Exmination of Witnesses (Questions 160-159)
YVETTE COOPER
MP, DR RUSSELL
HAMILTON AND
PROFESSOR MIKE
RICHARDS
WEDNESDAY 6 FEBRUARY 2002
160. Thank you for that information. So you
do maintain that it is one-to-one really with the charities in
that case?
(Yvette Cooper) Given that the assessment by the charities
has been done is about £180 million of charitable research;
obviously if there is any other assessment of that spend or calculation
then we will look again at it, but that is certainly, as we understand
it, the best estimate available. What is worth bearing in mind
as well is that the £190 million that we have calculated
is before the additional money set out in the cancer plan to be
spent on, in particular, the National Cancer Research Network
which will end up being an additional £20 million a year
once that is fully up and operational.
161. But you will understand that people are
suspicious that it comes out to close to 1:1 in the sense that
people might argue "Are we really comparing like with like?".
Are we comparing the same, or are you adding in figures that will
have been funded for the NHS which are pertinent to cancer care
and treatment and so on, but would have been there anyway?
(Yvette Cooper) I think the assessment we did was
not to look at cancer care but at cancer research, but it is certainly
true that the NHS would pay for different aspects of the research
than the charities because the NHS funds the infrastructure that
will carry out a lot of the trials, but I think that is relevant
because in other countries and other health systems you might
have to pay for that out of the charitable spend or out of the
direct research budget. So I think it is important to count that
in because it is money that the NHS is investing in supporting
cancer research as well.
162. Yes, but it is a question of how we define
cancer research. Some of us would have different definitions,
I am sure. Patient care is obviously—you can have research
into patient care and trials and so on, but how much of that money
is for real research into asking questions where we do not know
the answers and not just the normal care that our great National
Health Service provides? That is the suspicion I think around
the country.
(Yvette Cooper) Our assessment is that the £73
million is all additional. It is research and on top of the care
that might be being provided in other areas, where the research
is not taking place.
(Professor Richards) I would endorse that. I believe
this figure of £190 million is the best we can come up with
at this stage and I believe it is all research costs, not care
costs. It is the extra cost, some of that £73 million, which
is needed to support research. I think I would just reiterate
what the Minister has said: that as we get more information on
this through the creation of the database at the National Cancer
Research Institute, it will be much more transparent to everybody
what this research is and what it is covering.
Dr Turner
163. You will forgive us for still feeling somewhat
confused because after all, as a result of our report and the
response to it, the Government made the commitment to increase
research funding to match the work of the charities which, by
implication at least, accepted that there was double the investment
into research coming from the charities. It seems to me that in
producing this figure of £190 million, you have got to that
very quickly. Are you saying that this is because of new money
or is this in fact an accounting exercise, and could it be that
the money has been spent before, or is being spent on cancer research,
but not classified as such? Is this a re-badging exercise?
(Yvette Cooper) No, I do not think so. When we made
the commitment to match the money spent by the charities, we certainly
never accepted that the charities were spending double what was
being spent by the NHS. We have never accepted that as an assessment
or what was being spent by the Government as a whole. When we
did the first assessment of the kind of ballpark calculations
of what was being spent on cancer, I thought at that time that
we would need to increase the investment to match the money being
spent by the charities, but we were at that stage very clearly
planning to increase the spending by at least another £20
million a year as part of the cancer research networks, and the
rough estimates that we had when we first looked at this was that
that additional money would take us up beyond matching the spend
by the charities. When we have looked into this in more detail
and done the full calculations and got the information back from
the different organisations that contribute to this, and when
we looked at the most recent figures for 2000 and 2001, that added
up to the £190 million that we have set out for you but it
does not detract from our commitment on top of that still to spend
the additional £20 million which is what we had decided when
we announced the National Cancer Plan. So it certainly does not
mean that we have changed our position that we are not going to
increase the investment: we are. We have done the detailed look
at the figures that the Committee asked us to, and it has come
out higher when you include the additional organisations and when
you look at the most recent figures than we had originally expected.
