Examination of witnesses (Questions 40-54)
MS HAZEL
BLEARS, PROFESSOR
MIKE RICHARDS
AND DR
RUSSELL HAMILTON
MONDAY 15 JULY 2002
40. So from that point of view you are understating,
because you are building a cancer centre for 100 million quid,
it is entirely devoted to cancer, and it is not included in these
figures?
(Professor Richards) With the exception of the capital
funds I mentioned to do with the specific cancer equipment, that
is correct, we are understating it because there are major developments
in various parts of the country relating to cancer.
41. Sorry, chair, for this but it seems quite
a key point. Does that apply also to infrastructural projects
for cancer research as well?
(Dr Hamilton) The figures we have given are only revenue
spent on cancer research. The NHS R&D budget for research
is not a capital budget except for minor items.
42. But there will be interest payments on accounts
and so on that will need to be factored in, will there not? We
are facing the criticisms made by the charities that basically
the Government does not fund one-for-one in terms of cancer research.
Now we are starting to find that maybe there are some hidden figures,
that maybe the Government is putting more in than we thought because
some of the commitments you are making have got buried somewhere
else.
(Ms Blears) My understanding on this funding is that
this funding, other than the equipment, is about revenue funding,
so it is funding for consultants and for radiotherapists to increase
the capacity of the service because that is what the Cancer Plan
is about—which is better screening, diagnosis, treatment
and after care—and all of that is about increasing the capacity
of the service which has been underfunded and so has not got enough
capacity to treat people. This is really about revenue expenditure.
43. But debt servicing is revenue and linked
to infrastructural investment.
(Professor Richards) Going back to when you were talking
about the research side of it—and I will look to my colleague
for confirmation on this—our figures are related to the
revenue costs of research but so too, I believe, are the charities'
figures.
(Dr Hamilton) That is my understanding.
Mr McWalter: They are an exactly like but confusing
accounting standards?
Dr Turner
44. Can I bring us back to the Cancer Plan for
a minute. If cancer centres do not meet Cancer Plan targets, what
will happen? Will there be sanctions? Will there be special measures
to help them? What will happen? How will you make sure that the
targets are met?
(Professor Richards) That is through the process of
performance management. This is where I as the National Cancer
Director will work closely with the strategic health authorities
and if, for example, we identify particular hospitals that are
not meeting targets, let's say, on waiting times for diagnosis
and treatment of cancer, I would want to work with the strategic
health authority chief executive to look at what the problems
are in that locality and to make sure we can put that right, because
the whole idea of the Cancer Plan is to ensure equal access across
the whole country to high-quality services.
45. Would it then mean that you would apply
additional funding if you find that through no fault of a particular
cancer centre they had not got the staff to deliver the targets
because it had not come through because of the problems it started
out with? Will you put in more resources to make sure that the
target happened?
(Ms Blears) I think we will take this one step at
a time. What we will be doing is, as I have said, meeting every
cancer network lead, going through what they have got for their
money, and if they have been able to spend it, as some of them
have, very well, then that will be fine. If they have not spent
it, what are the gaps? Let us have a look at that information
and then we can take some rational decisions about what steps
we need to take. We will be monitoring the Cancer Plan very closely
indeed through the performance management system. I hope it is
very much a hypothetical situation that they are not meeting the
targets but then clearly we would need to take action in terms
of extra capacity or whatever other steps we can take in the system.
We are some steps down the road to that. My information is that,
broadly speaking, we are meeting the requirements of the plan.
As far as the data that we have got so far—and this is early
days trying to get at the data—we have got some of the hard
data about the two week referral times but the data from first
diagnosis to treatment is obviously more difficult to get. As
we get through the Cancer Plan we will be getting more information
so that we can monitor properly. We will take this one step at
a time. Clearly our top priority is to make sure that the commitments
we have put out in the Cancer Plan are met because those will
be the top priorities of the patients who need treatment.
Mr Dhanda
46. A slight change of tack—cancer registration.
The Follow-up Report was quite critical of the Department in terms
of cancer registration. How do you feel yourselves now in terms
of the cancer registries and how secure do you feel they are now
that the Control of Patient Information Regulations are at last
in force, although it has taken quite a long time to get there?
