Examination of Witnesses (Questions 20-39)
16 JUNE 2004
DEPARTMENT OF
HEALTH
Q20 Mr Field: That was my second question,
five or fewer for people suffering from prostate cancer; that
is one operation less than every two months. Clearly you have
to have some cut-off point to do with the analysis, but what sort
of expertise do you think somebody builds up doing so few operations,
even if they are doing five a year?
Professor Richards: What we have
said is that we want to see prostatectomy being done in places
which are doing 50 or more major procedures—that can be
prostatectomy or removal of the bladder—in a year, and that
is what we are working towards. After all, we have to put in place
the capacity in those hospitals to take on those patients.
Q21 Mr Field: Is it not likely that surgeons
will build up that expertise if they are part of a team where
their colleagues deal with those who it is suggested should not
be operated on, rather than, what can still happen, somebody is
diagnosed and really the team is largely the leader and they decide
all forms of treatment, and not just those which lead to operations?
Professor Richards: I am not sure
if I have fully understood that.
Q22 Mr Field: If you go to Guy's they
have a team and if you are going to be treated by an operation
there is one of the consultants who specialises. If you are being
treated in other ways, you will see one of the other specialists,
according to how you have been diagnosed. Where Guy's is today,
should we not try to see other hospitals there very shortly?
Professor Richards: Absolutely.
One of the key elements of each of these recommendations, from
the improving outcomes guidance documents, focuses on the need
for multi-disciplinary teams, whether that is in breast cancer
or indeed in prostate cancer, and we are working hard to set up
those teams. That has been one of the major changes over the last
few years in this country and we estimate now that approximately
80% of cancer patients are being seen by specialist teams, and
that is probably as high as anywhere in the world.
Q23 Mr Field: Do you have the power to
forbid hospitals meddling in areas which would be concentrated
better in centres of excellence?
Professor Richards: The approach
we have taken is to issue guidance from NICE, to convert that
into standards which then we appraise as we go round visiting,
and we will be sharing the outputs of those appraisals with the
Healthcare Commission, who are set up, as you know, to inspect
hospitals.
Q24 Mr Field: Does not that come back
to the Chairman's point about people knowing? Should we not be
publishing tables saying "Keep away from this hospital if
you value your life"? I can do the figures for you now, you
just have to fill in the details. It does not take much work.
It requires will, does it not, and taking on some very powerful
people?
Professor Richards: We are making
those very changes now. That is precisely what NICE has recommended
and what the action plans are all about, but it does take time
to get the workforce into place, to get the capacity in the relevant
hospitals and we are working as fast as we can to implement that.
Q25 Mr Field: I think we see where our
report might go. Sir Nigel, your Secretary of State is usually
very good at aiming his boot at the right part of someone's anatomy,
but recently he said "Why don't all these middle-class yuppies
get off the backs of single mums under 21 who are smoking themselves
to death?" Do you not think, for once, that he was missing
the target, that our concern should be that we do seem to have
a supply route of women who find themselves at 21 with three children,
sometimes by different fathers, who are on sink estates, and then
it is a hell of a job for them to rebuild their lives from that
position? Should we not be concentrating more on not worrying
about whether they smoke but trying to see fewer women ending
up in that position?
Sir Nigel Crisp: I think the Secretary
of State, and it was a Labour Party meeting, I understand,—
Q26 Mr Field: That makes it better then,
really?
Sir Nigel Crisp: I do not know
the exact circumstances. The point that I believe he was making
within that was it is not just a matter of choice, it is a matter
of circumstances, and circumstances will dictate your health,
so I suspect that he would agree with the point that you were
making. Certainly a lot of work we do in the Department is aimed
at trying to tackle the determinants of health as well as the
symptoms and I think that is your point, is it not?
Q27 Mr Field: It is.
Sir Nigel Crisp: The circumstances
people find themselves in are fantastically important.
Q28 Jon Trickett: Paragraph 1.3 was referred
to by the Chairman also, and in fact the same sentence stood out,
it caught my eye as well, referring to the variation within district
health authorities, from 101 deaths per 100,000 to 193, almost
twice, presumably, more cancers. Can you tell me what the situation
is, or was, in Wakefield, where we were between 101 and 193, because
the table does not seem to be here?
Sir Nigel Crisp: I am sure we
can, but not immediately.
Q29 Jon Trickett: Can you provide us
with a list of the 95 district health authorities, just a table
for the Committee, so that we can have a look?
