Examination of Witnesses (Questions 1-19)
16 JUNE 2004
DEPARTMENT OF
HEALTH
Q1 Chairman: Welcome, Sir Nigel. "Tackling
cancer in England" is the subject of our Report today and
we are delighted to be joined once again by Sir Nigel Crisp, who
of course is the Permanent Secretary and the Accounting Officer
at the Department of Health. We are joined also by Professor Mike
Richards, who is the National Cancer Director. Professor, you
have just published a report in the last few days, have you not,
which I think got some publicity, so Members may wish to ask you
about that?
Professor Richards: I have, indeed.
Q2 Chairman: Sir Nigel, could I ask you,
please, to look at paragraph 1.3, which you can find on page nine,
where you will read that mortality rates for cancer in some parts
of the country are almost twice as high as in others. Does this
mean that the NHS is not doing enough for people in deprived areas?
Sir Nigel Crisp: There is a complex
set of reasons for that, which are to do with both lifestyle and
incidence of cancer in those areas but also supervision of services
in those areas and we need to tackle both ends of that equation.
You will be aware from elsewhere in this Report that we have been
setting some of our targets, for example, for reduction of smoking,
deliberately to focus more on deprived areas to try to affect
the issues of incidence. We have been targeting resources such
as staff and machinery in those areas as well in order to try
to start to change that balance. Obviously, Professor Richards
will be able to provide you with much more information about that.
Professor Richards: I think one
of the major factors in both the incidence of cancer and the mortality
from cancer relates to smoking and its impact on lung cancer,
in particular, which is the commonest killer from cancer. We know
that smoking rates vary according to levels of social deprivation
and that is one of the key factors in driving the mortality rates.
Q3 Chairman: Leading on from that, Sir
Nigel, perhaps we can look at awareness campaigns, and if you
look at page 32 and paragraphs 2.30 to 2.32 you will see that,
in paragraph 2.31: "In 2000 the Department undertook to develop
a cancer public awareness programme." I do not think recently
we have seen any public awareness programmes. What is going on?
Sir Nigel Crisp: We have done
two things on this. Firstly, we have been carrying out research
into what is the best way to do this so that we can get a proper
picture on that and I believe that research is due to be reported
on this year, but in the meantime we have not done nothing. We
have backed with grants a number of voluntary organisations to
hold campaigns on certain conditions, such as bowel cancer, and
indeed those voluntary organisations have been extremely active
in doing that in a whole range of areas. We expect to move on
with more of a national campaign, about cancer, but also we are
continuing to fund voluntary organisations on that basis.
Q4 Chairman: There is nothing new about
this and, certainly listening to the last answer, one would have
thought this was absolutely basic. Rather than just rely on voluntary
organisations, even if you are helping them, one would have thought
that a comprehensive national programme, say, on skin cancer,
signs you should look at, prostate, smoking, something which you
mentioned, is an elementary step, is it not? I am surprised we
do not see it emanating from the NHS, with all the resources you
have at your command?
Professor Richards: Of course,
on smoking, we have had just exactly that sort of campaign, a
major media campaign. We are working very closely with the charities,
and the Department of Health has been funding both Cancer Research
UK and British Heart Foundation to run those campaigns, which
I am sure you will have seen. Certainly our research on the effectiveness
of those campaigns is that they have very, very high levels of
awareness in the population. Almost certainly they do have an
impact on people who are beginning to think already about giving
up smoking doing so and possibly then attending the Stop Smoking
services which we have set in place since 2000.
Q5 Chairman: It says here: "a survey
of men in 1999 found that only one-quarter of them considered
that they knew `a lot' or `a fair amount' about prostate cancer;"
so what public awareness campaigns have you had actually on prostate
cancer, for instance?
Professor Richards: We have had
a particular focus on prostate cancer since 2000.
Q6 Chairman: It has not achieved much
apparently, has it, from what we read here?
Professor Richards: I think there
are particular problems in raising awareness of prostate cancer,
I will acknowledge that. What we have done is have a prostate
cancer risk management programme, firstly making sure that GPs
are aware of prostate cancer and what to do about it, how to advise
patients on whether or not to have a PSA test and what are the
pros and cons of that decision. We are working with GPs across
the country on that and we wanted to make sure that was in place.
Equally, we have been working with the prostate cancer charity,
and with the Department of Health we have set up a Prostate Cancer
Advisory Group, which I chair, and one of the key tasks of that
Prostate Cancer Advisory Group is to advise on awareness programmes.
Q7 Chairman: This is all very well but
I am not sure if we are any further forward: "a survey of
women over 50 in 2003 found that two-thirds did not realise the
risk of breast cancer increased with age." It seems that
when self-diagnosis is just so important in this area, whether
it is skin or prostate or breast cancer, you are simply not getting
your message through to the general public. I am wondering whether
you are putting sufficient resources into this area?
