Select Committee on Public Accounts Minutes of Evidence


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footnote, but it is the decision of surgeons and you admitted it yourself, some of them wilfully, some of them perhaps out of date or out of touch, some of them for reasons best known to themselves are deliberately not doing what their compatriots are doing in other hospitals or even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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