(Ms Blears) I am acutely aware of the timescale that
it took to get the Regulations in force. We had to go through
the Nolan procedure for appointing the members of the PIAG which
was quite a lengthy procedure. I took the regulations through
the House and members may know that they were incredibly controversial.
20 Members attended the Statutory Instrument Committee and raised
a series of very deeply held points about patient confidentiality.
It was necessary, again, to try to strike a balance. So much in
this field is about striking a balance between patient confidentiality
and the need to protect cancer registries. I am pleased that Members
did accept the need to protect the registry and clearly they have
now gone through, but I think there was an application for registries
as a whole to be included in the Regulations and that was rejected
by PIAG because they wanted to see specific applications coming
to them so that they could keep up the pressure for patient confidentiality.
What PIAG want to see is that wherever practicable—I think
that is the word in the Regulations—then information should
be used that is not confidential or is anonymised or encrypted
to ensure patient confidentiality. They want to keep the momentum
on rather than just approving the status quo and I think that
is the right thing to do. PIAG then have a responsibility every
12 months for their decisions to be kept under review. As I said
at the outset, the cancer registries are now meeting to see if
there is anything further they can do to make more progress on
encryption and anonymisation because Section 60 is meant to be
a transitional power until we can get to the stage, if we possibly
can, of having information which is not patient confidential.
In terms of the registries we might not get to that point. The
registries were a top priority to be protected through the Regulations.
They are now there and they will be reviewed on an annual basis,
but I am content at the moment that the registries had broad support
across the clinical field and even across the patient group fields
because of the essential work that they undertake.
47. You mentioned how controversial it was getting
it through the House and Members were quite upset about certain
parts of it. Is that in any way a failure of the Department in
terms of getting across to Members the importance of cancer services?
(Ms Blears) No, I do not think it is. I say that fairly,
having thought about it, because in a way there was criticism
from some of the research community that we were not doing things
fast enough in order to protect the very essential public health
research as well as cancer research and then there was criticism
from the patient groups that we were going far too far in encroaching
on patient confidentiality. There was criticism, if you like,
from both sides and in those circumstances I suppose the conclusion
can be that you have not managed to please anybody so maybe you
have struck the right balance. I do not know. I do not feel it
is a failure to get the arguments across. There are deeply held
views from conviction on these matters at both ends of the spectrum
and, therefore, trying to make sure people are aware of the essential
work carried out by cancer registries was very important. I think
it was MacMillan which provided some good information to Members
during that debate about how valuable the registries were, how
they helped us look at the extent of disease, how they helped
us do prevention work as well and I think that was quite an important
factor in persuading Members to support the Regulations.
48. There seems to be a bit of a difference
between the report's position and your own guidance with regard
to the GMC's guidance in this. I gather your response said it
was for the GMC itself to decide for itself when and if guidance
is issued to clinicians. Do you stand by that?
(Ms Blears) It is for the GMC to decide when it issues
guidance to clinicians because clearly it will decide its own
procedures and that is what it was doing in that case. I am pleased
to say that during the debate on the Regulations, if I recall
correctly, the GMC did give support to cancer registries being
maintained with protection under the law. We say in our response
that the "GMC's guidance on confidentiality was an accurate
reflection of common law requirements." Unfortunately, the
common law does give a great deal of emphasis to confidentiality,
the importance of informed consent, and that is what makes it
so difficult for clinicians to operate in an atmosphere before
we had the Regulations. Now we have got the Regulations, clinicians
can feel a lot more secure in the work they are undertaking.
49. Another thing that was called for in the
report was a National Cancer Act on the back of one in the United
States of America back in 1971 and the Department is not of the
same view. Is that still the case and, if so, why?
