Examination of Witnesses (Questions 100-119)
16 JUNE 2004
DEPARTMENT OF
HEALTH
Q100 Mr Bacon: Can you say, for each
cancer network, how much money is spent in them in total, and
then, this is my request, the chart, in other words, this chart
here with extra information? First, the stuff which you have got
there, the percentage of eligible women receiving it, it would
be quite helpful, I think, to have it as a numerical percentage
rather than a bar chart. Then also the number of nurses, the number
of pharmacists and the number of chemotherapy suites. Can you
do that?
Professor Richards: At the moment,
we do not have that information.
Q101 Mr Bacon: You do not know? How do
you know that is the reason it varies if you do not even know
how many there are?
Professor Richards: We asked the
networks themselves what they saw as the problems, and again we
have set up a chemotherapy advisory group.
Q102 Mr Bacon: Can you send us what you
have got, as much information as you have got?
Professor Richards: Yes, indeed.[5]
A lot of this information is in the report which I published two
days ago and I will be happy to provide you with a copy of that
report.
Q103 Mr Bacon: Really I would like this
figure 39 but expanded for inclusion in our report and appendix?
Professor Richards: We have, effectively,
similar figures to that for all 16 drugs which have been to NICE,
in a slightly different format, and we can send that to you.
Q104 Mr Bacon: It is Herceptin I am interested
in particularly, simply because of this huge variation. Especially
when on the left-hand side there is South West London, everyone
knows that is a rich part of the country, they are up at 90%,
and you are down at 5% at the other end. Then we hear it is nothing
to do with funding. It just sounds odd. Is it just that there
are loads of nurses down in South West London?
Professor Richards: I think there
are different factors in individual networks.
Q105 Mr Bacon: This is why I need as
much information as possible on the number of pharmacists, the
number of nurses, etc. If you could send that to us it would be
great. Could I ask you to turn to page 36, the radiology point,
this is just a point of clarification again. Sir Nigel, you used
the word "bottlenecks" and the Report here says, in
paragraph 2.52: "many radiology departments provided rapid
access for patients with suspected cancer: 74% of departments
for suspected breast cancer, 46% for suspected lung cancer"
and so on. Really the question to which I would like to know the
answer is, why is it not all radiology departments, and you were
saying it is simply that we do not have enough trained staff,
or what? 74% sounds quite high but what about the other 26%, and
46% does not sound that high at all?
Sir Nigel Crisp: I think there
will be different reasons for each of these. If I remember rightly,
the Audit Commission survey may give you some of the answers to
that question as to why there are different reasons for those
different numbers which are referred to there. I am sorry. I do
not know if Professor Richards may be able to say something useful
on that.
Professor Richards: I think all
that information comes from the Audit Commission's own report,
to the best of my knowledge.
Q106 Mr Bacon: Your recommendation is
that where people are suspected of having cancer they should be
prioritised, but it does not always happen, does it?
Professor Richards: It is done
on the basis of clinical need and my experience as a cancer clinician
is that when one needs to get a patient scanned urgently usually
one can, because radiology departments work very closely with
cancer teams to make sure that happens.
Q107 Mr Bacon: If I could ask about the
graph on page 21, this says that the incidence rates vary considerably
across the country, and indeed—this is the point I wanted
to get to—that mortality rates can vary by as much as 20%
between strategic health authorities with almost identical levels
of incidence. I found this a very difficult graph to read but
can you give me an example, Sir Nigel, of two SHAs which have
identical levels of incidence where the mortality varies by 20%?
Professor Richards: Can I take
this one. If you look towards the left-hand end and there is a
blip up.
Q108 Mr Bacon: From Northumberland, Tyne
& Wear, or roughly around there anyway?
Professor Richards: I am not sure
whether it is Northumberland, Tyne & Wear, but round about
there.
Q109 Mr Bacon: Where it is 25 and then
shortly afterwards it is 30?
Professor Richards: As against,
let us say, Thames Valley, at the other end of the graph, at the
right-hand end. Then if you look higher at the incidence rates
which were on the higher level you will find that there is a major
difference in incidence.
Q110 Mr Bacon: That is not what I am
talking about. The whole point is, my question is about ones which
have an identical level. If you read the thing at the top, please,
it says: "Mortality rates can vary by as much as 20% between
SHAs with almost identical levels of incidence." If you go
to your example of, I think it is, West Yorkshire, and it is very
difficult to read, on the left-hand side where there is that sort
of kink upwards, the bottom part of that kink, if you go up to
the higher chart you get incidence, if you go up to the top part
of that kink and go up to the chart you get another incidence
level, it is almost identical. Is that what it is talking about?
