Examination of Witnesses (Questions 60 - 79)
WEDNESDAY 20 MAY 1998
MR ALAN
LANGLANDS, DR
SUE ATKINSON,
and MRS JULIETTA
PATNICK
60. It has got better but—
(Mr Langlands) The latest figures
are up from 7 per cent to 7.3 per cent. It has got much better.
The period between 1992 and 1996 was spent sorting all of this
out, putting the data systems in place, building the agreement
with the professions concerned that we were measuring the right
things, and we are now able to track progress on a consistent
basis. This snapshot is taken in a period where we are only 11
months into that cycle.
61. I think that is precisely the point
I am making, it is 11 months into the cycle yet it was drawn to
the attention of the NHS Executive back in 1992. Do you think
it takes five years and one month to put it into position? Do
you think this is acting quick enough and fast enough regarding
the health of this nation?
(Mr Langlands) As the report said,
and as the Chairman said at the beginning, a great deal of progress
has been made since the 1990 [2]
report. We are talking about one element in relation to laboratory
smear screening here.
62. I agree with that, Mr Langlands, I will
come on to other elements where speed has not been of the essence.
(Mr Langlands) The other area where
the Com mittee did call very clearly for quantified standards
was in relation to the coverage rate. Following that discussion
the figure of 80 per cent was set. The figure that is now being
achieved across the country is 85 per cent. There is a weakness
not meeting these figures, as we have been discussing, in 13 health
authorities. That is progress.
63. It apparently is the case that your
definition of progress and speed of progress may not necessarily
correspond with mine.
(Mr Langlands) Wanting something
to happen does not make it happen.
64. No, and that is why leadership and direction
is necessary.
(Mr Langlands) That is what I think
we have been giving.
65. Can I take you on to the question that
was actually raised by the Chairman. This is page 36, paragraphs
3.6 and 3.7, regarding the smear tests for women under 20 when
the medical evidence appar ently suggests that the risks of cervical
cancer are very small. You responded to the Chairman that a number
of doctors want to continue. If I could take the point made by
Mr Love, what about the spread of best practice? What advice has
been given by the NHS Executive to these doctors to say this is
a use of resources that can be better directed? When did such
advice go out?
(Mr Langlands) In setting up the
scheme to target people in the 25-64 age band it was clear from
the outset that was the target population and that was a figure
or a range agreed by the professions at that time. There have
been, from the professions them selves, guidelines along those
lines. The clinical guidelines, very comprehensive for the whole
pro gramme, that have now been sent out by the Executive in 1997
set out not just the point that we should stick to that number
but also the research evidence supporting it. Doctors change their
behav iour and their pattern of working by looking at the science
and looking at the evidence. They operate on the basis of knowledge
rather than belief. We are helping, hopefully, to reduce that
number by provid ing the right knowledge base from which they
can operate.
66. So the answer is the Executive's advice
went out in 1997?
(Mr Langlands) The National Screening
Pro gramme went out in 1997 based on evidence. [3]
67. If I can take you to page 41. I accept
the difficulty of getting the message over to certain quarters
of the medical profession who are—how can I put it—traditional
in every sense of the word. I fully agree with any arguments on
that. Can you explain, if I take you to page 41, paragraph 3.21,
why one-third of the health authorities apparently failed to contact
general practices which have persistently high rights of inadequate
cervical smears? I say that because I recognise the difficulties,
and one has seen pro grammes on the difficulties, of doing the
correct analysis of these smears, they are not easy to understand
and not easy to interpret, I go along with that, but nevertheless
I have a number of questions that ask why has not an advice and
training programme been put out earlier on this?
(Mr Langlands) Again, the advice
has been consistently clear on that issue. What you see here is
a response to a very specific question and set of questions from
the NAO. There is absolutely no doubt that good practice is that
there is direct feedback to general practitioners or wider, in
fact, to—a rather awful term—the smear taker who is often the
practice nurse. That relationship between the laboratory and the
people taking the smear test is a key relationship and one that
we focus on in the arrangements that we have set up.
68. Again, when did that advice and those
arrangements go out?
(Mr Langlands) That sort of advice
has been going out consistently through the four [4]
year life of the programme. The great catalogue of guidance that
is listed here in the appendix sets that out. We are continuing
to work on that on two fronts. One, by upping the training and
building, if you like, the natural relationships between the laboratories
and the smear takers. This summer we are going to have another
initiative by sending out to all the people who take the smears
a resource pack and by initiating some training for these groups
of people.
