The National Cancer Action Plan

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

The Cancer Steering Committee published the National Cancer Action Plan in February 2000. It included a number of policy recommendations. The Danish Centre for Evaluation and Health Technology Assessment has evaluated the implementation of the recommendations. It concludes that the plan suffers from i) too imprecise recommendations to make a comprehensive evaluation possible; ii) it being to early to have data available in the form of e.g. 5- and 10-yr survival rates.

Purpose of health policy or idea

In 1998 the Minister of Health established a Cancer Steering Committee (which continues to exist) to look at the background for the Danish performance on cancer treatments and to investigate possible improvements of cancer treatment. Basically the background was a concern that the quality of the treatment in Denmark trailed that of the Nordic and many of the European countries. The Cancer Steering Committee published the National Cancer Action Plan in February 2000.

The plan included as its most important part a set of policy proposals aimed at bringing Denmark up to the performance standard achieved by European countries at a similar income level.

Basically the set of policy proposals consisted of a number of either broad declarations of intent or fairly specific ad-hoc proposals. The implicit assumption was that the proposals could be implemented by within the existing structure by a combination of command and additional funding.

The initiative to carry out an investigation of the Danish performance on cancer treatments was taken by the central government but the counties (which own and run he hospitals) took part in the preparatory work and the implementation of the plan.

The recommendations covered 10 fields and the goals to achieve was specified as follows:

Prevention: Adoption of the Government's 1999 public health programme.

1. Education of health-care personnel: Focus on competencies and strengthened further education.
2. Delays in the patient pathway: Greater focus on possible delays in the patient pathway.
3. Planning of diagnosis and treatment: Recommendations of regional (and possibly County) cancer groups to assess organisation of optimal patient pathways.
4. Expansion of diagnostic and treatment capacity: Introduction of new methods, greater capacity for radiotherapy and chemotherapy, optimised distribution of tasks and resources.
5. Centralisation of surgical treatment expertise: Centralisation at selected departments with a sufficient patient population.
6. Screening: Gradual introduction of breast cancer screening and trial introduction of intestinal cancer screening.
7. Research and development: Prioritisation of research and development, among other means through support to central registers and clinical databases.
8. Rehabilitation: Offer for all cancer patients, adapted to their individual needs; systematic collection of experience.
9. Palliation: Expansion of capacity; systematic collection of experience.

 The government and the counties started implementing the plan in 2000. In 2001 the Danish Centre for Evaluation and Health Technology Assessment (DACEHTA) was assigned responsibility for evaluating the extent to which recommendations of the Cancer Action Plan had been implemented by the Counties and other relevant stakeholders. The evaluation was published in March 2004.

Type of incentives

Command and additional funding

Groups affected

The Counties, Personnel at hospitals

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

It is well known from studies of public policy that there may be an incentive to make evaluations difficult to carry out. The existence of asymmetric information makes it possible to avoid monitoring and stewardship is thereby made more difficult (asymmetric information in this way constitutes a source of the technical phenomenon of so-called government failure; just as it causes so-called market failure when using the market place). The presence of audit mechanisms is one way of tying to mitigate the effects of this particular form of failure and like most countries Denmark has several public institutions carrying out audit-functions. The evaluation of the Cancer Action Plan by the Danish Centre for Evaluation and Health Technology Assessment (DACEHTA) is valuable in pointing a finger to some of the in-build vagueness in the original Cancer Plan and to call for the incorporation of more specific and measurable policy-goals in the committees ongoing work. The fact that the initial plan from year 2000 contained fuzzy goals indicates that there may be a need for not only ex-post measures pointing at fuzzy goals but a need for a build-in procedure that generally furthers the use of measurable policy-goals. 

Political and economic background

The National Cancer Action Plan and the policy that followed was a consequence of the publicly available information that the Danish performance was markedly poorer than what was found in similar countries.

Change based on an overall national health policy statement

Change based on the report by the government initiated Cancer Steering Committee. The plan was published as ?the National Cancer Action Plan? in February 2000.

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

The ad-hoc recognition of particular problems in particular areas and the consequent compilation of ad-hoc answers in form of so-called action-plans is a policy form with a long tradition in Denmark. 

 

It is also in line with tradition that initiatives originate with the central government rather than with the counties. Typically it is for the counties to implement the central governments initiatives. The tensions between the central governments ambitions on behalf of the counties and the counties assessment of what is possible typically results in a game over budgets.