Professor Richards: I think what
we want to make sure we do is put resources where they are going
to be effective. What we do not want to do is worry people unnecessarily,
or indeed overburden general practitioners.
Q8 Chairman: Perhaps it is only a start
then, is it, not worrying people unnecessarily?
Professor Richards: It is getting
that balance right. One of the bits of research that Sir Nigel
was referring to has looked at, first of all, what the factors
are which might cause patients to delay, but also looking at the
world research on what interventions may be effective in reducing
delays by patients. Sadly, there is very, very little evidence
worldwide on what is actually effective in this area.
Q9 Chairman: Others can come in on that.
Let us move on now. Sir Nigel, please can you look at page 36,
paragraph 2.51. Obviously the demand for radiological services
is increasing all the time. Are you recruiting enough skilled
staff to meet your targets?
Sir Nigel Crisp: Not yet, is the
straightforward answer. As you say, this is partly because we
are seeing many more patients and partly because in a number of
areas we have changed the treatments which are offered through
radiotherapy so they take longer. This has become a really significant
bottleneck in the Service now so this is a very serious issue
for us. We have recruited a lot more diagnostic radiographers;
there has been a big increase, of 1,300, in fact, in the last
six years. We have more than doubled the number of people going
into training. We have introduced radiology academics, in order
to get more trainees through the system, and we have introduced
what we call a tiered skills mix model, in other words, making
sure that people with a lower level of skills can do more work
than they have done in the past. All of this is only holding the
problem level at the moment. We will see it start to improve over
the next few years as some of the trainees come on line, but it
is worth pointing out that this is a worldwide problem so this
is not just about going for recruitment elsewhere.
Q10 Chairman: Then let us leave diagnosis
and go on to treatment now and look at paragraphs 2.76 and 2.77
and talk about radiotherapy, shall we, Sir Nigel? If you look
at 2.77, which you will find on page 42, you will see, three-quarters
of the way down that paragraph, that in a survey conducted they
indicate the situation has not improved since the previous such
survey in 1998. I find that rather alarming, that radiotherapy
services appear to be getting worse, not better. What have you
got to say about that?
Sir Nigel Crisp: In a sense, it
is repeating slightly what I have just said. Because we have got
more patients, because we have changed our radiotherapies
delivered, because we are identifying people earlier, we have
got a much bigger throughput and the machinery has to run slower
because we are operating a changed regime. We are doing a great
deal both to increase recruitment of staff, which is the biggest
bottleneck, and to put in more machines around the country, but
it is a big problem.
Q11 Chairman: Thank you. Others can come
in on that if they wish. Just carrying on now, can you please
look at page 44, figure 39, "Variations in the percentage
of eligible cancer patients receiving Herceptin in the 6 months
before NICE approval (October 2001-March 2002) . . ." Looking
at that figure, I found those variations rather alarming. Do they
alarm you?
Sir Nigel Crisp: Indeed. This
is again a subject which Professor Richards can talk about better
than I can, but, I agree with you, this is a significant problem,
it is a serious issue. This was why, having issued the NICE guidance,
the Secretary of State asked Professor Richards to see if it was
getting through and if it was making a difference in terms of
reducing variation and increasing the take-up of the drugs.
Q12 Chairman: We have got the example
of this drug here but I am told, Professor, that there are 15
or 20 drugs which are in this position, are there not?
Professor Richards: There are
16 drugs which have been appraised by NICE and 15 of those were
approved by NICE. Also we looked at four standard drugs which
are used in chemotherapy and have been used for the last 20 years.
We looked at the whole period from July to December of 2003, at
all of those drugs together, and the conclusion in my report was
that the variation between cancer networks was unacceptably high.
I should say also that since the appraisal by NICE the overall
usage of those drugs has gone up quite considerably and there
is evidence that over time the variations are narrowing, but not
enough. What we looked into also was the factors underlying those
variations and there were two principal factors which came through
from that. It was not the funding of the drugs per se but, in
some parts of the country, it was to do with the capacity, that
is having enough nurses, enough pharmacists and indeed, sometimes,
enough space in chemotherapy suites. It has to be remembered that
the amount of chemotherapy being given in this country has gone
up markedly over the last decade. That was one of the factors,
the capacity, and the other factor is clinician variation. Because
of those factors, I made a number of recommendations to the Secretary
of State and I am very pleased to say that he accepted all of
my recommendations on that. One is that we have asked the strategic
health authorities responsible for individual networks to provide
a commentary on the position in their locality. I will be developing
a capacity model which then we will work with, with NICE, when
they are doing future appraisals, and we will be able to apply
it to past appraisals too, to look at the number of nurses and
pharmacists we need to deliver these treatments. We will go on
monitoring data in the same way as we did for this Report and,
most importantly, it has been agreed that we will bring forward
electronic prescribing of chemotherapy—which was scheduled
to come on stream within the national programme for IT between
2008 and 2010—to 2006.
