Examination of Witnesses (Questions 120 - 139)
WEDNESDAY 20 MAY 1998
MR ALAN
LANGLANDS, DR
SUE ATKINSON,
and MRS JULIETTA
PATNICK
120. Mr Langlands, on that same paragraph
why is it not more strongly stated in your guidelines that all
staff should participate in the staff efficiency testing scheme?
(Mr Langlands) It is clearly part
of the accredita tion scheme which is now being applied across
all laboratories that that should be the case.
121. You have not done it yet. Paragraph
4.15 says that only 90 per cent of laboratories maintain a register
of record of smears requiring further investi gation. This does
mean there in some laboratories in which there are smears that
do require further investigation there are no records kept and
no follow-up can be made. This occurred in the Kent and Canterbury
case.
(Mr Langlands) The distinction here
is between an aggregate and the individual test. The individual
tests are being properly handled. The aggregate infor mation from
which staff on both sides of this relationship could learn, it
is suggested here, is not being collected on a consistent basis.
That again is something that we are working towards.
122. I do not quite follow that. If it is
kept on an individual basis 100 per cent, surely the aggregate
as well must be 100 per cent?
(Mr Langlands) No-one is adding
it up in the cases that are suggested here.
123. On figure 14 45 per cent of laboratories
can transfer information to health authorities electronically.
That seems to be an omission. Are we back to our old friend Read
Codes again?
(Mr Langlands) No, we are not back
to Read Codes fortunately but I am sure we will be one day.
124. I hope not.
(Mr Langlands) The other 55 per
cent often have very good, very effective paper based systems.
The aim, not just in this area but in a whole lot of other areas,
is to facilitate electronic data from GPs to hospitals. Of course,
if we are going to do that on a consistent basis, you are right,
we will need a language in which both sides can speak to each
other.
125. I have asked you questions on the laboratory
shortcomings, may I now move you on to the shortcomings in the
colposcopists. I am referring to page 82, paragraph 5.21. That
paragraph says that the colposcopists should see 100 new cases
each year, although the average is 247, and it is met in 72 per
cent of the cases but ten per cent did not know whether is had
been. The report goes on to say: "This suggests that there
are a number of colposcopy clinics which are too small, and see
fewer new patients than is advisable." In other words, in
this area there is a risk to patients. What is being done about
that?
(Mr Langlands) I said earlier that
one of the objectives was to improve information on col poscopy.
I do not think I read from this that it is necessarily the case
that all those who did not answer the question properly are not
meeting the target. There are certainly some people who will not
be. As a matter of clinical guidance our aim is to ensure that
people deal with the right critical mass of work.
126. Finally, Mr Langlands, on figure 24
on the next page, 90 per cent or more of women with moderate or
severe abnormal smears should have a biopsy and only 75 per cent
of the laboratories met this target. Again, if an abnormality
is found should it not be routine practice that a biopsy is taken?
(Mr Langlands) Maybe Mrs Patnick
can help me. It should be routine practice, that is the purpose
of the guidance.
(Mrs Patnick) Again, this is guidance
that was issued in 1996 at the time that the survey was undertaken.
There had never been quantified guid ance like this before to
help colposcopists understand what best practice was. Colposcopy
is a fairly new science, perhaps in the last ten or 15 years in
this country, and this is the first time that there has ever been
any measures against which colposcopists can audit their performance.
127. I must just come back to Mr Hope's
point. Time and time again we have found that you have quoted
the guidance and the whole system is not coming up to the guidance.
You have got targets for a year here, what are you going to do
when you personally investigate this, Mr Langlands, and find that
those targets are still not being met?
(Mr Langlands) I think we are pretty
confident, given the measures that have been put in place, that
the targets will be met in the future. The point that is being
made consistently through this is that these targets were set
in March 1996, many of them are new. This snapshot runs right
through all of these tables, it was taken in February 1997. It
will take time to change each part of the system. I am confident,
given the mechanisms we now have in place that we will see consistent
progress against these targets.
Mr Clifton-Brown: Chairman, I have
given Mr Langlands the final reply, I hope that we will not have
to quote his words in the future. Thank you very much, Mr Langlands.
Mr Campbell
128. Mr Langlands, good afternoon. I do
not remember the Crimean War but I imagine you may feel as if
this session started as long ago as that so I will not keep you
too long. Further to your answer to Mr Love I want to take you
back to the 13 authorities that are not meeting their 80 per cent
target and the nine that have a recall period of three years rather
than five years. You have told us that you do not discourage authorities
to stick with the three year period even though you have some
reservations about whether that is the best use of resources.
Does not the fact that you are not discouraging them away from
the three year target make it much more expensive to get them
to the 80 per cent level? Over a ten year period, for example,
it will be more than 50 per cent more expensive.
(Mr Langlands) I do not think it
makes it that much more expensive. Of course, there is, as the
report points out, a gain in terms of improvements in the incidence
of cancer. I think it is extremely difficult when a population
who have been taking part in this programme three yearly contemplate
having the service taken away. As I pointed out earlier, this
is not an option. Our priority is to up the coverage and in each
of the 13 areas we can see consistent progress over the last few
years and that is what we want to continue.
