Examination of Witnesses (Questions 20
- 39)
MONDAY 9 FEBRUARY 1998
MR GEOFFREY
RICHARD SCAIFE
and SIR DAVID
CARTER; MR
JAMIE MORTIMER
20. You agreed this Report?
(Mr Scaife) Yes.
21. So in other words you accept that footnote,
but it is the decision of surgeons and you admitted it yourself,
some of them wilfully, some of them perhaps out of date or out
of touch, some of them for reasons best known to themselves are
deliberately not doing what their compatriots are doing in other
hospitals or even alongside them.
(Mr Scaife) Chairman, I explained
that for the West Glasgow University Trust Sir David and I met
the senior consultant there and asked him to explain and he told
us about the different case mix that they have in that major teaching
hospital and the fact that that is where the eye cancers go to
in Scotland.
22. I accept that, but you have accepted
that you have agreed to the footnote. We perfectly accept that
the mix of severity of cases will make a difference, but you have
agreed to more than that, you have agreed to the fact that it
is the willingness of the doctors that is denying people the medical
treatment they need and all you have done is talk to them. When
did you talk to the hospital?
(Mr Scaife) We met the President
of the Royal College who works at this hospital last week.
23. Last week, just before you came here?
This came out in November. You would have had it well in advance
for agreement and yet it is only last week, with a situation as
appalling as this, that you saw fit to actually go and talk to
them and accept silly and quite unsustainable explanations of
the differences that exist. Do you feel you have done your job
properly? I do not think you have, I have to tell you.
(Mr Scaife) Yes, I do. We drew the
Report to the attention of the service. We wrote to the President
of the Royal College as soon as we received the Report. I think
it is important to bear in mind that the variation here is a variation
in the level of day surgery and it is not the case that the variation
in the level of day surgery implies that the patients of this
hospital are not getting the treatment that they are entitled
to.
24. It is hard to reconcile that with the
information in figure 17, is it not, where it shows a mix of treatments
and it still has these abnormal differences between them? I am
amazed that you have come here today so unprepared to answer questions.
(Mr Scaife) Chairman, I have explained
that we drew the Report to the attention of the service, that
we approached the President of the Royal College, that we met
him last week because we wanted to discuss with him the willingness
of himself and his colleagues to cooperate with our Intercollegiate
Guidelines Network to produce the guidelines for the service.
The variation in the level of day surgery for cataracts is precisely
that. It does not imply that the population of Glasgow is not
getting a service. They are getting a service but much of it involves
an overnight stay and is not performed on a day basis, which is
the case in Ninewells Hospital in Dundee, as shown in the figure
above.
25. Glasgow is a city, an urban area and
transport is reasonably available. So why is it they are there
on overnight stays?
(Mr Scaife) It is a major teaching
hospital. It is in the centre of Glasgow. It attracts many referrals
from a very wide catchment and for some conditions, including
eye cancer, it attracts referrals from the whole of Scotland.
So people are travelling huge distances in order to access some
of the very specialised treatments on offer in that particular
hospital.
26. Let us look then at the most vulnerable
section of the population. Turn to page 31, figure 13. We are
dealing here with an ailment that is essentially highly correlated
with older age and here you have in figure 13 that age group picked
out. You have the over 65s who are about one in seven of the population
of Scotland and we have GP practices so it is not just the surgeons.
You look at the top level and you find that one patient in 30
over 65 in the left-hand practice is receiving treatment and yet
you go to the opposite extreme and you find it is one in 250.
That is 13 times more than the one in the other. How do you explain
that degree of difference? What have you done about that and who
have you spoken to?
(Mr Scaife) Chairman, we cannot
explain precisely the variation in treatment rates between individual
GP practices.
27. Why not? Is that not what you are there
for?
(Mr Scaife) No.
28. Why not?
(Mr Scaife) The job of looking at
individual practices and at looking at differential levels of
need and differential levels of service uptake is a job for the
local health board.
29. So do you think the local health boards
have been doing their jobs then? Do you ever talk to them and
ask them how they explain this? It may be their job, but are you
not there to make sure they are doing their job properly?
(Mr Scaife) Yes, we are, Chairman,
and again through the needs assessment work undertaken by all
the health boards in Scotland we have drawn attention to the need
to look behind expressed demand and to measure morbidity within
the population, and generally the health boards in Scotland do
perform that task and do look behind the individual figures.
