The National Cancer Control Programme was once viewed as the success story within a beleaguered health service. However, an organisational review obtained by this newspaper highlights concerns that the Programme’s influence has waned and its structures are no longer fit-for-purpose. Paul Mulholland reports
The 2021 implementation report of the National Cancer Strategy 2017-2026 was published at the beginning of December 2022. The report provided an update on implementation of the strategy’s 52 recommendations, the majority of which fall under the remit of the National Cancer Control Programme (NCCP). Reflecting its importance in raising the standard of cancer care, one recommendation in the 2017 strategy is for the NCCP itself to be empowered. The recommendation (no.44) recognised the “central role of the NCCP” in ensuring the strategy is implemented. It called for the Programme to be “strengthened, including through the use of service level agreements, and through a direct role in financial allocations through Hospital Groups through activity-based funding (ABF)”.
Like other elements in the strategy, implementation has been affected by the impact of Covid-19 on cancer services, with significant delays to diagnoses and treatment caused by the pandemic. It has also been hampered by other factors.
As previously reported in the Medical Independent (MI), the roll-out of ABF has been slower than initially envisaged. This has impacted on the plan to strengthen the NCCP’s role in allocating funding through the process.
MI has also reported on concerns about the NCCP’s continuing lack of power regarding funding. In a letter to the then newly appointed National Director of the NCCP, Prof Risteárd Ó Laoide, on 17 August 2020, the Irish Society of Medical Oncology (ISMO) President Dr Deirdre O’Mahony stated that ISMO was increasingly concerned about the funding provided for new cancer medications, as well as deficits in general resourcing.
“It is increasingly obvious the NCCP does not have the necessary power to fulfil its mission,” wrote Dr O’Mahony.
“The failure to provide appropriate resources for new drugs, facilities, and staffing in a timely manner mean that Irish cancer survival figures will inevitably deteriorate compared to standard international benchmarks.”
ISMO threatened to withdraw from working with the NCCP on this basis. However, following a meeting with the Programme, it was decided not to follow through with this course of action.
On 9 October 2020, in a letter to the NCCP National Director after a meeting, Dr O’Mahony stated: “We were relieved to hear that your evaluation of the NCCP placement at the decision-making table was similar to our own.”
New material obtained by MI through Freedom of Information (FoI) law shows that when Prof Ó Laoide became National Director, he sought a review of the Programme.
It was noted on his appointment that the NCCP had not been subject to substantive changes since its establishment in 2007. During this time, multiple structural changes had occurred within the HSE, including the formation of Hospital Groups and Community Healthcare Organisations.
PwC was commissioned to conduct the organisational review.
The focus of the review was the organisational function and structure of the NCCP within the HSE. The review also examined how the NCCP worked with allied bodies, such as the National Cancer Registry Ireland (NCRI) and the National Screening Service (NSS).
It took place in the final quarter of 2020.
The review allowed NCCP staff to contribute their views on the successes and failures of the past, as well as exploring how the Programme might address future challenges arising from demographic changes, the impact of the Covid-19 pandemic, and the implementation of the cancer strategy.
PwC’s report, which MI received through FoI, was completed in December 2020.
The report’s introduction stated: “The commencement of a new Director and significantly increased funding for the NCCP in Budget 2021 [€20 million in new development funding was secured for cancer services] provides an opportunity for the NCCP to refocus and re-prioritise the areas it will look to address over the remaining years of the current cancer strategy. Therefore, the nature of this review has been widely regarded as both timely and necessary by all the stakeholders we met, internally and externally.”
Historically, the NCCP has had a strong brand and is “recognised for its successful delivery of transformational change”, according to the review. The reform of the delivery model of cancer care with the establishment of eight centres in 2008 was referenced as the prime example of the Programme’s early success.
However, in recent years there is the perception its “brand has diminished” and there was “an urgent need for action to address this”, stated the PwC review.
The regression in the NCCP’s influence and impact was due a range of factors, including a lack of funding, loss of political backing, and a change in reporting lines within the HSE.