Approach of idea

The approach of the idea is described as:
renewed: A time-honored approach. Reacting to a problem using known instruments

Stakeholder positions

The policy-proposals/policy-goals gained widespread support reflecting that the central stakeholders (except consumers) enjoyed membership of the committee. This is also the case today (the committee's work is an ongoing process). Consumers are to a certain extent indirectly represented on the committee through the presence of a special interest organisation.

Influences in policy making and legislation

The policy did involve additional funding and the counties are of the opinion that they have implemented the plan.

Adoption and implementation

The main stakeholders were involved in the formulation of policy. The evaluation (see above) assesses the extent to which the plan has been implemented. One of several questions raised has been the counties implementation of the capacity and location of scanners, which the evaluation deems to be only partly in compliance with the expansion proposed in the Cancer Action Plan (because the increase in the number of scanners has largely taken place outside the oncology centres). Consequently the performance of the counties has been called into question and related to the in Denmark on-going debate on the future organisation of the regions. 

Monitoring and evaluation

In 2001 the Danish Centre for Evaluation and Health Technology Assessment (DACEHTA) was assigned responsibility for evaluating the extent to which recommendations of the Cancer Action Plan had been implemented by the Counties and other relevant stakeholders. The conclusions of the evaluation are (quoted from English summary):

"The evaluation has been able to present results within the following areas:

* Clarification of the degree of compliance with a number of recommendations at the clinical level based on a number of selected check points

* Proposals for a number of indicators for future monitoring of the cancer area

* A picture of the research activity and actors

* The status of a number of non-clinical focus areas in the Cancer Action Plan

* An example of how to tackle evaluation of a health care programme

* Identification of a number of future focus areas.

Due primarily to lack of data and time and resource constraints, however, the evaluation has been unable to shed light on the following areas:

* There is no complete evaluation of the recommendations of the Cancer Action Plan since the majority of the recommendations are too imprecise, the period since publication too short, and the focus area too broad to allow a comprehensive evaluation

* It does not contain an evaluation of the complete patient pathway for the three types of cancer (this would have required a much more comprehensive nationwide questionnaire survey or more comprehensive case notes audit)

* It does not encompass all aspects of the cancer area (too demanding of time and resources)

* It does not provide an overview of the effect of the Cancer Action Plan on patients treated since the year 2000 (except to some extent in the lung cancer area) due to the fact that the recommendations of the Cancer Action Plan cannot be isolated from other initiatives, that the causal relationship between effort and effects is uncertain, and that the effect data are incomplete

* The evaluation has generally been limited by a lack of ''baseline data'', a lack of indicators and a lack of data for the endeavours made up to 2003."

Review mechanisms

Halbzeitevaluation

Dimensions of evaluation

Prozess, Ergebnis

Results of evaluation

An evaluation has been carried out by the Danish Centre for Evaluation and Health Technology Assessment (DACEHTA). DACEHTA is part of the National Board of Health (which is part of the Ministry of Health).

Expected outcome

Taking a step back and observing the policy with a meta-policy perspective the striking feature of the policy is that - as stressed in the evaluation by the Danish Centre for Evaluation and Health Technology Assessment (DACEHTA) - the goals of the policy are so fuzzy as to make an evaluation extremely difficult.

References

Sources of Information

• A summary of the National Cancer Plan is available from the homepage of the National Board of Health: 
  
  Summary of National Cancer Action Plan (in English)
• The evaluation published by the Danish Centre for Evaluation and Health Technology Assessment (DACEHTA) is available from the homepage of the Danish Centre for Evaluation and HTA, National Board of Health: 
  The complete evaluation (in Danish)
  A summary of the evaluation (in English)
  Question regarding the evaluation can be directed to Lisbeth Høeg-Jensen, M.Sc. (Econ.), Danish Centre for Evaluation and HTA, National Board of Health, lhj@sst.dk.
• The European record, including the Danish  on cancer survival is analyzed in: 
  M.P. Coleman et al.: " EUROCARE-3 summary: cancer survival in Europe at the end of the 20th century", Annals of Oncology, 2003, vol 14, supplement 5, p. 128-149.
• Generally on evaluations and the role in public policy:
  L. Pritchett (2002): "It Pays to be Ignorant: A Simple Political Economy of Rigorous Program Evaluation", J.o. Policy Reform Vol. 5(4), pp. 251-269.

 

Author/s and/or contributors to this survey

Michael O. Appel

Empfohlene Zitierweise für diesen Online-Artikel:

Michael O. Appel. "The National Cancer Action Plan". Health Policy Monitor, 09/10/2004. Available at http://www.hpm.org/survey/dk/a4/1