Sir Nigel Crisp: I suspect we
may have it, but certainly we can provide it for the Committee.[2]
Q30 Jon Trickett: If you could provide
it for the members, because we have some indication, but not much,
I think, in the rest of the Report of the variations which are
going on, but this particular table I think will be extremely
striking. Probably it is publicly available but I could not put
my hand to it before the meeting. It would be helpful for us to
have a look at that. The paragraph goes on to announce improvements
across the board in survival rates. My own mother died recently
from a brain tumour and I was struck by the immense professionalism
of the NHS staff, and through you I would like to thank everybody
working in cancer services. It is a truly humbling experience
to go on to cancer wards and meet both the courage of patients
and also the professionalism of the staff. Anything I say about
variations in treatment, and so on, I do not want to reflect in
any way on the professionalism of the staff. I want to try to
understand better the lack of uniformity in treatment over time
between the districts, because the final sentence in the same
paragraph says that progress was not uniform, so it is marking
the fact that progress is being made. Larger improvements are
being made in some districts than others, and variations in the
level of improvement were not obviously linked to the levels of
affluence and deprivation, it says. I struggle to understand that
sentence, because the rest of the paper seems to say the exact
opposite, and honestly I do not understand that. Can you tell
me what the sentence means?
Professor Richards: Can I try
to explain that. The levels of mortality do depend on levels of
deprivation, and that is quite clear. If you look over the past
few years at what the changes in mortality have been, that is
what is not linked to deprivation and so there are very deprived
areas that have made more rapid progress, there are some deprived
areas that have made less rapid progress. Equally, for the more
affluent areas, there are some that have made good progress and
some that have made less good progress.
Q31 Jon Trickett: I thought that was
what you would say. I want to go on to paragraph 1.5 then, if
I may, which talks about the "survival gap". I think
that the survival gap is the gap between the number of people
who survive cancer for a period of five years, as measured across
the social classes. Am I right in that being a layman's way of
expressing it?
Professor Richards: Yes.
Q32 Jon Trickett: Looking at the number
of people surviving five years, between rich and poor there is
a gap, is there not, in survival?
Professor Richards: There is,
indeed.
Q33 Jon Trickett: I think that the sentence
we have just discussed, in paragraph 1.3, is saying that the change
in the survival gap over time has not changed in relation to socioeconomic
deprivation, and that was your answer. I think I am trying to
demonstrate that is not the case, actually?
Professor Richards: Can I try
to explain, that we have to look at three different parameters.
One is incidence, the number of new cases, one is mortality, the
death rate, and the third is survival rates, the proportion of
patients surviving five years who have got cancer. The complexity
of this is that you see differences for each of these things,
so the survival rate, that is the number living for five years
after a diagnosis of cancer, has been getting wider, in some instances,
between rich and poor. When you look at survival and what influences
that, there are two main things there. One is how advanced the
disease was when the patient came to treatment, and the second
obviously is the treatment they receive.
Q34 Jon Trickett: I do not want to go
down that track, if you do not mind. I am trying to understand
what is happening between social classes in Britain in relation
to cancer. What we discover, I think, in this paragraph and the
bullet points beneath, is that, for example, in rectal and colon
cancer actually the survival gap between the social classes has
grown steeply, so fewer working class people than middle class
are surviving for five years than they were at the beginning at
the study. Is that not the case?
Professor Richards: I think it
is important to say that across all sectors of the population
survival rates are improving for colon and rectal cancers.
Q35 Jon Trickett: You have said all that
already.
Professor Richards: I have not
for survival, but the improvement in survival is faster in the
more affluent groups, yes.
Q36 Jon Trickett: The whole tenor of
these two paragraphs taken together, I think, is putting a fog
over this issue and I want to try to bring it out. That is how
I have read it, probably a dozen times, each paragraph, and noticed
that?
Sir Nigel Crisp: May I have a
go at this, as a fellow layman. I think the first paragraph, relating
to mortality, and this one is relating to survival rates, mortality
is the death rate, survival rates are those who survive five years,
and the two may go in different directions.
Q37 Jon Trickett: I do not think that
is exactly the case, but let me try to proceed a bit further.
In paragraph 1.5, the first sentence terminates with a very, very
small, barely legible, "iv" after "survival gap".
You have to run round the paper to find out what that refers to,
and it refers to a learned paper produced in a medical journal,
which, I have to confess, takes some reading for a layman. You
have referred to the author of this paper. The author of the paper
says the following, two sentences, and I will take them one at
a time, if I may. "The deprivation gap in survival between
rich and poor was wider for patients diagnosed in the late nineties
than in the late 1980s. Increases in cancer survival in England
and Wales during the 1990s are shown to be significantly associated
with a widening deprivation gap in survival." First of all,
do you accept that, and, secondly, do you think that we have really
captured the essence of that sentence in this Report?
Professor Richards: First of all,
can I say, of course, this is not my report, this is the National
Audit Office Report.
Q38 Jon Trickett: You have agreed every
word of it?
Professor Richards: I have agreed
every word of it.
Q39 Jon Trickett: I am running out of
time rapidly and I want to try to get to the bottom of this?
Professor Richards: The gap in
survival has widened. I fully accept what is in this Report. I
fully accept what Professor Michel Coleman has written in his
paper. The reasons for that, I am trying to explain, are partly—
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