That is very welcome but it does not detract from the need to
spend the additional £20 million and from our commitment
to spend the additional £20 million as well.
Geraldine Smith
164. Minister, are you aware of NHS Trusts using
Cancer Plan funds to reduce a debt, for example, and not using
them for the appropriate reason? Have you any examples?
(Yvette Cooper) I assume you are not talking about
on the research front but on the general money allocated for cancer
services?
165. Yes.
(Yvette Cooper) We are obviously concerned to make
sure that the targets that we have set in terms of the Cancer
Plan and the improvements that we have set out in the Cancer Plan
happen in practice. We know that there has been concern from some
areas about making sure that the money gets through to the front
line in order to deliver those improvements and we are monitoring
the situation. We have monitored at the beginning of the spending
round that different areas had to put in their assessments, and
we will do that again at the end of the financial year. We are
also putting in place improved performance management structures
to monitor not simply the inputs but also the outputs, which I
think is most important here—how they are doing in terms
of delivering their targets on waiting times and in terms of implementing
the guidance and improving outcomes guidance that we have set
out. So we are aware of concerns; we are keen to make sure that
improvements in cancer take place; we are very clearly monitoring
the position, and we will certainly review it to see if new structures
need to be put in place to reinforce that.
166. So has it happened? Have they been using
Cancer Plan funds to reduce debts?
(Yvette Cooper) We have made it very clear that this
investment was allocated to them to improve cancer services, and
that is what we expect to see happen and they will need to account
for the investment at the end of this financial year. At that
point we will be in a position to see where the money has been
used and what decisions have taken place at each local level.
167. Is that not too late, once it is the end
of the financial year, if they have used the money for something
else? There is not much you can do about it?
(Yvette Cooper) We have given them very clear direction
that we expect to see these targets met, and we have set in place
new monitoring proposals including peer review assessments that
are taking place, and I think what we will have in place from
strategic health authorities will be a big step forward as well
in terms of the management framework. But we have made a choice
about this which is to say that, in the end, the line by line
decisions about what money gets spent where, have to be taken
at the local level: it cannot all be directed from the centre.
What we need to do is manage the output and not simply expect
the Government in Whitehall sets down every single detail of where
the money gets spent. That means we need to make sure that there
are clear targets in place, especially when it comes to a clinical
priority like cancer, and that there are proper monitoring arrangements.
Those are still developing because of the development of the Strategic
Health Authority so that will take time to bed down properly,
but I think that is the right approach rather than trying to micro-manage
everything from the centre.
Geraldine Smith: Just coming back to that, it
seems you cannot have it both ways: you either say to the Trust,
"This is money for cancer; you spend that money dealing with
cancer services", or you do not. If you are not going to
take any action if they do not spend it on Cancer Plan and cancer
care, then there is no point doing it. You might as well leave
them to manage the services and spend the money how they know
best. I have an example in my own local Trust. One of the problems
they have is they followed the Government's policy, spending money
how they have been directed to spend it, but as a result they
are short of money in other areas. Is it not just a case that
basically we need more money in the Health Service?
Chairman
168. Why not just give to the NCRI all of the
cancer money? The cancer charity money goes there, so why not
put the Department money in too?
(Yvette Cooper) Because that is for research and,
whilst research is important, it is not the entire component of
the Cancer Plan so we do not think that all the money should be
funded through research channels. I think, for example, we have
to make sure that we keep investing in the prevention side and
other sides, and often the research approach can end up being
very much concentrated on drugs and treatments and we need to
bear in mind the whole gamut of issues relating to cancer as well.
So I would not accept that that would be the right funding stream.
