Examination of Witnesses (Questions 40-59)
DEPARTMENT OF
HEALTH AND
THE NATIONAL
CANCER DIRECTOR
21 MARCH 2005
Q40 Mr Jenkins: But there should in effect
be a package for the patient and boxes which should be ticked
to show that they have now received the benefits advice, they
have now received the side effects and they have now received
the pain identification and what to do about it and where to come
back to.
Professor Richards: Yes.
Q41 Mr Jenkins: Obviously those tick
boxes are not being ticked at the present time.
Professor Richards: One of the
things that we are doing more work on at the moment is how best
to assess patients' needs across the whole range of things, from
pain relief, through financial benefits to social support, whatever
it may be, so that we can make sure that the patient's needs are,
first of all, discovered and then we can act on it. If we do not
ask patients about their financial status, we are not going to
know who should then be referred on to DWP.
Q42 Mr Williams: Why is it that the London
experience seems to be so bad? Looked at as a Welsh MP, we think
of London as having the great training hospitals, much easier
to recruit consultants and medical staff. So what has gone wrong?
Why is it that London at the end of all that seems to have a worse
experience than their neighbouring regions?
Sir Nigel Crisp: As I said at
the beginning, I agree with you, the inputs are actually, if anything,
better in London. The inputs, the amount of money, the resource
going in is, if anything, the same level or maybe better in London
and the outcomes, in other words people's survival rates are,
if anything, better in London again. It is actually something
about just how they are treated and some kind of people factor.
We think the biggest issue on this is staff turnover and therefore
not continuity of care, continuity of the conversation, continuity
of the point about information which Mr Jenkins has been pulling
out. We are actually trying to understand it in much more detail
for the all communities in London, because, again, London is not
remotely homogenous in terms of what people need. That is why,
this having come out so clearly here and elsewhere, a lot of work
is now going on in London to try to identify what it is that would
make a difference.
Q43 Mr Williams: In a way we are surprised
that you were surprised. We would have expected you to have identified
this a lot earlier, particularly practising clinicians.
Professor Richards: I do not think
there is any one single reason for it. I agree with Sir Nigel
that it is likely to be staff turnover. I think it is worth remembering
that a lot of young people come to train in London, they may spend
a year or two working in London. Then they may choose to move
elsewhere in the country, whereas in some other towns and cities,
people are there for life, if you like, so it is a lot easier
to provide continuity of care. What we have to do is to make sure
we have the systems in place to overcome that, even though there
may be a higher natural turnover in London. We know, for example,
that more agency staff are used in London. There is more transfer
of people from one hospital to another in London because they
can move from hospital A to hospital B and they do from time to
time. Each of the five Strategic Health Authorities in London
is taking this very seriously. I alerted them to these findings.
They have written back to me. I have talked to several about it.
North East London Strategic Health Authority is taking a lead
on this on behalf of London. They have some extremely interesting
work going on in Newham in terms of black and minority ethnic
groups to see what their experience of care is. Equally, the King's
Fund have taken a major interest in this. They produced a document
called Capital Health a couple of years ago and they are interested
in working with us. What we are doing in practice is that each
one of the five strategic health authorities has asked its network
to produce an action plan to show how they will be implementing
the supportive and palliative care guidance from NICE. We will
be then making sure that those action plans are implemented. We
will also be reviewing all the services in London through our
peer review assessment programme and that is being done during
the course of this year. We will ask the teams which are going
round doing that to pay particular attention to the patient experience
and what is being done locally.
Q44 Mr Williams: We have the inter-regional
information here, the comparative response in relation to London.
You have referred to an intra-regional league, the regions within
the region. Do we have the same degree of variation within the
regions within the London region?
Professor Richards: It is important
to remember that for this survey only a sample of trusts were
chosen. I think half a dozen trusts in London took part in this
survey and about 43 or 44 from outside London, so we do not have
the full picture for London. In the previous survey, back in 2000,
every trust in the country took part in that, but on this occasion,
it was just a sample. I think what we can say is that collectively
the experience of care for Londoners was less good than elsewhere,
but what we cannot say is, within London, whether one place was
particularly better than another.
Q45 Mr Williams: And yet there will be
some centres of excellence in amongst them.
Professor Richards: Yes, but even
with that each one needs to look at its own results and make sure
they are as good as we would hope them to be.