(Ms Blears) It is the case that we remain of the view
that we have got sufficient levers and powers to make sure that
cancer remains a priority for the National Health Service. As
I say, it is one of our top priorities that we set out as soon
as we came into government, together with coronary heart disease,
mental health and care for older people. The situation is different
than that in America. They do not have a publicly-funded national
health service and therefore sometimes they have to have special
provisions for special circumstances and they have to vote appropriations
into particular services. We have powers to make directions. We
have had a long discussion about hypothecation, ear-marking and
ring-fencing and that debate will no doubt go on. In our current
legislative framework and the way in which we organise the National
Health Service we do not need to have special legislation for
particular diseases. Again, this brings us back to the broader
debate about shifting the balance of power, about trying to say
that as a health service and a national health service that people
are entitled to certain levels and standards of service not just
for cancer but for a range of conditions, and that what we need
to set in frame as a government is national standards for the
whole range of services so that people can see in a transparent
fashion what I am entitled to and then, equally, for that to be
delivered at local level. Simply to single out one disease such
as cancer, no doubt it is a priority absolutely for the Government,
but to single that out for a special legislative framework would
be invidious, and I do not think we have any need to do it because
we can devote resources under our current legislative framework.
Mr McWalter
50. Part of what has been concerning this Committee
is the general business about how effective the NHS is at interacting
with the voluntary sector and to try to clarify some of the issues
that are involved there. I do not want to throw this at you cold
now but I would be grateful if you could review the current arrangements
for hospice funding where currently some hospices maybe fund more
than 70 per cent of their own operating costs from voluntary money
and the Government puts in less than 30 per cent. Where that kind
of imbalance has occurred, particularly given the fact hospices
are more and more dependent on having NHS-trained and paid staff,
the Government will look carefully at that with a view to seeing
if in the end we have got our act together on the cancer research
side—and I am not convinced yet as to whether we might—to
see if we need to apply that principle of one-to-one funding in
all those other areas as well so that precious and important relationship
is protected.
(Ms Blears) I am acutely conscious of the tremendous
contribution made by hospices to palliative care in this country.
I am very aware of their concerns about the resources getting
to them and their services. We have received a number of representations
from Help the Hospices and from a number of Members and I think
I am to attend the All-Party Hospice Group later this week to
carry on discussing—
51. See you there.
(Ms Blears)—And having a dialogue on this with
Members, which I will continue to do. I am acutely conscious as
well of the need to try and make sure that palliative care receives
as much attention as all of our other cancer services. Palliative
care has increasingly become recognised as a clinical priority
that perhaps it was not 20 or 30 years ago. We are real world
leaders in palliative care due to the efforts of the hospice movement
largely, and therefore seeking to draw those into the service.
52. You are not prepared at this stage to make
a general commitment to a one-for-one funding regime when possible
or when that seems to be most appropriate? I would be grateful
if you would reflect on whether that might be a general policy.
(Ms Blears) I am certainly not in a position to make
that commitment here today but I certainly hear what Members have
said.
Dr Turner
53. If the new Regulations do not succeed in
getting 100 per cent or near 100 per cent registration, will you
look again at the possibility of making cancer is notifiable disease
to ensure registration?
(Ms Blears) As I outlined earlier, the cancer registries
have been approved under the regulations, they do now have the
protection of a regulatory regime in Section 60 and in the regulations
rather than having to rely on the common law position, so they
have a greater degree of recognition and security now. I think
there is an acknowledgement that the work carried out by cancer
registries is absolutely fundamental to our understanding and
our monitoring and increasing services and prevention agenda and
therefore I think at this stage I am satisfied that cancer registries
are now under the umbrella of those Regulations and have security
for their future actions.
54. Do we know what percentage of cancer patients
are registered?
(Professor Richards) It is a slightly unanswerable
question because if you do not know that they have got cancer
they are not in the registry. What we do do is to see how many
patients come through on death certificates that we had not previously
known about and we are constantly striving to decrease that proportion.
They are referred to as "patients recorded by death certificate
only" and we are striving to decrease that figure, which
varies across the country. We are working on that all the time
and that proportion is going down. I think we can be confident
that the quality of our cancer registration has been going up
over the past few years.
Chairman: Minister, you can tell that this Committee
has got the ball in and it is waggling it about. We are interested
in seeing what happens over the next few months. We do welcome
you coming here and telling us about your plans to ensure that
the money does get through to where I am sure you and I would
both like it to go. Thank you too, Professor Richards and Dr Hamilton,
for contributing to our session. We hope we do not see you for
a while but we will wait and see how the cancer networks, which
are very new, work out. Thank you very much for giving us your
time.
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