Examination of Witnesses (Questions 40 - 59)
WEDNESDAY 20 MAY 1998
MR ALAN
LANGLANDS, DR
SUE ATKINSON,
and MRS JULIETTA
PATNICK
40. I respect your intent but, as I say,
I am just slightly sceptical about the progress that is being
made and the priority of these objectives. If I could turn briefly,
Chairman, to the C&AG and ask him about Appendix 5 and audit
methodology? You list there literature research, seminar discussions,
why, quite simply, did you not carry out an opinion poll so there
was a really broad sample of women who could provide confidential
feedback on the experience of undergoing the tests, waiting for
the results, and tell you whether or not they got the results
on time? Was there any attempt made to take a broad sample like
that?
(Sir John Bourn) When we reviewed
the literature it did include information on surveys of that kind.
41. So it was secondhand data?
(Sir John Bourn) Yes, it was.
Mr Wardle: Nothing wrong with that.
Thank you.
Mr Love
42. Good afternoon, Mr Langlands. I would
like to take you back to the issue of coverage and to those 13
health authorities. Like Ms Eagle, one of those is indeed my own
health authority. She asked you questions in relation to the number
of those authorities having reduced their repeat period to three
years from five years, and should they not be focusing their resources
on getting up to the 80 per cent level, and I do not think you
quite answered that question. Are you taking steps to get those
health authorities to focus primarily on the coverage issue?
(Mr Langlands) We are asking people
to focus on the coverage issue, but we are not asking them or
we are not insisting that they extend the frequency from three
to five years. I think it is very difficult when that service
has been provided for people who do use the service to withdraw
it. There is no doubt in terms of resources, in terms of management
action, in terms of the sort of discussions which go on between
the regions and the health authorities, the emphasis is on coverage
and particularly coverage in relation to the most vulnerable groups
in the population.
43. I am a little worried by that answer
in that I would like some reassurance that despite the difficulties,
and I accept there are major difficulties in extending coverage
in those inner city areas, you are giving them priority. Let me
take an example. I read through the report and on two occasions,
for both Camden & Islington and Enfield & Haringey, which
are known to me, they are within those 13 authorities yet they
come out on several occasions as having best practice. So here
are two health authorities—and another example was given in terms
of Merseyside—already pursuing best practice but well below the
80 per cent targets. What is being done to ensure that they get
up to that 80 per cent target?
(Mr Langlands) Can I first of all
assure the Committee that we are not talking here about a financial
constraint or a financial trade-off between frequency and coverage.
That is clear. The whole system of coverage runs through the GP
system and we want improved coverage. The progress that has been
made in the two places you cite is very marked indeed, I think
from a figure in one case of 40 per cent up to 69, and that is
continuing, and it is to do with sorting out the contact list,
tracking people who move around in that population, accessing
the—
44. Before you get on to those issues, because
I do want to go on to them, can I just ask is there any specific
targeting of those 13 authorities by your department in order
to ensure they get up to that 80 per cent figure?
(Mr Langlands) Yes, and that has
been a consistent position through the years, which is why you
have seen these marked improvements in the two places you have
cited.
45. We have had a number of examples of
what is being done to drive those numbers up, but can I take you
to a number of issues, first of all patient registers? This is
a particular problem in inner city areas. A lot of people believe
that could be partially solved by new technology. Are there any
special schemes for those 13 authorities to introduce new technology
for patient registers?
(Mr Langlands) There are special
schemes and the intention, as I think we discussed last time,
is to try and improve technology across the board in the Health
Service. Certainly the family health service authorities and now
the health authorities who are responsible for these things, have
made a huge investment in improving their systems, cleaning up
their registers, improving their system of tracking a number of
people who in these settings tend to be pretty transient. There
are built in mechanisms between GPs and health authorities to
try and ensure that we are always on top of the latest change
of address. So the issue of information and all the other things
we have mentioned are precisely the things that the regional directors
push when they are discussing these problems with the health workers.
We are seeing, as I have said earlier, good progress in all 13.
46. Can I take you to another issue and
that is in relation to general practitioners and in particular
the vexed question of single-handed practitioners? Let me mention
that in relation to two issues. The suggestion in the report of
best practice suggests a practice nurse, and we talked earlier
about male general practitioners and the fact that may not be
the most appropriate way in which to take a smear, the introduction
of practice nurses, the difficulty with a single-handed practice.
Also when the Chairman mentioned earlier the number of people
under 20 years of age who are still being screened, you did omit
to mention that the report does indicate that it is a small number
of GPs who continue to carry out that practice. I wonder, have
you got any information as to whether that is single-handed GP
practices and whether there is any correlation in relation to
inner city areas in single GP practices?
