Examination of Witnesses (Questions 80
- 99)
MONDAY 9 FEBRUARY 1998
MR GEOFFREY
RICHARD SCAIFE
and SIR DAVID
CARTER; MR
JAMIE MORTIMER
80. Do not repeat the same excuse. The point
I am getting at is that you are always lagging behind. If by 1993
you had only reached 7.7 per cent when the target was 30 per cent
then you knew you had to do something special to catch up but
nothing seems to have been done.
(Mr Scaife) Chairman, when the target
was produced in 1992 earlier in that same year The Scottish Office
Audit Unit had looked at cataract surgery and had proposed (without
putting a time limit on it) that an optimistic target for the
NHS in Scotland would be to achieve a level of 20 per cent of
cataract operations undertaken on a day case basis. Later that
same year the Scottish Health Service Advisory Council suggested
that in little over a year the NHS in Scotland could go from 0.4
per cent to 30 per cent and that by the end of 1997 that they
could go to 80 per cent. I think that was a very ambitious target
to set to go from 0.4 to 30 per cent in a little over a year.
81. You have not an objected to the target.
The Report makes no reference to you objecting to the target saying
it is too high. What is the point of a target that cannot be achieved?
If you thought it could not be achieved why did you not make that
clear?
(Mr Scaife) I have said that the
target is ambitious, Chairman, I have not said it cannot be achieved.
82. Although it has not be achieved.
(Mr Scaife) Colleagues are beginning
to say, "We might not quite make the 80 per cent." What
I am suggesting is that to go from less than half of one per cent
to 30 per cent in just over a year was over-ambitious.
83. Do you believe that if some areas are
able to do it others ought to be able to do it? The Borders went
from 13 per cent to 90 per cent in six months.
(Mr Scaife) Yes[4],
they have been developing their service, they have recruited additional
consultant staff and again the Borders do rely to some extent
on Edinburgh for their specialist services. Borders is quite a
small hospital, as you might expect.
84. What attempts have you made? Do you
consider it to be your job to spread best practice?
(Mr Scaife) Yes I do and I endeavour
to do that across the whole range of services for which I am responsible.
85. What steps have you taken in respect
of cataract surgery switching to day cases to ensure that the
clear success of some areas has been passed on to other areas?
I do not see any evidence of that because there is such a wide
variation in performance and achievement.
(Mr Scaife) Chairman, I have already
accepted that we have got a wide variation in performance but
I have also explained that performance overall has been increasing
and increasing significantly.
86. Not increasing anywhere near to achieving
the target. The result is that people are virtually blind when
they need not be. It is not even a matter of more resources. You
can treat more people with the same money in day case surgery.
Do you not think that therefore puts you and your Department in
a pivotal position to achieve these targets? You appear to see
yourselves as interested observers who pass on reports.
(Mr Scaife) No, Chairman. I have
already explained by drawing attention to the waiting list issue
that there is not a huge growing number of patients waiting in
the wings who have been denied access to cataract surgery. I have
demonstrated that the numbers of patients being treated has climbed
very steadily and has increased by 50 per cent in the last five
years or so. The question here is whether patients could be treated
better surgically on a day case basis as opposed to being kept
in overnight.
87. Would you turn to Page 28, Paragraph
2.38. This has already been referred to by Mr Williams. There
is a needs assessments for cataracts surgery for 1993 published
by the Scottish Forum for Public Health Medicine suggesting there
could be over 24,000 new cases each year. You accepted that figure
when Mr Williams put it to you. Indeed, it is in the Report. You
are treating 16,000. That to me is an area of unmet need which
savings arising out of day care surgery could tackle.
(Mr Scaife) Chairman, I have explained
that the 24,000 figure is the estimate of the number of new cataracts
arising in a year in Scotland. The same report produced by the
Public Health Doctors in Scotland suggested that the number of
patients who needed to be treated in any one year should be at
about the 16,000 level which is the level we currently achieve.
88. Conveniently that is the level you currently
achieve. Did you not also say that nobody should wait more than
12 months?
(Mr Scaife) We achieve that target.
89. You achieve that too. If there are 24,000
new cases a year there are 24,000 new cases the following year.
Given that the population is ageing that figure might well have
gone up by now I would have thought. That is a figure from 1993.
Do you not think you should be doing more to bring people forward?
(Sir David Carter) I think the 24,000
was based on the Framingham Study and it is an estimate of prevalence.
It does not necessarily follow that the incidence is the same.
