is still struggling to close the gap between England and other European countries. A study by Bernard Rachet et al, (2007) published in the Lancet Oncology journal also suggested that some of the improvements in cancer in England merely reflect ongoing trends in cancer cure rather than real change. There are also large variations in cancer cure and survival rates across the country, with patients in the North West of England still more likely to die earlier from the same cancer as those in the South of England. An editorial in the journal also warns that the time has come to consider more fundamental change in the NHS than the Cancer Plan and Cancer Reform Strategy offers. The study by Bernard Rachet et al, (2007) in The Lancet Oncology journal looked at survival rates for 21 common cancers, comparing the rates in England and Wales, ( in Wales a similar scheme like Cancer Plan was introduced only in 2006) most cancers showed a rise in survival rates in England compared to Wales after 2001, but there was a fall in the survival rates in England compared to Wales for bladder cancer, Hodgkin's lymphoma and leukaemia (blood cancer).

According to the Professor Karol Sikora, medical director of Cancer Partners UK, (Lancet Oncology 2009) that there is no striking improvement in the cancer cure rates and survival rates in England, despite the huge resources involved in the NHS cancer Plan and Cancer reform strategy, also there is still wide regional variation in survival, with deprivation still being linked to poor outcome, a factor which the plan was meant to address. Also according to Karol Sikora, access to new cancer drugs in England is also poor, the latest EU comparator (2008) shows that the use of six cancer drugs approved in the past three years is fivefold less in the UK than the EU average.

According to Ciaran Devane Macmillan Cancer Support (Telegraph UK April 2010), although there are more cancer survivors in England because of both the improvements in treatment and an ageing population, but this does not show the whole picture of cancer policy of England. After once the treatment of cancer ends, many patients feel abandoned by the NHS and struggle to cope with the long-term effects of cancer, and cancer treatment. The NHS cancer policy needs to ensure all cancer patients have the support they need to manage the long term effects of cancer treatment.

A recent report by National Radiotherapy Advisory Group (2007) suggests that England need a massive 90% expansion in radiotherapy provision for cancer patients. According to Crump (2009) that in England radiotherapy for cancer patients is at the same level as it was in the 1980s, with only 7% of eligible patients getting precisely targeted intensity-modulated radiotherapy.

In conclusion of this assignment, although the recent public health policy developments in field of cancer have shown some success in England but there are certain areas where significant improvement is require like early detection of cancers to reduce higher incidence rates of cancer by decreasing the waiting times for patients and cancer survival rates especially when comparing to other top European countries. There is a need to change cancer policy of England to meet the real requirements of current and future cancer patients.

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