Economist Brian Easton draws attention to the complexities of implementing a politician’s promises or popular demands and says we are going to be disappointed because once again many manifesto promises got fudged in the heat of the campaign

This is a re-post of an article originally published on pundit.co.nz. It is here with permission.

Did you think the incoming government promised to extend bowel screening to 50-59 year olds? The promise was more limited – and more feasible.

National’s Manifesto promised:

Bowel cancer is the second highest cause of cancer death in New Zealand, while we have one of the highest rates of bowel cancer in the world. More than 3,000 people are diagnosed with bowel cancer each year and over 1,200 will die from the disease. Screening is one of the most effective ways to find bowel cancer early before it spreads. The National Bowel Screening Programme is available for eligible men and women aged 60 to 74. National will immediately commission work on a business case for progressively lowering the bowel cancer screening age to 50.

A ‘business case’ is an investigation of whether and how a particular project should be undertaken. The commercialist jargon arrived with neoliberalism and often has the implication that the project will go ahead anyway although sometimes business cases conclude that proceeding may not make sense – which does not always inhibit enthusiasts.

The bowel screening program is separate from what happens to a patient with symptoms (which I’ve listed at the end), who is referred by a general practitioner to a hospital gastroenterologist. This is not confined to any particular age group; there is evidence of increasing rates of bowel cancer among those under the age of 50.

Whatever the GP’s conclusion, the specialist makes a separate assessment and may decline to proceed. It’s a clinical judgement so they may make the wrong decision – which may be lethal for the patient. But I have heard GPs suggesting that a particular specialist is rejecting too many. Perhaps they are overwhelmed with referrals but I have heard the claim that they may be holding back in order to meet screening targets (referrals are not included in the targets). There are some well-documented cases where the patient and their families were badly let down by the system.

A referred patient judged vulnerable gets a physical investigation (hopefully without too long a wait). The most common investigation involves a colonoscopy in which an endoscope inserted up the rectum. (There are other means but this account simplifies to get the essence of the issue.) They don’t look just for signs of cancer but also for bowel ‘polyps’ which can potentially turn cancerous, which are then excised – so the investigation is not just about identifying cancer but preventing it. (There is an analogy here with cervical screening, which is also concerned with precancerous conditions.)

Aside from the resources, the inconvenience and the time involvement of the procedure it is also necessary for the patient to first purge the bowel of any faeces which is not a pleasant experience – but neither is bowel cancer.

I’ve just described what happens if you go to your doctor. A bowel screening program is the other way around. The medical system reaches out to you to find out whether you should go on to a colonoscopy.

Designing an effective screening program is not easy. It took almost a decade to get the cervical screening program fully running. Today its success is evident in the falling rates of the incidence of and mortality from cervical cancer.

Indicative of the challenges, the national bowel screening program was rolled out between July 2017 and May 2022 preceded by a pilot program in the Waitemata DHB area which began in November 2011. Pilots are necessary to design an effective system, particularly as success depends on public co-operation on matters which are intimate, and where cultural differences may be significant.

Initially the intention was to follow the international recommended standard of screening all those in the 50 to 74 age group. The Waitemata pilot did that but the national program was restricted to 60 to 74 age group and the sensitivity of the test was decreased.

The reason for the beginning age of 60 being higher than recommended one of 50 years, for most of the population, is because it was judged that we simply did not have the resources – the skilled workers and facilities – to cover everyone. (However, for Maori and Pasifika the age of eligibility is 50 because bowel cancer occurs earlier among those ethnic groups.) Resource limitations are the reason why the 2023 manifesto promise is only for a ‘business case’ for lowering the age and not for immediate implementation.

Faced with the shortage the business case could politely say ‘I am sorry Minister, but no’ or ‘not for now’. More likely they will look at whether we can obtain more gastroenterologists, the main bottleneck. It takes years to train one. Could we obtain more overseas? Other possibilities would be to use simpler but not as effective investigating alternatives instead of a colonoscopy, which may be better than doing nothing but are more likely to miss some cases. Apparently some of the alternatives can be applied by less well-trained paramedics and GPs (but we are short of the latter too).

I would hope, too, that the business case looks at the question of GP referrals of symptomatic patients. I would like to think the grumblings I hear refer only to very limited instances. Perhaps not.

These sort of evaluations of medical treatments are of intrinsic interest to an economist. Over the years I have contributed to a number, always working with members of the medical profession who know far more than I ever shall about the medical issues. But they usually require assistance in thinking through the resource implications – which is not just having a plausible case to get Treasury to cough up the cash.

I thought it also useful to draw attention to the complexities of implementing a politician’s promises or popular demands. You are going to be disappointed because once again many manifesto promises got fudged in the heat of the campaign.

Don’t be too tough on them. In this case the Labour Party made a similar promise; perhaps it was softer because they understood the challenges better. From the longer term perspective, this is another step towards markedly reducing bowel cancer.

Appendix: Bowel Cancer Symptoms

Bowel Cancer New Zealand advises:

‘Being aware of the symptoms is the first step you can take to prevent bowel cancer. Symptoms may come and go so don’t wait if you have any of these concerns, no matter what age you are. Symptoms may include:

     Bleeding from the bottom (rectal bleeding)

     Change of bowel motions/habits that come and go over several weeks

     Anaemia

     Severe persistent or periodic abdominal pain

     A lump or mass in the abdomen

     Tiredness and loss of weight for no obvious reason

If you have any of these symptoms, or you are concerned about your bowel health, see your GP right away.’

There is also a genetic component to bowel cancer so family history of it is another factor taken into consideration.

(This column has been checked out by medical specialists.)

*Brian Easton, an independent scholar, is an economist, social statistician, public policy analyst and historian. He was the Listener economic columnist from 1978 to 2014. This is a re-post of an article originally published on pundit.co.nz. It is here with permission.