To deal with your point, the framework we have to move to is managing
by output and by delivery. That does not mean saying, "That
is it; we just hand over the money and it is up to the NHS what
it does with it and we do not care any more"—quite
the reverse. We set them clear outputs in terms of the targets
they need to meet on waiting times and so on, and we have to manage
their ability to meet those. Some will be able to do that more
efficiently than others, especially where they have the cancer
collaboratives in place. They will be able to do that more effectively
given the resources they have than others, and it will in the
end be up to local areas to make those decisions. However, we
have done the assessment about the amount of money we believe
is needed in order to deliver those changes. We do expect the
changes to be delivered: we have allocated them the money in order
to do so: they may choose to spend additional money on it. If
your conclusion is, "Does the NHS need more money across
the board?"—yes, definitely it does. Of course. It
is getting more. We all know that a real increase is around 7
per cent above inflation compared to 3 per cent above inflation
which has been the historical average over the last 30 to 40 years,
and we need to maintain the substantial increases and that will
take time. So we need to be realistic that we cannot solve all
the problems of historical underfunding all at once. Yes, of course,
there are still pressures in the NHS—we know that very clearly—and
there will be local pressures which will often be very strongly
felt and, yes, in the end a lot of additional money is needed,
but only so long as the money is accompanied by the right forms
to make sure it is spent well as well.
169. Does all the research money go through
the NCRI?
(Yvette Cooper) All the research money has been co-ordinated
by the NCRI. When we had this discussion about what an NCRI might
be a couple of years ago when your Committee was advocating this,
the points we made then were that we would be uneasy about a bricks
and mortar institution that effectively centralised everything,
and I think the strength of the approach with the networks is
to spread everything outwards across the country so that we have
people able to get into trials everywhere in the country—not
simply a few big research centres but across the country—so
I think there is a post-code lottery of research issue here that
is quite important to address. I think it would be a shame if
all of the money was too tightly centralised but I do think it
is right that it is properly co-ordinated by the different organisations
working in partnership through the NCRI, and I think the closer
that they are able to work in partnership, the more it will look
like the sort of single co-ordinated funding stream, even though
the individual partners are making their own decisions about where
best to put their money and resources
Bob Spink
170. While we are talking about the Cancer Plan
and delivery at the sharp end, could I ask Professor Richards
what the policy is on centres of excellence? Would he confirm
that there will be, in each local area, retained units for the
common cancers that make up about 50 per cent—that is lung,
breast and colorectal? Is he looking at a target of about a million
population to support a centre of excellence to deal with the
other cancers, and does he know that this is causing a lot of
unrest around the country where there are centres of excellence
that people want to retain, with smaller than the guideline one
million population, such as at Southend? I wonder what can be
done to retain those centres of excellence, not to be throwing
the baby out with the bathwater on these?
(Professor Richards) The approach we have taken here
is to develop evidence-based national guidance. This started in
1996 with the breast cancer guidance. That was followed by the
colorectal cancer guidance in 1997, by the lung cancer guidance
in 1998, by gynaecological cancer guidance in 1999 and, most recently,
at the beginning of 2001 by the guidance on upper gastrointestinal
cancers—cancers of the oesophagus, stomach and pancreas.
In each, we have committed ourselves to making this guidance evidence-based.
It is very complex but we look at all the evidence worldwide in
coming to our conclusions. For example, with the common cancers
of breast and colorectal, there was evidence certainly for breast
cancer that, if a surgeon was treating more than thirty patients
a year, that was associated with better outcomes than if they
were treating less than that per annum. There is also evidence
to support the use of specialist teams—that is, radiologists,
pathologists, oncologists, surgeons, nurse specialists, palliative
care specialists—working together. But with a disease like
breast cancer you can achieve those numbers because breast cancer
is, sadly, very common in virtually very district general hospital
in the country—not all but most. When we come to cancers
like oesophageal cancer and stomach, the picture is somewhat different.
They are less common, intrinsically, and also less of those patients
undergo surgeries, so, for example, only about 30 per cent of
patients with oesophageal cancer will undergo a major resection.