Q46 Mr Williams: If someone came to you
and said they had a choice of treatment in London or treatment
in, say, the Manchester area, would what you have just said lead
you to say "Steer clear of London"?
Professor Richards: No, because
as Sir Nigel Crisp said just a minute ago, the results in terms
of survival rates are every bit as good in London as they are
elsewhere. I think we need to look at the whole picture. The patient's
experience is one part of it. We need to look at the survival,
we need to look at the use of anti-cancer drugs, the waits for
radiotherapy, everything and put it together. When I have done
that, there is no one part of the country that I would say is
perfect on everything and no one part that is worst on everything.
They all have things that they need to improve on.
Sir Nigel Crisp: May I just make
one point on that which is that these were six hospitals in London—I
think it was six—and they ranged from those that you would
know terribly well to less well known ones.
Q47 Mr Williams: You were not necessarily
comparing like with like in each of the sub-regions?
Sir Nigel Crisp: That is probably
true, but I actually think the challenge to those hospitals is:
why do patients prefer the experience in Manchester? I think they
need to look very clearly at what it is that they are doing in
Manchester that may be a better experience, even if the outcome
in London may be better and the inputs in London.
Q48 Mr Williams: Is that being studied?
Sir Nigel Crisp: The cancer networks
do sit down and learn together and patient experience has now
recently become much higher as one of the things which are being
looked at through the cancer collaborative.
Q49 Mr Williams: That sounds fine. I
have no doubt it is what happens when specialists meet together
in conferences and that sort of thing, but how systematic is this
process of learning the good practice from other areas?
Professor Richards: It is systematic.
I get all 34 of the cancer networks in England together three
times a year, that is the medical director of the network, the
network manager, the lead nurse and a whole range of other people
involved in those cancer networks, about 300 or more people. We
get together three times a year at a conference in order that
we can make sure that we are sharing experience across all the
networks, that I can communicate things out from the Department
of Health and, most importantly, so that I can hear from them
what their problems are.
Q50 Mr Williams: That is fine. That is
exchange of personal opinion, but it is therefore highly occasional.
Are you systematising this, are you now following up this realisation
with statistical analysis for our next report?
Professor Richards: Yes.
Q51 Mr Williams: I am not trying to catch
you out.
Professor Richards: We are. We
measure a whole lot of different things on cancer. We have already
talked today about waiting times for cancer and those are collected
in every hospital across the country in order that we can see
the different positions. We also have this peer review programme
where we visit every hospital, but where the hospitals are assessed
against a very detailed manual of service measures. It is a thick
document and that will give us a very clear readout on whether
hospitals have the necessary services in place, for example whether
they have the clinical nurse specialists that I have been talking
about. So that is being done and we are in the middle of a round
of the peer review visits at present.
Q52 Mr Williams: Coming back to a point
which has been raised by my colleague, the written reports. A
lot of people obviously are in a virtual state of shock when they
are receiving their diagnosis and when they are talking things
through. They may not comprehend and indeed, in so far as there
may be technical language, it is may be that they do not understand
what is being said. How automatic is the written report becoming,
and is this not particularly important, thinking of a section
of the report which refers to a fortunately relatively low percentage
of cases, but still too many cases, where the consultation about
diagnosis lasts only ten minutes. If it is a very short time and
the person is being given bad news and is in shock, it is doubly
important, is it not, that they have something they can take away
to discuss with their families?
Professor Richards: I agree that
it is good practice and I was delighted that the NICE guidance
specifically recommended it. Remember that that guidance only
came out in March of last year and so did not affect the patients
in this survey who were being surveyed at exactly that time. We
will have to reinforce these messages, that this is good practice,
we will have to encourage teams across the country to adopt this
practice, but that I am absolutely committed to do, because having
delivered that sort of practice myself, I know it is both feasible
and I know it is highly acceptable to patients. I personally will
encourage it as much as I can.
Q53 Mr Williams: How difficult does it
become for you, and I recognise that this is patchy around the
country, with linguistic difficulties now becoming a factor? Is
this complicating the application of this process?
