A change in governance structure at BC Cancer shifted the organization’s priority from excellence in cancer control to fiscal management, leading to the growing waiting times and staff burnout now plaguing the system, according to four former heads of the agency.
But British Columbia Health Minister Adrian Dix said in an interview that although he is aware of the complaints about governance, he believes the fundamental issue facing BC Cancer is increasing demand for care owing to the province’s growing and aging population.
All four former heads of the agency traced the decline to 2001, when BC Cancer was placed under the purview of B.C.’s newly created Provincial Health Services Authority. PHSA has since been responsible for governing, managing and funding BC Cancer, along with dozens of other programs and services.
“The cancer agency was created to deliver a program of cancer control for the public of B.C. – that’s in its public mandate,” said Simon Sutcliffe, who served as president of BC Cancer from 2000 to 2009 and is now president of the non-profit Two Worlds Cancer Collaboration. “However, those decisions now aren’t the ones taken by BC Cancer. They’re taken by health authorities, and largely on the strength of the budgets that are available to support those decisions.”
“It shifted the whole emphasis away from medicine and science leading into the future to budget management – to make the medicine fit with the budget.”
The Globe and Mail spoke with Dr. Sutcliffe and the three other former presidents of BC Cancer as part of an investigation, which found that waiting times for cancer treatment in the province are growing, while BC Cancer physicians are reporting the highest levels of stress and burnout among their counterparts at all Canadian cancer agencies. Insiders fear the province is not prepared for a projected surge in cancer cases.
BC Cancer is a provincial, government-funded treatment and research organization, with six regional cancer centres in the province. The agency once had its own board of directors and a direct line to B.C.’s Ministry of Health. And it also had what Dr. Sutcliffe described as “a level of freedom to exercise strategic decisions” about its path forward.
In the late 1990s and early 2000s, the agency established itself as a leader in global cancer control by making significant investments in recruiting, both domestically and internationally. It also spent heavily on emerging fields of expertise, such as genome sciences, functional imaging and molecular pathology, Dr. Sutcliffe said.
The change in governance brought new layers of bureaucracy that put distance between BC Cancer and the health leadership of the province. Proposed initiatives by successive presidents – including attempts to build costly new treatment infrastructure and recruit new specialists – went ignored, the former heads said.
“We would have been considered the pre-eminent agency in the 2000s, and I think now we would be average,” Dr. Sutcliffe said.
He conceded that some budget controls were needed. “We were shifting from the 1990s into the 2000s, and economic restraint was coming with it. But we didn’t need layers of fiscal management that superseded good medicine and science,” he said.
When Dr. Sutcliffe resigned from the agency in 2009, he became the first of several presidents to leave their posts because they felt their hands were tied.
“I didn’t believe I could actually meaningfully do anything constructive to change cancer control and outcomes in B.C., because those decisions were no longer within my purview,” he said.
His successor, David Levy, resigned after less than two years on the job. The next president, Max Coppes, left after two years, and the following president, Malcolm Moore, after three-and-a-half. The BC Cancer presidency is typically a five-year, renewable term. Dr. Coppes and Dr. Moore spoke with The Globe and echoed Dr. Sutcliffe’s concerns.
One year prior to his departure, Dr. Moore unsuccessfully proposed to the PHSA board the creation of a quality council, which would have invited broader public input on how resources should be prioritized. Dr. Sutcliffe said such a body would have given the public a voice in cancer care.
“What are the innovative changes in medicine that are going to lead to improved cancer control rates for the population of B.C.?” Dr. Sutcliffe said. “That’s a different question from, ‘Can we operate 24-hour chemotherapy, radiation therapy and acute care services?’”
Mr. Dix, the health minister, said he has heard the concerns about BC Cancer’s governance structure. But the agency’s current challenges, he said, would be better addressed by hiring more staff to meet demand.
“A lot of the cancer people don’t like it, just as a lot of the paramedics didn’t like similar changes at PHSA, where they’re in that sort of a model, so they’re under the bailiwick of a vice-president,” he said.
“I’m not sure that’s the key problem, or that a redesign of the management structure is necessarily what we need. But I know we need more oncologists and more technologists. And we’re training more. But it’s a pressure point, no question about it.”
The Health Minister acknowledged that the agency has fallen in prominence.
“I think it is fair to say that in ’04, ’03, BC Cancer was described as a leader and, in the following 10 to 12 years, they lost that,” he said.
Don Carlow, who served as BC Cancer’s president from 1994 to 2000, said international evidence has outlined essential elements of effective cancer control programs. He said those include adequate equipment, drugs and staff; effective governance and leadership; and timely, patient-centred care. BC Cancer has fallen behind in these things, he said.
A system of performance monitoring, a well-developed lead cancer centre and an active research program are also crucial, he added, citing research from groups such as the Organization for Economic Co-operation and Development, the Organization for European Cancer Institutes and the International Cancer Benchmarking Partnership.
“Just as clinicians are expected to deliver care in accordance with evidence derived from research, I would say that the policy-makers in relation to cancer should look at system design, system governance, system leadership and capacity based on international evidence,” Dr. Carlow said.
With a report from Justine Hunter