30. This table does not bear that out, does
it? Just look at it. GP practices -I am not sure how many there
are, probably about 20 or so-and you have this incredible variation
and you are not able to explain it away at all. You can explain
why there would be some difference, and we would accept there
would be some difference, but it does not explain that magnitude
of difference. Let us go across the page to Figure 12. This is
in one health board and it shows the cataract treatment rates
in one local government district within one health board. This
is an area of social deprivation. The Scottish average, we see
from Figure 11 a page before, is 320 cases per 100,000 population,
here in this deprived area the best is only 1:400. Not one district
even achieves the Scottish average, not one section. Where would
this be? What area is this? It is not identified for us. Perhaps
the C&AG can tell us which area it is.
(Sir John Bourn) It is in Ayrshire
and Arran, Chairman.
31. Can you think of any good reason why
it should be so abysmal when it is supposed to be looking after
people in a socially deprived area?
(Mr Scaife) I cannot explain the
particular effect of that local government district--
32. Why not? You knew you were coming here,
you agreed this report, you knew you were going to be questioned
about it, you must have known you would be asked to explain things.
Why can you not tell me the answer? Up to now we have not had
many answers, just a few excuses.
(Mr Scaife) Chairman, the issue
here is not so much which particular local district area this
happens to be, we were not told which region it was in and we
were not told which particular districts--
33. C&AG, had they asked would you have
told them?
(Sir John Bourn) Certainly.
34. Did you think of asking?
(Mr Scaife) No, we did not.
Mr Williams: That is it. I have nothing
more to say.
Jane Griffiths
35. I want to continue to follow up a little
on this whole question of variations in treatment rates. I know
others have already raised it but I think it is worth pursuing
a little further. If I understood your previous reply correctly
you said you do not know why there are variations in referral
rates, is that right? You do not know why there are higher rates
of referrals in some places than in others?
(Mr Scaife) Chairman, I think the
issue is that there are a lot of variables at play. These are
treatment rates, so there are variables in terms of whether patients
come forward in the first place, whether they visit the optician,
whether they visit their general practitioner, whether they complain
they have a problem with their eyes, whether the general practitioner
as part of a routine check would look at visual acuity or not.
So there is a whole host of variables in the primary setting,
whether one is visiting the optician or whether one is going to
one's GP. Then there are the variables which have already been
alluded to by the Committee about what happens when you arrive
at the hospital. So a whole host of variables at play.
36. Yes, I understand that, but some GPs
do a visual acuity check as a matter of course for elderly people
and others do not. Do you believe there is a case to be made for
all GPs being required to do that?
(Mr Scaife) Chairman, as I said
earlier, if we were to consider doing that, that would be a significant
policy shift and one would have to work through all the implications
of such a move and Government has not addressed that to this point
in time.
37. Have you considered the possible effects
on non-direct NHS matters like social services costs if people
are waiting and not being referred and at 60 are effectively blind
and therefore disabled? No matter what their lifestyle has been
they will not be able operate in the way they have been accustomed
and they will need help. Have the implications of that been considered?
(Mr Scaife) Increasingly we are
looking at the effects on social work and on the wider community
in deciding where to put our resources. Of course, the check you
are referring to would be for the over-75s and not to the general
population, so one is looking at a relatively small number. Again
I would point to the fact that over the five years which is the
subject of this report the number of patients being treated has
increased from something a little over 10,000 to something over
16,000, so more and more patients are coming forward for treatment.
The question is, what is there out in the community which is not
coming forward. I have already explained that when the public
health consultants looked at this in 1993 they gauged a level
of about 16,000 would be about the level they would expect to
see. What we do not actually know is what else there is out there
which is not coming forward, and whether, if it did come forward,
the visual impairment would be such that a cataract operation
would be warranted.
38. But it does follow, does it not, that
more people can be treated if more of the treatment is done under
day surgery because you can process more people, so the people
are waiting for a shorter time. Forgive me if this question sounds
naive.
(Mr Scaife) I do not think anyone
has raised the possibility that patients are not getting treated
because the level of day surgery is approximately 43 per cent
as opposed to some higher level. The number is climbing and climbing
very steadily. As I have said, we have gone from 10,000 to 16,000
in five years, and the number is still increasing, so I do not
think it is the case that patients are being denied treatment.
More and more patients are being treated and are being treated
within the waiting times that ministers have specified patients
should be treated within for cataracts.
39. What are the waiting times that people
have?
(Mr Scaife) The best figure is that
about 83 per cent of all patients who are treated for a cataract
are treated within three months of being referred.
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