Q13 Chairman: So the long and the short
of it is that when you come back to this Committee in three years'
time, or whenever it is, we are not going to see a graph like
this, where you have got availability, say, in Derby/Burton is
10%, going up to South West London 90%? All these variations are
going to be a thing of the past when you come to see us at our
next meeting, are they?
Professor Richards: I am confident
that the variations will be reduced. I am not saying that they will
be eliminated totally because there are individual clinical factors,
and after all one needs to take account of patient preference
as to whether they have these treatments.
Q14 Chairman: The last variation I want
to deal with is, going straight over to figure 41, "Access
to treatment for lung cancer patients diagnosed in 2000 varies
with age," you see a huge variation for patients receiving
chemotherapy under 75 and over 75. Looking at this figure, it
strikes me that there is no doubt that there is discrimination
against older people?
Professor Richards: I think the
difficulty with assessing whether there is ageism or not is that
what we need to know is what was the extent of the disease in
these patients, younger versus older. We need to know also the
extent of their frailty or co-morbidity and we need to know about
their preferences. Unfortunately, at the moment, we do not have
information on those three very important factors. It is worth
remembering, with lung cancer, that by the time they present to
hospital the vast majority of patients have got disease which
is at an inoperable stage. We do need that information. We are
setting up a National Clinical Audit Programme for lung cancer
specifically and that is being rolled out at the moment. That
will collect the very information that we need in order to be
able to tell whether or not there are unacceptable variations
by age.
Chairman: Thank you.
Q15 Mr Field: Professor Richards, on
behalf of my constituents who are treated at the Oncology Centre in
Clatterbridge, can I thank you for the improvement your work has
really made on a centre of excellence.
Professor Richards: Thank you.
Q16 Mr Field: Can I turn to Chapter 2
of the Report and ask you a couple of questions on that. If you
or any of your family were diagnosed with cancer, heaven forbid
that they should be, and the choice was that they went to a hospital
where there were not many operations performed on people suffering
from cancer and the treatment was that they should be operated
on, would you accept that decision or would you move heaven and
earth to get them into a hospital which operated on large numbers
of people suffering from cancer?
Professor Richards: One of the
things that we have been doing over the last few years is develop
improving outcomes guidance on individual cancers: breast cancer,
colorectal cancer, lung cancer, gynaecological cancers, etc. In
each of those documents, which are under the auspices now of the
National Institute for Clinical Excellence, we have looked at
the relationship between the numbers of operations performed and
outcome, and for some surgical procedures there is no doubt that
there is a better outcome with higher throughput. For example,
oesophagectomy would be one example and prostatectomy would be
another. The guidance which has come out from NICE does say that
we should concentrate those services in hospitals which have got
larger volumes and we have asked the Health Service, each cancer
network, to develop action plans to show how they will move towards
that and those action plans are due in by the end of this month.
Q17 Mr Field: So the answer to my question?
Professor Richards: The answer
to your question is, yes, I would prefer people to be treated
where there is expertise and we are moving as fast as we possibly
can to make sure that is the case for all people who need that
surgery.
Q18 Mr Field: One of the things the Report,
which does so much, does not do, it does not give me, anyway,
the figure for how many of those operated on for cancer are operated
on in the centres where very large numbers of operations are done
and how many are scattered across other hospitals where very few
are done. Do you have that figure at all?
Professor Richards: I do not have
the figure off the top of my head. We have collected figures through
hospital episode statistics on individual hospitals across the
country for all of those procedures where there is evidence that
volume is linked to outcome. I am sure this will be one of the
topics which the National Audit Office will want to look at in
their other Cancer Plan report.
Q19 Mr Field: Might we have a note on
that?[1]
The reason I ask the question is that, if you were going to be
tougher and say "It wouldn't be good enough for my family
so it's not actually good enough for anybody else," at some
stage soon, if the numbers operated on outside these great centres
are relatively small, you might put a ban, might you not, on these
operations scattered around, a few at a time, in different hospitals?
Professor Richards: That is exactly
what we are working towards. For example, for prostatectomy, we
have already said that, those people who are doing five or fewer
a year, we are strongly recommending that should be moved and
centralised. Also we have set up an appraisal process for cancer
services and we will be going round to individual hospitals looking
at what they are doing. That will be one of the things that we
will be looking at specifically.
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