69. I have actually got a number of questions
that all follow on the same path. It does appear that the general
practices have not been either voluntarily or forcibly brought
up to speed on the way in which these methods have been carried
out. As we see, only half the general practices in the NAO survey
have received data on the practice's rate of inadequate smears,
only 40 per cent get information on the rate of inadequate smears
by individuals on their staff. It does appear that there has been
a series of testing taking place whereupon the results of those
smears have not been visited back on the individuals to say "I
am sorry, you have not been carrying out the job adequately and
correctly" and this report seems to indicate that.
(Mr Langlands) I think what the
report is indicating is that none of that has been systematically
recorded. What has been taking place are all the individual transactions.
What the report rightly rounds on is the need to learn from the
total experience and improved practice based on that experience.
The new systems we are putting in place are precisely directed
at that objective.
70. Mr Langlands, are you not being just
a little disingenuous on this. What you are effectively saying
is that there is a large number of people, GPs and so on, carrying
out these tests but the results have not been correctly co-ordinated
and tabulated and as such, I will not say they have been worse
than useless, they have meant that a tremendous amount of effort
has taken place without the proper results being drawn from them.
(Mr Langlands) I am not saying that.
What I am saying is that we have taken important steps in the
wake of the last NAO report to quantify the standards, to agree
these. We are now putting in place, and have put in place, guidance
and systems to ensure that we improve compliance. That is the
logical way of developing this service and that is what we are
trying to do.
71. Mr Langlands, my last question to you
is bearing in mind what you have just said, how are you able to
ensure that what you have just remarked about getting systems
back actually takes place?
(Mr Langlands) By a variety of mechanisms.
By the checking of mechanisms we have put in place. By the failsafe
mechanisms that are described in the report. By the improvements
in the information systems that we have been talking about. By
systems of audit which essentially are systems that create peer
pressure rather than top down management. By building, as we have
painstakingly been doing, professional commitment to the fact
that we are doing the right thing. Having done that, we now have
a way of applying pressure to people who perhaps are not playing
their part in this service in the way that they should.
Mr Hope
72. I am going to punch straight in if I
may. Just one question to pick up what other people have asked.
When will the 13 health authorities who have not yet met the 80
per cent coverage target actually meet their 80 per cent coverage
rate?
(Mr Langlands) We do not know because
they are often dealing with these very difficult groups. I can
certainly give the Committee details of this. Each of them will
have a target for the year ahead and what we hope to achieve,
as we have been achieving through the last five or six years,
is consistent progress in each of these areas. I cannot put a
date on when each of the 13 will meet their targets.
73. If you are saying they have made progress
and they are setting targets for making more progress, when are
they targeted to reach the target of 80 per cent?
(Mr Langlands) The targets are incremental.
74. As targets will inevitably be.
(Mr Langlands) The objective is
to meet the 80 per cent as quickly as possible. You can see a
huge leap very quickly, as in the case of the Camden example from
40 to 69. In other cases where they may be at 75 it is going to
take much longer to get to the last bit of the population.
75. How much longer?
(Mr Langlands) I do not know. I
can give you clear information of what is expected in each of
these 13 places in the year ahead.
76. You can say in the year ahead there
is a target for improvement?
(Mr Langlands) That is right.
77. Is there a target for improvement in
the year following the year ahead and the year following that
year ahead?
(Mr Langlands) No.
78. Why not?
(Mr Langlands) Because this, as
we discussed earlier, particularly in these high figures in the
high 70s that we are dealing with, is not—
79. Others are managing it. It is only 13
of the health authorities that are not managing it so we know
that it can be done. Why are they not setting targets year on
year to reach the target of 80 per cent?
(Mr Langlands) There are different
problems in different parts of the country. It is more difficult
to—
2 Note by Witness: The report was actually made in
1992, not 1990. Back
3
Note by Witness: The most recent guidance on when smears should
and should not be taken was issued in December 1997 and post-dates
the NAO study. Guidance in force at the time of the NAO study
dates from 1992. The 1992 guidance stated that screening was not
justified in teenagers providing there was high take-up of screening
invitations among women in their early twenties. The 1997 guidance
states that there is no justification for including teenagers
in the cervical screening programme. Back
4
Note by Witness: The life of the programme is actually 10 tens,
not four as stated. Back
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