Prevalence is a measure of how much cataract there is in the community
at any given time, and the incidence is the number of new cases
that will come forward each year.
90. How many new cases do come forward each
year?
(Mr Scaife) 16,000. The waiting
list is not growing and we treated 16,000 cases in 1996/97.
Maria Eagle: You were aware of the
fact that GPs are referring rather too late on average. They are
referring when people are virtually blind--
Chairman
91. I just want to make a point to you.
The actual wording here that you have agreed is: "The Scottish
Forum for Public Health Medicine published a needs assessment
for cataract surgery in 1993 which estimated there could be over
24,000 new cases each year." If you do not think that is
true you should have objected to that at the point you agreed
that Report. As it stands here it reads as though there are 24,000
new cases for cataract surgery each year. I cannot read it any
other way. It is not prevalence; it is cases.
(Sir David Carter) It is an estimate
at the end of the day. The reality is that at present we have
16,000 --
Chairman: It is a 50 per cent variation
from 16,000. That is not the sort of estimate I would expect to
be out by that level.
Maria Eagle
92. That is right. Thank you, Mr Chairman.
It does mystify me, I must say, that you come out with real estimates
that happen to be exactly the same as the level of people you
manage to treat. I was going to go on to make a further point
about GP referrals. If we have problems with consultants in switching
to new methods, we certainly have problems with GPs in terms of
referrals. It seems quite clear from the photograph on Page 33
and Paragraphs 2.47 and 2.48, already referred to, that many GPs
are referring people at much too late a stage. Whilst one admits
that maybe people struggle on and do not go to their doctor, it
may be that GPs are leaving it too long after they know there
is a problem before referring. The GP's themselves seem to be
quite defensive. Paragraph 2.47: "Many GPs prefer not to
quote specific referral acuities ..." Quite a defensive reaction
from GPs.
(Mr Scaife) I agree with the comment.
93. Does that not concern you?
(Mr Scaife) Yes it does, but it
could also mean that general practitioners are seeking to explain
that it is not just the level of acuity; it is a question of what
the patient hopes to be able to do, what the patient needs in
order to maintain his or her lifestyle.
94. Eyesight would help, would it not?
(Mr Scaife) We are talking about
acuity, these are not absolutes. The figure I quoted before of
16,000 cases was the figure which was quoted in 1993 in the document
you referred to which also quotes the 24,000 figure. So what I
am seeking to confirm is that the public health consultants in
Scotland were suggesting in 1993 that we ought to be treating
something like 16,000 patients and that is the level we are treating
patients at currently.
95. Can I ask you what you have done? You
said to the Chairman and also to Mr Williams that you had been
sending the Report out to people in the service, you had spoken
to senior consultants about the findings in the Report, that only
last week you met with the President of the Royal College. What
was the outcome of that meeting?
(Mr Scaife) It was a meeting where
we were talking about the activities of the College and seeking
to enlist the support of the Royal College in producing clinical
guidelines for the Health Service in Scotland and encouraging
the President of the College to work with our people on the production
of those guidelines.
96. Are the guidelines going to be specifically
about cataract surgery and switching to day case surgery, or are
they going to encompass a whole range of other things?
(Mr Scaife) We would expect the
guidelines to be about the management of cataracts and to be pushing
quite hard the case for increasing the proportion of cataract
operations which are carried out on a day case basis.
97. Within what timescale do you expect
those guidelines to be produced?
(Sir David Carter) The normal guideline
production is somewhere between six to nine months.
98. Why did you not produce guidelines such
as that back in 1992, or at an earlier date, when it became clear
the targets which had been set by you were not being met? Why
have you waited five years down the line to see the President
of the Royal College about this?
(Mr Scaife) Chairman, we have produced
a range of clinical guidelines for the NHS in Scotland. It is
simply the case that cataract surgery was not one of the top priorities.
99. Is your Department unable to deal with
anything other than a top priority, or is it also able to deal
with other matters?
(Mr Scaife) Chairman, I have explained
the work we have undertaken in commending the targets, commending
the Report, encouraging our health boards to take the targets
fully into account. I have explained about our efforts to encourage
our health board and trusts to deal with variations in performance
and variations in expressed demand. Obviously we have to settle
on priorities and in a service as huge as the NHS I think it is
right we are selective. In Scotland the priorities, as I have
already explained, have been to do with coronary heart disease,
cancer, mental health and so on.
4 Note: See Evidence, Appendix 1, page 17 (PAC 195). Back
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