We looked at the evidence, both from this country and abroad,
and there is a relationship between hospitals and/or doctors that
treat larger numbers of patients in a year and better outcomes—better
outcomes partly in relation to the thirty day peri-operative mortality
rates but also in relation to longer-term survival rates. The
guidance therefore recommended that surgical services for patients
with esophagogastric cancers should be concentrated in centres
serving populations of one million or more. For pancreatic cancers
the recommendation was that it should be at the level of two million
or more. Clearly that will take time to implement, and one has
to look very carefully at the impact at a local area. I am aware
of the issues in Southend: Southend is, by cancer network standards,
a relatively small cancer network serving a population of 680,000,
and so does not fulfil that one million population. It is an excellent
cancer service provider and certainly, in liaison with the eastern
regional office of the NHS, I have agreed to get involved there
to see what we can do for the best interests of local patients,
absolutely confirming that Southend is a cancer centre that will
continue to be a cancer centre and making sure that we can design
the service that does meet the guidance. I would just add one
further point: I was involved in a meeting about two weeks ago
with the association of upper gastrointestinal surgeons: we went
through the rationale for the guidance and they endorsed the guidance,
but also endorsed the need for there to be an implementation plan
and it could not be done overnight.
Geraldine Smith
171. Finally, just to come back on this, I feel
quite strongly that if we are telling the public that we are spending
money on cancer plans and we are funding those plans, and NHS
Trusts are using that money for something else—for very
good reasons because they have underfunding in other areas—we
are not being completely honest with the public. We are saying
we are funding and we are saying there are certain amounts of
money available but it is not getting through at the grass roots.
I think we have to be honest with people and have an honest debate
about the Health Service, because I think overall we need to put
more funding in and I think the British people have to be aware
that they have to pay for that funding, so I think we need a more
honest and open debate. Just speaking with my local NHS Trust
manager, I say to him, "Every year you are getting more money—I
know you are, I have seen the figures—so why is your deficit
worse than ever?", and he says that it is because the Government
are asking them to do so much more in the Health Service; quite
rightly so. The preventative measures you have mentioned to make
sure people do not get cancer in the first place all cost money,
and when we ask those managers in the NHS Trust to implement those
policies we have to give them funding to match that. So I guess
I am just appealing for more money for the NHS.
(Yvette Cooper) I agree that we do need more money
for the Health Service. We have seen substantial extra investment
going in and we are seeing it making a real difference already
in certain areas. There is a long way to go but it is making progress
already, and I would agree too that that does mean a national
debate about the kind of Health Service we want to see, and that
is exactly what the Wanless Report was all about. I think it is
also possible for the NHS to do more. It is true we are dealing
with a backlog of underfunding and with a long, long legacy of
under-investment in the Health Service, but it is also possible
for the NHS to do more. The cancer collaboratives are one of the
best examples of this. With very little extra investment and just
by reforming the way they do things, they are having quite remarkable
results in terms of cutting waiting times. There are some examples
where they have cut waiting times by 50 per cent and so on just
by changing the way they provide the service and re-organise it,
so it is not just about money; it is also about the reform and
the way we do things as well. Finally, on cancer, we are clear
that we have made additional investment available for cancer to
the NHS and we also have clear targets that we expect them to
meet as a result. We will monitor the situation and look very
carefully at what this looks like at the end of this year and
look forward to what we need to put in place to make sure we deliver
cancer improvements we have set out in the National Cancer Plan.
It is one of the priorities, so we are determined to deliver on
it, and I think we have to make sure we have the right mechanism
in place, as you say, to make sure the money reaches the clinicians
on the ground and delivers the improvements we need.