“There is also a perceived mismatch between the seniority of NCCP personnel engaging with the cancer centres and the nature of that engagement,” according to the review.
“The role of the National Director in terms of that outward engagement, setting and driving the strategic agenda for the NCCP (and building buy-in and commitment to this across the system) is seen as critical.
“To enable this to occur there needs to be a strong and high performing senior management team within the NCCP to lead the day-to-day operations.”
Role and mandate
PwC also concluded there is a lack of “clarity and alignment” amongst the NCCP’s stakeholders on what the role and mandate of the Programme is and should be.
The views expressed by interviewees, who ranged from those working within the organisation to external stakeholders, were diverse. Some stated the NCCP was responsible for the execution of the cancer strategy, while others said its main role was to provide advisory support. Feedback received defined the Programme’s main role as being related to everything from performance management to the coordination of the services, training and education.
There was a general view that the NCCP should be a strategic organisation that sets the course for cancer care in Ireland and drives transformation across the system.
“However, today, it is viewed by many stakeholders as micromanaging at an operational level and supplicating roles carried out elsewhere in the HSE. This is seen to contribute to the diminution of its role and influence.”
The review also indicated that the NCCP has “not always had the levers to deliver on aspects of its role”.
“We have heard throughout our work that the power and influence of the NCCP is seen as diluted by the absence of levers such as a cancer-specific accountability framework… funding flows and a blurring of the lines in terms of its remit to the Acute Hospital Division in the HSE,” according to the report.
“The role of the NCCP around co-ordination of service, performance management and quality assurance of services… is seen by some as duplicative and ‘without teeth’.”
There was also the view amongst stakeholders that the Programme could have been stronger and more vocal in addressing performance issues in individual hospitals, regardless of the formal levers available. An example cited was a failure to stop the continuation of surgeries outside of the national cancer centres.
PwC noted the NCCP received “little investment funding” in the years preceding Budget 2021. External stakeholders said the lack of financing has led to a diminution of authority and impact.
“There is a view that without funding there is no real impetus for hospitals to engage with the NCCP,” according to the report.
“This has had an impact on how the NCCP is viewed, with some hospitals choosing not to engage, or engaging ‘out of politeness’.”
There were also concerns expressed in relation to the transparency of funding and how it was allocated.
“We understand there is a process that allows the NCCP to allocate and move funding year-on-year between cancer centres; however, more work could be done to ensure the NCCP finance team and the [HSE] Acute’s finance team are aligned on this process.”
Relationship with other HSE sections
It was noted that the NCCP has a unique role within the HSE. The Programme
was described as having a “quasi-independent function” within the Executive’s structure, which is distinct from the clinical programmes
“Going forward the NCCP should look to leverage the influence that the NCCP has in this unique status.”
It is a separate directorate within the function of the Chief Clinical Officer (CCO). The Programme’s National Director reports directly to the CCO. At one point, the NCCP reported directly to the HSE CEO.
“The change in governance and reporting structure has been viewed, by some stakeholders, as a ‘loss of clout’ and there is a perception that its authority has waned since its inception as a result.”
However, the CCO Dr Colm Henry told MI the Programme continues to have a strong voice within the HSE (see panel).
To deliver its remit and ensure that cancer has a strong voice, the report stated it must work collaboratively with other divisions of the HSE, including Operations, Finance and Acute Operations. For example, the National Director for Acute Operations is responsible for the performance of the national cancer centres.
“We have been told of incidences when NCCP has not been engaged in discussions and decisions relating to cancer services,” according to the review.
To improve interaction and communication, the NCCP should consider putting in place a memorandum of understanding (MoU) with the separate divisions.
“Furthermore, some stakeholders have indicated concerns and confusion about the relationship between the NCCP, the HSE, Acute’s provider team and the cancer centres. Improved clarity around roles and responsibilities of the NCCP in relation to performance management and funding allocation would be beneficial.”
The internal organisation of the NCCP was described in the review as “unclear” and “no longer fit-for-purpose”.
The Programme’s staff said the structure was “very siloed in nature with significant opportunity for improvements in teamwork and interactions between work streams”.