Professor Richards: It is talking
about that kink, yes. I am sorry.
Q111 Mr Bacon: Is it possible that we
can have this chart reproduced in a way that is more easy to read,
and in particular where you can see which hospital or which SHA
or cancer network, or whatever it is, is being talked about?
Professor Richards: Certainly
it would be possible to reproduce this graph, one of them as bars
and the other as a line. I think that would be possible to do.
Q112 Mr Bacon: I think if we could just
see which specifically, rather than having to work it out by drawing
a line and hoping, it would be very helpful? If you could turn
to pages 54 and 55, there is a chart of mortality rates and it
shows England and Wales in comparison with a number of other countries,
including the United States, France and Germany. It does not include
Japan, which I would have thought would be interesting, but it
does include those other, very big countries. If you turn over
the page to 56/57, which is talking about survival rates, once
again you have got England, actually not England and Wales any
more just England, but suddenly Germany, the United States and
France, with the exception of the top left, where there is a France
one, French data is included here as it is collected more widely,
all those big ones have disappeared, so you are not comparing
like with like really, are you?
Professor Richards: Can I explain
this. The mortality figures which are shown on page 55 come from
global data called GLOBOCAN and that covers virtually all countries
in the world, or certainly all developed countries in the world,
that provide data on this.
Q113 Mr Bacon: I can see that they come
from different sources. What I really want to know is, why do
we not have survival rate information on these major countries?
Professor Richards: Because the
one source that is reliable on survival rates is the series of
EUROCARE studies which are shown here and those are related to
European countries.
Q114 Mr Bacon: We have got Slovakia and
Slovenia and Estonia, are you telling me that you cannot find
reliable survival rate information for the United States, Germany
and France for all these different cancers?
Professor Richards: In terms of
being directly comparable data that have been looked at by the
researchers and deemed by them to be valid comparisons, at the
moment that is for Europe only.
Q115 Mr Bacon: You have just done this
before for mortality. I will tell you why I ask this, it is because
I have heard many times anecdotally that our survival rates for
a range of leading cancers are lower—survival rates, mark
you—than in the United States, in Germany and in other European
countries. If you look at the brief, which unfortunately you do
not have the benefit of but I do, which the National Audit Office
has supplied to us to go with this Report, it says, and I quote:
"For countries in Europe where reliable comparisons are possible,
England's survival rates consistently fall below those of the
best and are typically higher only than Scotland and Eastern Europe.
The US consistently out-performs Europe on cancer survival—people
there appear to be diagnosed when their cancer is at an earlier
stage of development." I would like to see some information
on survival rates of the top five largest economies in the world
and you do not seem to be able to provide it?
Professor Richards: Can I just
say, the reason why Germany does not feature in the survival figures
is that the cancer registration in Germany is reported for about
only 1% of their population. That is why, in combination with
the National Audit Office, we were not sure that their data was
a reliable comparison. What we have put here is where we know
the comparisons are reliable. Yes, I will accept that the reported
survival rates in the United States are better than ours and we
can show that, but it is not from a direct comparison as this
is done.
Q116 Mr Bacon: You have been Cancer Director
for five years. Are you saying that nothing has been done in the
last five years to sort this out? Surely it is much more interesting
for us to compare ourselves with Germany, France and the United
States than it is with Slovakia?
Professor Richards: Frankly, our
cancer registration is better than that of the United States.
The United States has a programme called the SEER programme which
covers about 14%.
Q117 Chairman: That was not the question
you were asked. It was a specific question and Mr Bacon's time
is now up. He asked you a specific question. Will you please give
a specific answer? He wants to know why you have been in this
job for five years and we still cannot get a proper comparison
between the United States, France and Germany, and that seems
a fair question which now you have got to answer?
Professor Richards: The simple
answer is that I am not responsible for cancer registration in
Germany or the United States.
Q118 Mr Bacon: You mentioned the SEER
programme, and I know I am intruding on the Chairman's generosity.
In paragraph 1.22, on page 24, it says, and I quote: "Five-year
relative survival rates for all cancers in the United States were
56% for persons diagnosed in 1987 and 63% for persons diagnosed
in 1992. Recent research on breast cancer has shown that the higher
survival rates . . . compared with Europe . . . are linked to
diagnosis of the disease at a less advanced stage in the United
States." Are you saying that is not correct?
Professor Richards: No. What I
am saying is, those are reported results in the United States.
I have just come back from the United States where I have been
talking to experts over there and their reported rates are higher,
but in this Report we wanted to make sure we had data that was
directly comparable and so we went for those countries within
Europe for which we knew we had directly comparable figures.
Q119 Mr Bacon: Like Slovakia?
Professor Richards: Yes.
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