Mr McWalter
172. I am extremely confused about the answer
you gave to the question before last, because you were talking
about cancer research and then you were talking about assessing
outcomes, and you effectively slid from talking about cancer research,
where outcomes are naturally very difficult to quantify and delivered
often over a much longer time period and so on, to talking about
outcomes which are effectively the successes of treatment. That
made me smell a rat because it felt to me as if the money that
you are talking about for cancer research was, some of it, subtly
money for cancer treatment because, if you are talking about money
for research, it is very hard to specify those outcomes. I am
also worried about whether there is some double-accounting in
the system as well. If you take some translational cancer research,
for instance, in palliative care or where you might begin to get
somewhere close to outcomes-based research rather than the general
case which is not like that, then you might give us a figure and
say, "Look, we have spent all this money on research into
palliative care", and that is cancer expenditure so you give
us a figure of £20 billion or whatever for that, and then
you go to the Health Committee and they say, "How much are
you spending on palliative care?", and you say we are spending
£20 million. In other words, you get the same sum of money
doing the rounds. I am concerned, first of all, that there was
a real slide in what you said away from research into treatment,
and that made me suspect that the funding figure included a treatment
figure as well as a research one; and, secondly, I would like
a much clearer statement of the breakdown of this figure so that
my concern that there could be some double-accounting is obviated,
and the way you could do that is by telling us, for instance,
say what a global figure for palliative care is and then what
proportion of that would be used for research on effective methods
of palliative care and what proportion is broken down into the
cancer part of it.
(Yvette Cooper) Can I begin by trying to separate
out completely two issues—research and investment in improving
cancer services?
173. I separated them, but you pulled them together
again.
(Yvette Cooper) Yes. I think you are right, and what
I have been trying to do is answer different questions on research
and on funding coming one after another, so let me try and make
my answer clear and I apologise if I have not done so. The discussion
I was having on the cancer services and on outcomes would very
much amount to treatment, about services, about improving services
across the board, about what we expect the NHS to do everywhere
right across the country. So that is one whole set of arguments
about the investment going into cancer services. Separate from
that is another debate about cancer research and how we improve
it and invest in it. I at no stage meant to have the discussion
about how we manage the outcomes in the NHS that local hospital
trusts are delivering; at no stage did I mean that to apply to
the discussion about cancer research and the way in which the
national cancer research applied.
174. But I am talking about the £190 million.
(Yvette Cooper) I agree. The issue about the £190
million is about research spent and is completely separate from
the issue about how we manage the outcomes in the NHS. I think
probably the concerns you have about the breakdown of the £190
million seems to me to focus on the investment by the NHS in supporting
research. I think we will look again to see what additional information
we can provide you with that might provide you with some reassurance
about that, but we have been very clear in our intention in calculating
that money to tot up the money which is supporting research—not
the money we expect every area to be investing in improving outcomes
but the money that is supporting research—so we will look
again at what additional information we can provide for you but
I do not think there is more I can add at this stage that would
not simply confuse matters further.
(Dr Hamilton) It may be helpful just to set out how
we count funding that is related to research within the NHS, and
we identify three different types of costs: research costs, service
support costs and treatment costs. They are the costs that are
all associated, broadly, with people being in research within
the NHS. The first costs, research costs, are the direct costs
of undertaking research—designing research, collecting and
analysing the data, writing it up—and a key characteristic
of those costs is that they stop when the research stops. The
second costs, service support costs, are those directly associated
with the research study in the NHS—additional patient tests,
additional bed days, additional outpatient attendances—and
the key characteristic of those is that they stop when the research
stops, so they are directly associated with research. Those two
costs are the costs that we have identified and put into the figures
that we have provided for you. The third cost, treatment costs,
are the standard costs of being treated in the NHS whether you
are in a research study or not, and those costs are not identified
either in the figures for you, and, indeed, we do not identify
those figures separately. We do not currently identify what the
treatment costs are for patients who are in trials because it
is a health care cost, so the research and development budgets
within the Department of Health and the NHS only cover the first
two costs—research costs and service support costs—and
they are the costs we have presented for you.
175. When you provide those figures—and
I am very grateful for the answers given—can you also make
clear how NHS infrastructure costs are apportioned? That obviously
is going also to be an important component of us making quite
sure that these research figures are pukka.
(Dr Hamilton) Certainly.