(Mr Langlands) I do not know the
answer to the last part of that question. It may be my colleagues
have a view.
(Dr Atkinson) I do not think we
know there is a correlation. Certainly one of the things about
single-handed male GPs is that a number of places have been targeted
if there is a low up-take and tried to put in either practice
nurses or visiting practice nurses, or made it very clear to women
that they can access cervical smears from other places, such as
family planning clinics or even from another GP where they might
see a woman rather than a man.
(Mr Langlands) You will see in the
costings of this there is a sum set aside for the provision of
services in community based clinics, and they will tend to be
in inner city areas where single-handed GP practices are operating.
47. I understand that but there is still
a very specific problem in that area. Can I take you on to incentives
because you mentioned the issue of incentives and the report does
look favourably upon them. Since I think every authority is now
above 50 per cent and general practices are way passed that, why
is there still an incentive payment for 50 per cent? More particularly,
the 80 per cent incentive payment is easily achieved by most GPs
in ordinary areas and almost impossible to achieve, I suspect,
for GPs in the 13 areas I have highlighted. I wondered whether
there was an alternative incentive scheme which really would impinge
on inner city area general practices, which would be able to get
them to take more people who need this type of testing to be carried
out?
(Mr Langlands) I think there may
be, and I would be misleading you if I did not say that the current
incentive system for all the reasons you suggest is more to do
with terms and conditions of GPs rather than solving the very
specific problems you identified. But there are other mechanisms
that can help GPs in these areas, in other words we have ways
of spending money on this service that do not run through the
payments system and the incentive system. There is just recently
in legislation a system of section 36 grants, so-called, which
allow us to make specific allocations to GPs to help the development
of these sorts of services. For example, it will be that sort
of initiative that is funding the out-placement of practice nurses
that Dr Atkinson referred to. So we are not adopting a single
approach here. We are trying, particularly in inner cities, to
break down some of the rather stultifying regulation around general
practice to allow more innovation in what we know to be difficult
areas.
48. I do think dissemination of best practice
is something which needs to be reinforced by the Department, but
I shall not go into that at the moment because I am running out
of time and I want to move on to a second area which is about
external accreditation. I was somewhat surprised that external
accreditation was not mandatory. You did mention earlier all but
a handful would be done by June 1998, and the report talks in
terms of by May 1998 everyone being accredited. So my understanding
would be that there has been some slippage on what, presumably,
the Secretary of State pronounced upon last December. Can you
tell us what "all but a handful" means and when all
of the labs are going to be accredited?
(Mr Langlands) It is literally a
few, less than five, and the picture is changing all the time.
As I said, many of these labs where we had worries are merging
with bigger laboratories. One or two that we are dealing with,
whilst providing this service of smear screening and reporting,
are doing so outside the confines of the national programme, in
other words there are laboratories which are essentially dealing
with the internal work of the gynaecological department in their
hospitals. So it is not quite as clear cut as we say, but certainly
we know precisely those where there are still issues to be resolved
and discussions are in hand at the moment to resolve them.
49. Can you just give me some reassurance,
and please be brief, about these amalgamations which will take
place, because I know from my own local situation they are indeed
fraught with great difficulty? Can you assure me that forceful
management action is being taken to bring this about in the short-term?
(Mr Langlands) Six of them have
already taken place and there is no doubt that we are operating
in an environment where if we do have worries, and they are not
being resolved by reorganising the services, we will close laboratories.
But everyone is being co-operative in trying to make the improvements
and developments we want to make at the moment.
50. Can I go on to talk about the guidelines
and the issue of confusion? One of the things, as I understand
it, reading the report, is that you have issued these guidelines
but there are alternative local guidelines either which were already
in operation or which have come into operation. What action is
the Department taking to cut through all of this and ensure it
is the national guidelines that everyone looks to to ensure the
service is delivered to the standard required?
(Mr Langlands) Certainly on screening
and reporting, the national guidelines rule.
51. Has that been made absolutely clear
to everyone, including general practitioners?
(Mr Langlands) That has been made
absolutely clear to everyone. The important thing, I think, in
terms of encouraging confidence in the system is that these are
not guidelines which we thought of on our own, these are guidelines
which have been worked through with all the different professional
interest groups, which have been led by the NHS Cervical Screening
Programme on behalf of the Department of Health. There is no doubting
that. What we now are embarked on is the fraught question of changing
behaviour. Sometimes they are habits of a lifetime.
52. I do think some targets on the time
you would expect people to be up to the standard of the guidelines
may be something you would want to look at in the future.
(Mr Langlands) These targets will
be set specifically locally, taking account of local circumstances
through the regional system.