“At a practical level we heard of poor sharing of basic information across teams, hindering the ability of people to perform their work as effectively as possible,” according to the report.
“There is a real sense of confusion in the organisation as to what the actual organisation structure is, who is accountable for what, and who is working on what.”
The review noted there was an absence of detailed job descriptions for some roles.
“People spoke about joining the organisation with no clarity as to their role or accountabilities and in spending their first six months or more trying to navigate/figure out the organisation and to define their own role within it.”
There were also problems identified with the overall work culture, with a lack of recognition and transparency reported, for example.
The executive management team (EMT) and senior management team (SMT) are the two key governance fora within the NCCP. However, “both are seen as quite ineffective, static in nature (generally consisting only of status updates), and with no real outcomes or agreed actions coming from them.”
“There is a perception that not all voices are equally heard nor all areas given the same focus and discussion,” according to the report.
There was also a view that senior management was “quite disconnected” from other staff and “people feel they do not understand what is going on in the NCCP more broadly”, which PwC said had to be remedied.
A number of issues were reported with regard to communications, both internally and externally. In general, communication was described as “poor” and a source of “frustration” to staff. Regarding internal communication, staff were often unaware what other staff members were working on. Also, feedback suggested there was a lack of opportunities to mark achievements or success.
Regarding external communications, the report stated: “There is also a recognised need to better promote the role and achievements of the NCCP externally across stakeholders and the system. Social media presence is poor/non-existent in a formal way.”
The NCCP website was also described as “out of date”.
A total of 15 recommendations were made by PwC. The first was that the NCCP needs to define its role going forward in the context of the national cancer strategy and the governance and structures within the HSE and Department of Health.
The NCCP should also agree with all key stakeholders upon a smaller number of strategic priorities for the Programme under the cancer strategy and develop a roadmap as to how they will be achieved.
PwC identified a need to increase the visibility of the National Director across the HSE, the Department of Health, and cancer centres.
“Core to the role of the National Director will be a focus on bolstering
To enable his “external-facing” role, the National Director required “adequate support to lead the organisation internally”.
MoUs should be developed between key partners, such as the HSE, the Department, and cancer centres, while the NCCP needed to develop closer ways of working with the NCRI and NSS.
PwC recommended that a detailed review of the NCCP organisational structure is undertaken to ensure it is “fit-for-purpose” and “aligned with the redefined strategic priority areas”.
“As part of this work, design principles will need to be agreed… we recommend these should include a focus on ways of working, with an emphasis on breaking down existing silos.”
A review of the EMT and SMT should also take place.
Other recommendations related to defining roles and responsibilities, and improving areas such as leadership, communications, work culture, and training and engagement.
The final recommendation was on the need to understand and address the “change management challenge”.
“The recommendations set out in this document collectively form a wide-ranging transformation agenda for the NCCP,” according to PwC.
“This needs to be considered and understood in the context of the day-to-day work and activities that must continue to be progressed.
“Key to any successful is a robust approach to effective change management.”
The PwC review was discussed at EMT meetings in 2021. Director of Public Health at the NSS, Dr Caroline Mason Mohan, “flagged” an amendment in relation to screening and governance at the January meeting, after which the final report would be circulated to the CCO and NCCP staff.
“NCCP review to be circulated to staff once feedback on it has been received from the CCO,” according to minutes from the March 2021 meeting seen by this newspaper.
It appears implementation only picked up pace last year, however, with the appointment of a “change management advisor”.
At the EMT meeting in January 2022, Prof Ó Laoide informed attendees that the advisor had been appointed to assist with the implementation of the report’s recommendations. The advisor had held initial meetings with the SMT, according to the minutes.
At a meeting on 7 February, it was stated the advisor was meeting with the SMT and other Programme leads. The advisor planned to meet with clinical leads in the coming weeks. A SMT workshop was also scheduled to address recommendations related to the Programme’s internal structure.
“The NCCP is also working with HSE Organisation Development and Change for longer term sustainability,” according to the minutes.
At the March EMT meeting, attendees were told the SMT workshop had occurred and additional workshops would “take place, which will focus on individual recommendations”.