Mr Harris
176. Could we talk specifically about the National
Cancer Research Institute? The Committee has heard previously
quite positive comments about the Institute but one criticism
that has been raised is that, apart from the organisations and
individuals with which it is involved, its profile is quite low
beyond that circle. I do not know if you agree or not with that
charge, but I just wondered how you viewed that situation?
(Yvette Cooper) I think that may well be the case
at this stage. It is still very early on in its life and I think
it would probably be surprising if it had a huge national profile
at this stage. The more that it does in practice the higher its
profile will become, but it may be something that the various
members of the Institute will want to consider at some point as
it develops. I think at this stage it is probably not really surprising.
177. I think that was one of the few criticisms.
The general information coming across was more positive than that.
We did hear from one charity whose representatives were saying
that they were wary of being involved because of the high cost
of the contributions they were expected to make to the NCRI. Do
you think those contributions are set too high and how are the
levels of those contributions made? Do you think that, like that
charity, other organisations reflect that experience? Do you think
that there are a wider range of organisations who are put off
becoming involved because of the high costs?
(Yvette Cooper) The decision about the funding of
the Cancer Research Institute was that it should be 50/50 funded
by the public and charity sectors. I will maybe ask one of the
others to comment on how that is broken down within the sectors,
but I think there are huge advantages to having the Institute
itself, the running costs, funded on a 50/50 basis because I think
it is important that it does really represent both the public
and charitable investors in cancer research, and it really does
represent them and work on their behalf, otherwise the danger
will be that it just becomes the cycle for one or the other and
that would be a problem. I think it would be a mistake for it
to be purely public sector funded for that reason. It also does
need, of course, running costs. If it is going to do the things
we need to do in terms of setting up the database, to map the
entire range of cancer research that is taking place right across
the country, to co-ordinate that properly, to have a useful database
that can then be used to co-ordinate research into the future,
obviously that needs investment to do that.
(Dr Hamilton) On both points about the profile and
on the funding of it, I think we would agree with what Gordon
McVie and Paul Nurse said in general to this Committee, that it
does at the moment have a relatively low profile but its work
is how you should judge it and it has been very successful so
far. The NCRI itself and its forum and the Cancer Research Fund
and its forum have both been very successful in establishing major
initiatives under Prostate Cancer Research, National Cancer Research
Network, National Translational Cancer Research Network, and the
database that the Minister has just explained. All of these did
not exist before that organisation came into being and they are
fundamentally changing the way that cancer research in this country
is perceived and will operate in the future, with respect to outputs
rather than profile. With respect to its funding, the secretariat,
as the Minister has said, is funded on a 50/50 basis of public
funding and charity funding, but it is not primarily a requirement
of NCRI membership that the partners commit to make a big contribution
to that. The larger research charities pay the larger share of
the 50 per cent that is their contribution, so I cannot understand
why it would be a barrier to involvement within it—
178. But are there occasions when smaller charities,
for example, would have no contribution to make or be proportional
to their size?
(Yvette Cooper) I would need to look into that but
my expectation would be that there are small charities that are
members of NCRI that make no direct contribution.
179. Can you send that information?
(Dr Hamilton) Yes.
(Professor Richards) Adding to that, for a start the
overall running costs have deliberately been kept small and the
Secretariat has deliberately been kept small compatible with doing
the tasks that are very important. The partners in this agreed
that it would be symbolic that it should be a partnership and
therefore we should have contributions from both Government and
from the charity sector, and I think we have tried as far as possible
to make membership open to research charities, provided they fulfil
certain criteria. I think we have set a lower limit of around
one million turnover in terms of the research that they are doing
in a year: we have also said that these should be charities that
are conducting research that undergoes peer review. We have to
make sure it is high quality research that they are undertaking
and, thirdly, and importantly, that they are prepared to contribute
to the database that we have just been taking about. Within that,
however, I think most, if not all, of the charities we have talked
to are very keen to be members of the new partnership.
|
