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Tax Fat to Save livesFast Food Should Be Targeted Financially to Help the Nation's Health, Says Scotland's Cancer Tsar. And Some Delays in Cancer Treatment Can Be Beneficial, She Tells Jennifer Veitch

Posted on: Tuesday, 24 May 2005, 09:00 CDT

Putting a 2-per cent tax on fast food could be the next step after a smoking ban, if we want to boost cancer survival rates, according to a leading Scottish cancer specialist.

Dr Anna Gregor, Scotland's lead clinician for cancer, argues that more needs to be done to tackle patients' underlying illhealth and is recommending that the option of taxing Big Macs - currently under consideration in the US - might help. Revenue from a surcharge could be fed into healthy eating schemes.

Gregor is confident the proposed ban on smoking in enclosed public places will have a significant impact. Now, she would also like politicians to consider the fast food tax. City leaders in Detroit are currently considering a proposed 2-per cent levy to encourage people to eat more healthily.

"That would be a good idea, as long as we feed the tax back into good food, " she says. "The problem is that it may promote inequalities, because those who eat fast food are the poorest section of society." Similar socioeconomic issues apply to taxes on smoking, she points out.

"One argument for not putting a tax on these things is that you would hit hardest the people who can least afford it. But we know cigarette pricing is one of the most useful ways of modifying smoking habits. It'd be interesting to see whether Big Mac prices would modify eating habits."

"You have to give people alternatives. One of the great difficulties is that people have stopped being able to feed themselves - nobody cooks and people don't have family meals."

And her concern about Scotland's eating habits also extends to the quality of food served to NHS patients and staff.

"Absolutely - we need to get Jamie Oliver to do hospital food, " she says. The need for Scottish patients to take more responsibility for their own health has arisen as Gregor discusses the substantial challenge of meeting government deadlines.

As cancer care is one of the key areas in which healthcare targets have been set, few people can be more acutely aware of the imperative to meet national waiting time targets.

But Gregor's views may be unexpected - some targets are little more than guesswork, she admits, while some patients may actually benefit from having more time to prepare for treatment.

The Scottish Executive has pledged that by December this year, all cancer patients will start to receive treatment within two months of urgent referral.

Whether that ambitious target will be met remains to be seen; if not, it will be viewed as another indication that Scotland's health service is lagging behind progress south of the border.

While Gregor readily agrees that cancer patients should not wait longer than they need to, she is sceptical about setting too much importance on achieving a target which she argues may not be appropriate for everyone.

"We understand how important it is for patients not to wait unnecessarily because it is a time of anxiety and uncertainty, and there is a concern that their cancer may be progressing, " she says.

"But it is probably even more important for them to have an understanding that diagnosis and appropriate treatment of cancer is really quite a complicated business. They need to go through often quite a complex pathway of tests, and they also need to have a time to ref lect.

"Patients tell us that they want to be able to participate in the decision-making about their care.

If they are faced with decisions which will not only affect their life but their families', there can be such a thing as too fast."

She cites the example of the "one-stop shop" model of care which has reduced the time that patients wait for a diagnosis of breast cancer, but is not suitable for other cancers.

"In breast care it's very useful because nine out of 10 of the women referred to the breast clinic will have nothing wrong with them, so to be able to send away those nine reassured is well worth the effort and the anxiety for the one out of 10 who then has a serious diagnosis.

"To do that kind of model of care for people for whom there is a much greater certainty that they might have cancer is probably not appropriate, because patients need to have time to absorb the shock. The moment that you are told you have cancer - and I see it as a clinician - the shutters come down."

Gregor is refreshingly frank about the decision-making behind the two-month target.

"Let's just say there isn't much of a science about it. It was a bit of a guess on what would be the reasonable thing to do. We thought that would be to have a month to get the diagnosis, and then about another month to actually get the treatment sorted.

There is no biological reason for two months."

She adds that a two-month target has some clinical relevance, but it is not essential for a number of patients with slowgrowing cancers who may wish to wait a little longer.

Gregor suggests that some might even want to delay their treatment by a few days orweeks - a woman may not want to start chemotherapy if it means losing her hair before her daughter's wedding, for example - and that many patients could use the time to improve their health before starting their treatment or undergoing surgery.

"We have this preoccupation with waits, and this is almost a British disease, but is there something that we could be doing about spending the time that has to elapse more profitably?

"There is a benefit, for instance, if you have patients who know they are going to have an operation at a forthcoming date. They can stop smoking, address their diet, do a bit of exercise, put their affairs in order - prepare forwhat is ahead rather than just wait.

"To have an opportunity to do important things to improve their chances of benefit from treatment will empower patients, and will have huge benefits for them."

Gregor says the introduction of managed networks for cancer care - she is clinical director of the South-East Scotland Cancer Network - has improved the use of available resources.

But capacity and waiting times are not the only challenge for Scotland's health service. There is also the question of how to resolve the increasing need to centralise specialties such as cancer - for reasons of clinical safety as well as efficiency and affordability - with the desire for access to local services.

Gregor is now aware of the recommendations to be made by Professor David Kerr for the future configuration of acute hospital services, although she won't be drawn on the details.

She explains: "It's easier to concentrate on the bricks and mortar of the hospital buildings, when we should really concentrate on the functions.

"I'm convinced the way that we have set out the cancer services to develop through networks of care addresses some of the tensions, because these networks span different sectors and geographies.

"You can think of them as a safety net for patients, so they have the certainty and confidence that wherever they are they have a clear and integrated access to the specialist services, that the local provision is working not independently, but as a part of a greater whole with the appropriate support."

She adds: "The district general hospitals have been concerned about what separating some of these specialist and regional functions would do to their own sustainability, because if you take out the breast surgeons and colorectal surgeons, how can you have a rota?"

In fact, the network model can help to sustain local services, Gregor argues. "Without those networks the inevitability of the European Working Time Directive, affordability, clinical choice, and practicalities is for bigger teams - and bigger teams will be centrally placed.

"Through a combination of outreach, support, and shared appointments, networks enable them to keep the things that can stay locally.

"About three years ago the single-handed breast surgeon at St John's left, and we could not find anybody who would want to take up a single-handed breast surgeon post. So the breast unit in Edinburgh accepted responsibility for this, and the women in West Lothian have not noticed any difference. In fact the services have probably improved. This has happened invisibly.

"We have practical solutions that we can bring to the table for the benefit of patients."

As the population ages, Scotland is facing nothing less than an epidemic of cancer. Targets aside, Dr Gregor remains optimistic that improvements to public health could vastly improve outcomes for patients - provided that they too take some responsibility.

"It would make it less of a problem if we had a healthier population, in terms of our ability to manage it, " she says. "In Scotland a lot of our patients have so many underlying co- morbidities that they are perhaps not fit for some of the treatments which are now state of the art.

"If we do comparisons with other European patients in clinical trials, we can't get the intensity of therapy into our patients because of their underlying state of health.

"I'd like people to start thinking not just about the health service doing things to you, but what is the part of the contract that the patients bring to the story - what are their responsibilities?"

Cancer patients are often motivated to help themselves, she argues: "But you can see it in many aspects of healthcare where patients expect solutions from the healthcare system because it's there and it's free - even though a lifestyle modification they do themselves might be much more effective. So, how do we start having that discussion?"

Source: Herald, The; Glasgow (UK)

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