Examination of Witnesses (Questions 120-139)
16 JUNE 2004
DEPARTMENT OF
HEALTH
Q120 Mr Bacon: Sir Nigel, you were bursting
to say something, in all fairness?
Sir Nigel Crisp: I was going to
make the point that I do not think you can hold Professor Richards
accountable for how they account for cancer registration in the
United States, and if they do not do it on the same basis as we
do it is difficult to make a direct comparison.
Chairman: Could I ask the NAO, as it
seems to me this is absolutely basic, is there no way we can get
proper comparisons?
Q121 Jon Trickett: Chairman, I do not
want to intrude but I am certain that the Derek Wanless report
has something called "potential years of life lost"
(PYLL) and I am certain that they compare Australia, New Zealand,
America, ourselves and the advanced Western European countries
on cancer. I am quite certain that the information is there, if
they have not got it today?
Professor Richards: Can I say,
yes, it is, because that is based on death rates and death rates
are comparable. What you are asking here is on survival rates
where we do not have the direct comparison, because survival rates
require incidence data as well as the death data.
Q122 Chairman: Anyway that might have
been interesting to have in our report. Perhaps NAO could comment
on it?
Mr Burr: We are dependent upon
the data which exist for these countries and, as we are saying,
for survival it is patchy, but certainly we can have a look at
what is available.
Mr Bacon: This is fundamental, is it
not?
Q123 Chairman: James, do you want to
comment?
Mr Robertson: As Professor Richards
has said, we have attempted to draw together comparisons of data
which are comparable. The difficulty with data for other countries
is that it is collected from very small percentages of the population,
often parts of the population which are more affluent, and therefore,
as the Committee was saying earlier on, you could get a very distorted
picture of what the relative survival rates are, and that is why
we have used all the reliable data. I do not think there is any
more data that we can draw on but we have used the data that is
comparable in order not to be misleading.
Q124 Chairman: What about the point Mr
Trickett was putting to you?
Mr Robertson: I am sorry, could
you repeat that?
Q125 Jon Trickett: In the Wanless Reports,
of which there are several now, Wanless uses something very interesting
called PYLL, which stands for "potential years of life lost",
and he demonstrates that, on average, we die eight years younger
than they do in the United States, Australia and elsewhere, a
whole basket of countries. Wanless has done this most sophisticated
analysis on which the NHS funding for the next 20 years is being
determined, and for us to say that data is meaningless is quite
surprising, to be honest?
Mr Robertson: Those data relate
to mortality figures, and because mortality is better recorded
than survival and there are debates about how you define survival,
and so on, it is possible to draw on those figures. Indeed, figure
23 in the Report has got the comparison with other EU countries
on cancer mortality, so those you can use.
Chairman: I think that has been a useful
discussion.
Q126 Mr Williams: I was going to ask
a point about statistics anyhow. To NAO, were you surprised at
gaps in availability of statistics within the country? Ignore
the international comparisons for a moment because that is outside
NHS control. Were you surprised at the lack of any figures or
the up-to-date nature of the information or the quality of the
statistics which you found when you were trying to prepare this
Report?
Mr Robertson: When I first came
to looking at this, I was surprised about the age of figures for
survival, but at that point I did not understand that, if you
are looking at a five-year survival rate, you have to wait five
years in order to get that figure.
Q127 Mr Williams: They are then five
years out of date?
Mr Robertson: On that definition,
they must be.
Q128 Mr Williams: They are using the
figures they got five years ago?
Mr Robertson: Yes, and they must
always be out of date.
Q129 Mr Williams: That is 10 years. The
table which shows survival takes diagnosis in '94 as the latest
figure. Therefore, you are five years in '99, therefore we have
got another five years, so it is still five years out of date?
Mr Robertson: Certainly we would
have liked more recent data. That is a reflection of the way that
cancer registries deal with their data.
Q130 Mr Williams: Go on, Professor, we
are dodging about here?
Professor Richards: Can I comment
on that. The international comparisons do end with patients diagnosed
in 1994. We would like to have more up-to-date comparisons there.
Of course, for this country, we do have data, as in this Report,
up to at least 1999, from Professor Coleman's study. We are now
planning a further EUROCARE study, the cancer registries of Europe
getting together, and I hope that will bring us a whole lot more
up to date. I am encouraging them to look even more up to date
than just keeping five years behind, because there are modern
statistical methods that will allow us to get the survival rate
data more up to date.
Q131 Mr Williams: Are there any gaps
in the type of information that is available? If you were able
to wave a wand now and say, "I wish this information were
available," is there anything that comes to mind?