129. But nevertheless it raises the prospect
of some conflict between what you have consistently identified
this afternoon as your priority, which is 80 per cent coverage,
and yet the local priority, which appears to be reducing the recall
period. I want to come back to why there might be that difference
a little bit later on.
(Mr Langlands) There was not an
explicit choice. People in an ad hoc way, before there was a national
programme, instituted the three year cycle. As I pointed out,
there is no monetary choice being made here. It is not a case
of spending money on more frequent services at the expense of
less coverage.
130. But it nevertheless raises questions
about what the people on the ground actually regard as the most
important priority. I want to come back to that later, if I may.
Further to Ms Eagle's question, looking at figure 30 which is
on page 96, about regional inequalities, am I right in thinking
that the target payment scheme which you use takes no account
of a general practice's population profile. I want to ask you
why this is so when deprivation and ethnicity are clearly linked
to underscreening?
(Mr Langlands) On the target payments
on this issue, the objective is not to screen ever greater numbers
and certainly not to provide an incentive, if you like, to encourage
what have been referred to in the report as unscheduled smears.
The objective is to achieve better coverage and in general terms
that is working. It is absolutely true, wider than this programme,
that there are disparities, inequalities, in the allocation of
money to general practice in this country generally and that is
now being addressed.
131. If we could look briefly at figure
29 which is on the preceding page. This is a general question,
I do not know whether Mrs Patnick could perhaps answer this one.
This is about learning lessons from international comparisons.
That table tells us about the incidence of death rates from cancer
of the cervix and unfortunately we are near the top of that list.
Where are we in terms of any list which could measure the availability
and the effectiveness of our screening service?
(Mrs Patnick) The European Commission
has an initiative to compare cervical screening programmes across
Europe but, in fact, we have a very successful screening programme
in comparison with many countries which do not have organised
screening at all. Indeed, I think we are the largest country that
actually manages to screen its entire population. There is a project
at the Commission at the moment to do a comparative exercise and
this country has acted as the model, in the sense of reporting,
for all the other countries to follow.
132. In terms of expenditure on our programme,
are we average, do we spend more or do we spend less?
(Mrs Patnick) Other countries do
not know how much they spend at all so you cannot really make
a comparison.
133. I want to come back to Mr Langlands,
to one of your first statements this afternoon. You said quite
strongly "now we have a national system". I think that
is how you put it. We have heard some criticism about the lack
of progress and the speed of progress which has been made between
particularly the PAC report in 1992 up to 1996. Is it not the
case, and I think you have been hinting at this this afternoon,
that the previously devolved system which we had actually worked
against a national system, blurred account ability and made the
quality assurance, which we have picked up on this afternoon as
being crucially important, that much more difficult?
(Mr Langlands) I said there was
not a national quality assurance programme and that is right.
It is certainly the case, for the reasons we discussed earlier,
that the lack of that programme and the bottling up of these problems
in the example we have been dealing with was part of the problem.
I do not think that would happen now with a clear, national system
and greater regional and national checking. What I do not want
to do is devalue the work that was done between 1992 and 1996
in getting us to the sound base that Mrs Patnick has described.
134. Yes, but I am thinking perhaps more
widely than the screening programme. I am thinking about the more
fundamental changes, in particular the creation of an internal
market which by devolving the power actually made it much more
difficult to get national guidelines, perhaps not just in the
area in which you are working but across the health service.
(Mr Langlands) There are always
plenty of guidelines, the difficulty is consistently implement
ing them. The Government proposes to do that on a more regional
and a national basis. They clearly hope, and we clearly hope,
that will lead to some improvements.
135. You are confident that those improvements
will come because the system which had devolved power is no longer
in operation?
(Mr Langlands) There is a great
deal of commit ment to these proposals amongst health service
professionals and health service managers. I hope that we will
see progress but, of course, the proof of the pudding will be
in the eating.
Mr Campbell: Thank you.
Mr Williams
136. The figure in the report is £132
million has been spent. How has this varied over the last five
years?
(Mr Langlands) I am afraid I do
not have the back figures but I do not think it has varied enormously.
Half of it relates to the smear taking process in GPs and whilst
we have talked tonight about variations, over the last few years
the 80 per cent target has been pretty well achieved. That smear
taking part of the costing, which is £63 million, has not
varied very much other than by the usual inflation. I certainly
feel that as this programme of quality assurance takes a grip
there will have to be some investment in the screening parts of
the laboratories and I certainly feel that in improving our act
in relation to providing good information to people and getting
the communica tions right there will be some initial expense on
that.
137. The £132 million was which year?
(Mr Langlands) It is the 1995-96
year.
138. 1995-96?
(Mr Langlands) 1996-97, sorry.
139. So what are you spending this year
and what is your budget for next year?
(Mr Langlands) The figure for this
year will be the same figure with something like a 2.8 per cent
uplift.
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