The May meeting minutes stated: “Work is ongoing. Periodic updates will be provided at future Executive meetings.”
According to the 2021 cancer strategy implementation report: “The NCCP, reporting directly to the Chief Clinical Officer in the HSE, continued to work on enhancing NCCP governance over its separate budget and all funding allocations, continuing its central role in the HSE in ensuring the implementation of the national cancer strategy, with funding being utilised in a targeted way to maximise improvements in the quality and accessibility of cancer services.”
An NCCP spokesperson told MI the focus on addressing the impact of the Covid-19 pandemic and the response needed to support and maintain cancer services during that time has affected the pace of implementing the PwC recommendations.
“While the response to the Covid-19 pandemic and its impact on cancer care in 2020, 2021, and 2022, as well as the impact of the ransomware attack in 2021, have been the priority focus, the NCCP has advanced the recommendations of the review,” the spokesperson told MI.
For example, the spokesperson said there is now a greater degree of on-site engagement with cancer centres and other cancer care providers.
“This is an important element of the work of the NCCP that was, appropriately, impacted by infection control measures since the start of the pandemic,” they said.
There are also “stronger working relationships with the various partners involved in, and responsible for, elements of cancer services through the system”.
The final review of the implementation of recommendations of the scoping inquiry into the CervicalCheck screening programme, published in November, noted a MoU between the NCRI, the NCCP, and the National Health Intelligence Unit was signed in May 2022. This was “big step forward” in terms of sharing cancer data, according to the review.
Work on a social media strategy has not progressed but is hoped to be addressed in 2023.
The spokesperson said there have been “internal discussions [within] the NCCP team on the best way to organise itself, including the role of senior management and clinical advisors, to best support cancer services into the future”.
“This remains work in progress and will continue to evolve,” according to the spokesperson.
They added there are more leadership development opportunities for NCCP staff through HSE programmes and improved internal communications, “as well as opportunities for staff to present on key deliverables at appropriate fora.”
Additional reporting by Niamh Quinlan
NCCP has a ‘strong voice’ – Chief Clinical Officer
According to the HSE Chief Clinical Officer (CCO), Dr Colm Henry, the National Cancer Control Programme (NCCP) continues to have a “strong brand” and voice within the HSE.
The NCCP currently sits within the CCO’s division.
“It’s my belief it does have a very strong voice, a very strong identity,” Dr Henry told the Medical Independent (MI).
Dr Henry pointed to the clear leadership provided by Prof Tom Keane as the first Director of the NCCP and how the three national cancer strategies to date have raised standards of care.
The latest strategy, which covers
the period 2017-2026, “sets out very clearly our ambitions and targets over a ten-year period,” according to Dr Henry.
He said the HSE and the NCCP have “good relationships” with “key people” in the Department of Health, “which allows us to secure funding to keep driving the development of the strategy.”
“We still have a long way to go,” acknowledged Dr Henry.
“But if you look at the evidence, cancer survivorship is improving in Ireland. That is, to a large extent,
a consequence of the improved treatments and… the more sustained way we’ve developed services.”
MI also spoke to Prof Niall O’Higgins, Professor Emeritus of Surgery, University College Dublin. Prof O’Higgins was involved in setting the requirements for the establishment of the eight national cancer centres.
He stressed the centrality of Prof Keane’s role in implementing the initial transformation programme.
“[Prof Keane] was appointed not to develop the Programme, but
to actually implement it, with the weight of Government behind him,” according to Prof O’Higgins.
“That was an important decision because he was there to say, ‘I’m just following Government policy. I’m going to implement the plan. Don’t blame me if you don’t agree with
the plan. That is not my function. My function is to implement it.’ …and he was highly successful in that.”
When asked if the NCCP continues to have such an influential voice, Prof O’Higgins said the ultimate responsibility lies with the Minister for Health.
“You do get the feeling that we need very clear supportive direction from the Minister for Health… I think if there is
a feeling or a perception it is a little bit diminished in its thrust or aim, maybe it does require a little bit more firm leadership at a political level.”