Professor Richards: In terms of
the data on incidence survival/mortality, I think we are doing
well. What we need to do better on is getting the information
on the stage of disease which patients have and on any other illnesses
they have and on the treatment they have. That is why we have
put in place this National Clinical Audit Programme which will
do just that, and that will allow us then to answer a whole lot
of the questions you have been asking us today about the appropriateness
of treatment, for example, in different age groups.
Q132 Mr Williams: It was virtually 10
years ago that this Committee—I doubt if anyone else who
is here at the moment was on it at the time—actually commended
clinical audit as a very important tool, and yet here we are all
that time on and we are still bemoaning the fact that it is not
available. I do not criticise you for that, I can understand why
you wish you had it. However, we will leave that. Can I satisfy
a piece of ignorance here. Table 39, the percentage of eligible
women receiving Herceptin, how important a treatment is that?
Professor Richards: It is an important
treatment. It is a treatment given for breast cancer, for people
with advanced breast cancer. It is suitable for only a minority
of people with advanced breast cancer. It is a drug which attaches
to a particular receptor on the cancer cell which is present in
about a quarter of cases of breast cancer, but people who are
given that drug, on average, will survive approximately six months
longer than those who are not given it.
Q133 Mr Williams: It gives a further
six months of life?
Professor Richards: That is an
approximate figure, and so it is an important drug and we welcome
the fact that NICE approved it and we want to see it available
for everybody who can take it.
Q134 Mr Williams: I welcome that intention.
I know it is not within your gift to deliver. Looking at table
39, what strikes one, obviously quite out of any proportion to
the rest of the table, looking across the country, are the first
two figures, South West London and Dorset, and they were already
leading the country before the NICE approval. Since then, in the
case of South West London, the availability has increased four-fold
to virtually 90% of eligible women, and in the case of Dorset
by eight-fold, again 90%. Those are staggering increases. That
is a multiplication of figures which are already ahead of the
rest of the country. Why is it that when we go to the other end
of the table, the depressing end of the table, Arden, Derby/Burton
and West London, you get down to 1-30th of the best?[6]
A woman there has one chance in 30 of getting the extra six months
that people can expect if they live in South West London and Dorset.
Who is responsible? Why on earth cannot anything be done to get
greater equality of availability?
Professor Richards: As I have
said before, my own report says that these variations are unacceptable.
We have talked already about what some of those reasons are, particularly
the capacity in terms of having enough nurses and pharmacists.
Q135 Mr Williams: With respect, when
you look at the lower end of this table, and when I say the lower
end I am talking halfway up it, there is still virtually a three-fold
magnitude of difference. There cannot be that difference between
staff?
Professor Richards: No, I am not
saying it is all down to staff. I think also it is down to variation
between clinicians, and I have said it very clearly in my report
to the Secretary of State. One of the ways in which we can tackle
that is by collecting this sort of information, and even more
detailed information than this, and feeding it back to individual
practitioners.
Q136 Mr Williams: You want to feed it
to the public, not to the practitioners, feed it to the public
and let the public find out the extent of deprivation there is.
We want to make this as public as we can? I am not blaming you.
I get angry at the situation, not at you.
Professor Richards: What I am
saying is, we have got all the information for all the drugs approved
by NICE. Here we have just one drug. We have now put information
on all 16 cancer drugs appraised by NICE into the public domain,
named by cancer network, and we put that into the public domain
two days ago.
Q137 Mr Williams: Would this come within
the area that you said is not a matter of money, that money is
not the determining factor?
Professor Richards: The clear
view that we got from the cancer networks themselves was that
funding for the drugs themselves was not the issue. There may
be funding issues related to the staff, the pharmacists and the
nurses, but funding for the drugs was not the issue and that came
through very clearly in the survey that we undertook for my report.
Q138 Mr Williams: In that case, I regard
this as so important, because the figures are so widely different,
I would like as full a document as you can put in for us as a
supplementary note in relation to this particular diagram?
Professor Richards: As I said,
now that we have published my report, I will be happy to give
you copies of the full report as a supplementary to this.[7]
Q139 Mr Williams: That will be very helpful.
Thank you very much. One thing, to help us in our judgment when
we are dealing with our own local hospitals and health authorities,
you said that nearly always a scan can be organised urgently when
it is needed. From a layman's point of view, which is most of
us, how critical is time, what is "urgent" in terms
of getting someone to a scan?
Professor Richards: I think you
have to think of this in two different ways. First of all, the
anxiety that a patient faces when they have got either a definite
diagnosis of cancer—
6 Note by witness: The reference to West London
is erroneous. We believe that Mr Williams was using the old version
of the NAO's figure 39 and not the corrected version as West London
comes just after halfway and not in the last three. Back
7
Not printed-Variations in usage of cancer drugs approved by
NICE-Report of the Review undertaken by the National Cancer Director,
NICE, May 2004. Back
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