Professor Richards: That is an
additional complicating factor. I think we still really have quite
a long way to go with people who do read and write and understand
the English language. In terms of foreign languages, one of the
programmes which has in fact been funded through the lottery is
a telephone helpline to CancerBACUP, the information charity,
where there are interpreters available for the 12 commonest foreign
languages. That does at least mean that there is a direct access,
they can phone the nurse who is on the helpline and it is a three-way
conversation then, with immediate access to an interpreter. Equally,
at a local level, hospitals have their own arrangements for interpreters
and clearly they know what foreign languages are most likely to
be spoken on their patch.
Q54 Mr Williams: But it makes it more
important that they have this piece of paper if they are going
to have to get advice over a phone, does it not? There is something
to work on.
Professor Richards: Absolutely,
but this is a new and very welcome recommendation that we will
now implement into practice.
Q55 Mr Williams: May I ask one final
question, Chairman? I was surprised to see that as high a proportion
as a quarter of patients have not been warned of side effects.
It is a bit like fear of flying: things that are unpleasant can
often be tolerated better when you understand why they are happening.
Why is it that as many as 25% are not warned of what side effects
to expect? This is in figure 17.
Professor Richards: I think the
exact wording was something to the effect that the percentage
of those having a complete understanding of the side effects was
76%. There is a further proportion that had some level of understanding;
in fact I think it is figure 17 on page 18. There is a group there,
just over a further 10%, saying "Yes, and I understood some
of what was said". However, there are those, just one up
from the bottom, who say "No, side effects were not discussed
at all". Now that, to my mind, is unacceptable but I think
you will agree that the proportion for whom that was true has
decreased very considerably between 2000 and 2004, by more than
half, just looking at that graph.
Q56 Mr Jenkins: We see on page 28 that
the Princess Royal Hospital at Hull has an integrated support
system which seems to be first class and admirable. Why is it
so there and what plans do you have for rolling this system out?
Professor Richards: A number of
hospitals do now have different forms of information and support
centres and this is just one very good example in Hull. It is
an excellent example, but there is an excellent one at Mount Vernon
Cancer Centre, one at my own hospital at St Thomas's, a variety
of ones around the country supported by Macmillan Cancer Relief.
We do have a number of models of information and support centres
which give people direct access to any information they want about
cancer, but also where they can come and often where there are
complementary therapies offered, counsellors available. Those
services which did not exist five to 10 years ago, or were very
rare, are now becoming much more commonplace and the one in Hull
is one of them.
Q57 Mr Jenkins: So when do we expect
to see this sort of service at every centre for the treatment
of cancer?
Professor Richards: Again, the
NICE guidance sets out what services should be available to patients
in this way and we will be monitoring the implementation of that
guidance through the peer review appraisal programme that I described
a minute ago.
Q58 Mr Jenkins: What are you going to
do, Sir Nigel, to raise awareness amongst men of colon and bowel
cancer?
Sir Nigel Crisp: I am going to
refer again for some of the detail to Professor Richards, but
a large number of campaigns is starting to take place. We put
quite a lot of money into it. The other day I noticed one that
we are doing specifically aimed at groups from Asian backgrounds.
We are actually getting much more segmented in terms of our specific
targeting of particular people whom we think we need to get information
to. That is the broad approach that we have been taking, but I
do not know specifically on bowel cancer.
Professor Richards: This is a
very important topic for us at the moment, particularly as we
are going to be rolling out the bowel cancer screening programme
from next April. It is extremely important that men and women
in the population are aware of what bowel cancer is and also the
value of screening which undoubtedly saves lives. Several trials
have shown this now. I think we all agree on that. We have to
get those messages through in every possible way we can. We are
working with the relevant charities; for example, for bowel cancer
with Beating Bowel Cancer as a charity to raise the profile and
I attended a meeting with them just a week ago to do this very
thing. We are also planning to work with individual primary care
trusts and a programme called the Healthy Communities Collaborative.
They have been extremely successful in working with communities,
particularly with elderly people in the communities, to reduce
the rate of people who have serious falls in the community. If
they can do that for people falling over, we believe they can
also do it to raise the profile of cancer and we are working with
them to roll out some pilots as soon as possible.
Q59 Chairman: Just one last question,
by way of summary of this afternoon's hearing. Obviously a lot
of the work we do in this Committee is terribly important in terms
of saving money, but this impacts directly on people and therefore
is a very important hearing. When you appear in front of us in
four years' time, what improvements to these figures do you think
we will see?
Professor Richards: I think we
will see the continuation of the upward trend that we have seen
over the last four years.
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