53. Can I talk very briefly about the costs
in the laboratories? There is enormous variation between costs
from one to another. I know that the amalgamations will deal in
part with that problem. What other steps are you taking? There
is the whole issue about overall costs of this service which the
Committee of Public Accounts asked for previously. Can we have
some reassurance that your Department has got a handle on the
cost of providing this service, both in the labs and generally?
(Mr Langlands) I think we have a
handle on it but I talked earlier about the science of this whole
process not being very precise. I would be misleading you if I
said the process of costing to this level of detail, in a very
clear direct/indirect break-down of costs in some of these laboratory
settings, is a precise science. We have not traditionally operated
at that level of detail. What we are trying to do, and it is neatly
drawn out in the report and the profile shown, is to mimic that
approach across the Health Service. The removal, if you like,
of the purchaser-provider dynamic has to be replaced by something,
and one of the things it will be replaced by is a system of reference
costing and benchmarking, so the graphs that you see from time
to time in this Committee, courtesy of the NAO, you will see much
more readily in the future as a means of managing the Health Service.
But that is something we are working on and have been working
on over the last year.
Mr Love: I look forward to that.
Mr Page
54. Mr Langlands, on 4th March 1992, one
of your predecessors at the time, Mr Duncan Nichol—he eventually
received recognition for the number of times he appeared in front
of the Committee of Public Accounts by being given a knighthood—was
asked a question by a then member of the Committee, an extraordinarily
incisive question by a member whose name escapes me at the moment,
and this gentleman said, "This report on cervical screening,
if I have read it correctly, is somewhat critical of the data
collection within the Health Service", and the response from
a Dr Gray, in the position now occupied by Mrs Julietta Patnick,
said, "We do not have consistent long-term trends in the
figures we have been able to look at. The system is really producing
this type of detail consistently now." Is it not the truth
that six years on, whilst the system might be producing the figures,
the usage of it is flexible to say the least?
(Mr Langlands) Six years on the
Health Service has been reorganised twice, if you want to just
think about the nature of the organisational changes. Post-92,
it is absolutely right these figures were being collected but
they were being collected for local use; the people who used to
collect similar figures from other parts of the Health Service
on a national basis, no longer exist. We were running a devolved
health system and I have some experience of coming to this Committee
and explaining why I could not answer certain questions, and why
I could not answer certain questions is that data was not being
collected on a national basis. Of course, there is a substantial
cost attached to that sometimes. <stpa> That is no longer
the case. The quantification that you were asking for in 1992
is now in place, courtesy of a lot of hard work by the people
running the service, and that quantification is now being used
to support local and national quality assurance systems, and the
series of data you saw for 1996-97 in this report will be repeated
in subsequent years. We will be able to track in all these tables
in the back half of this report what progress we are making on
this programme. That was not an option open to us before.
55. I obviously hope this is again in the
future to be the case. If I could take you to page 37, paragraph
3.10, we see here an evaluation which has been taking place of
admittedly only a few numbers. I must ask the question, what research
has been undertaken to verify what it says here, whether 50 per
cent of unscheduled smears have been undertaken by only 18 per
cent of the general practices, as one 1996 study suggests? Is
it typical? That suggests that 82 per cent of the GPs are not
pulling their weight. If so, what are you doing about it?
(Mr Langlands) It is the other way
round, is it not? Sorry, I am having to read the sentence.
56. "... 50 per cent of all unscheduled
smears identified were taken in only 18 per cent of general practices
and only eight per cent of the NHS community clinics in the study
sample."
(Mr Langlands) The point there is
that unscheduled smears are not a good thing. Your assertion that
82 per cent are not pulling their weight is not right, it is the
other way round, 82 per cent are pulling their weight. The problem
relates to 18 per cent of the group, and the way to tackle that
group is through the relationship between the laboratory and the
people who are taking these smears and through the system of quality
assurance that is now being put in place.
57. Yes, but my point is why is it that
we have at this late stage, six years on, when all this clinical
data has now been collected as assured to the Committee, why have
we got 18 per cent going off doing what they are doing?
(Mr Langlands) The guidance against
which all these figures, including that one, are measured in this
report was issued in March 1996. The report was compiled by the
NAO in February 1997, 11 months after the institution of the guidance.
The point is that you do not change the behaviour of 100,000 people,
or a sub-set of that 100,000 people, in that short period.
58. Six years?
(Mr Langlands) Not six years. March
1996 to February 1997.
59. Mr Langlands, this is precisely the
point. Here we have a system which is being put in place to save
people's lives. Six years on we are finding that it is only just
being put in place and just about to change, having had these
sorts of assurances in 1992 that life the next month is going
to be brought up to speed. This is obviously not the case.
(Mr Langlands) It has been put in
place to save people's lives and it is saving people's lives,
and the figures show that throughout the period you are talking
about there was a 7 per cent reduction in the death rate.
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