Examination of Witnesses (Questions 1-19)
DEPARTMENT OF
HEALTH
23RD MARCH 2005
Q1 Chairman: Good afternoon. Welcome
to the Committee of Public Accounts. We are returning to the Cancer
Plan. We had one session on cancer on Monday. It is the second
session today and we are joined once again by Sir Nigel Crisp,
who is the Chief Executive of the NHS and Permanent Secretary
of the Department of Health, and Professor Mike Richards, who
is the National Cancer Director. Thank you very much for coming
back. You told me on Monday, Sir Nigel, that you had spent all
the additional money that you had received for cancer services
for 2003-04. Would you please reassure me what proportion of that
money has ended up in the front line—doctors, nurses, equipment,
drugs?
Sir Nigel Crisp: I think we are
talking about two questions there. You were first of all, I think,
referring to The Sunday Times and its assertions about
where money was going. If you look at where the money is going
we are spending a significant proportion of it on staff, which
is the front line by definition within the NHS. That is what The
Sunday Times article was implying, that spending it on staff
was not the front line, which was an odd argument. In terms of
the Cancer Plan, we are confident, as this document says (and
I think the wording from the NAO is slightly cautious), that the
early indications are that we have spent the amount of money that
we said we would on cancer, and that is directly on cancer. That
is not about overheads; that is in terms of being spent on the
services.
Q2 Chairman: It would be quite helpful
if we could have a note with a detailed breakdown of this, particularly
your point about staff, or maybe you can answer this point now.
People refer loosely to staff, to managers, nurses, doctors. It
would be helpful if you could shed light on this particular debate.
Sir Nigel Crisp: Let me answer
it on the whole NHS. We did indeed yesterday, I believe, publish
the latest staff census which showed a big increase in doctors
and nurses and staff in the caring role in the NHS last year.
86% of staff in the NHS had a direct role in hands-on care of
patients. The number of managers is slightly under 3% now, which
is a very small proportion compared to private health care, or
indeed compared to other industries. Those figures are available
and were put out yesterday.
Q3 Chairman: We are talking about the
Cancer Plan now. Perhaps you can give us the figures that relate
to both total numbers and increases.
Professor Richards: In terms of
cancer, the commitment that we gave was that by 2003-04 we would
be spending an extra £570 million per annum on cancer against
the baseline in 2000-01. What we have done is to ask the 34 cancer
networks to give us information on their new expenditure on cancer.
They have broken that down into the new drugs for cancer, staffing
and new services for cancer. What we can say at this point is
that we are confident that we will have got to and exceeded the
£570 million for cancer. We are asking the individual networks
to validate the figures at the moment and that is why we are not
in a position to give you a final result, but I hope that very
soon we will be in a position to have those final results and
there has always been a commitment that we will put that in the
public domain.
Q4 Chairman: The £570 million you
refer to is referred to in the Report at paragraph 1.10 on page
10, and you refer to the cancer networks. Please reassure me that
they are receiving according to need and the money is being spent
effectively.
Professor Richards: One of the
things that we will be able to tell when we have validated the
figures is how much is being spent in each of the 34 networks.
I am not yet in a position to give you those figures but we know
that all networks have increased their expenditure on cancer quite
considerably over the last three years.
Q5 Chairman: It was not quite what I
asked you. I asked you whether they had received according to
need, and I also want to know whether they can spend the extra
money you are giving them.
Professor Richards: They are spending
the extra money that we are giving them on cancer and the other
area that we have specifically invested in—
Q6 Chairman: Let us tidy it up a bit
more. They can all use the extra resources effectively?
Professor Richards: That is what
they are telling me, that they are using the extra resources.
Q7 Chairman: That is fine. There is a
reference in paragraph 2.10 on page 22 to Scotland. Unlike in
Scotland apparently in England we do not have any estimate of
the future cancer burden in our Cancer Plan. Surely this is quite
important, is it not?
Professor Richards: When we were
preparing the Cancer Plan we took account of what we knew to be
the trends for cancer in England in broad figures. If you take
all cancers together the numbers are going up by 1.5% per annum.
That is very largely because we have an ageing population and
cancer is predominantly a disease of the second half of life.
At that point we did not need more detailed estimates because
frankly we knew we had a catching-up job to do. That meant that
we needed to invest in staff, in machines, in getting these networks
working, and so at that point to do detailed planning 10 years
ahead was simply not necessary. I think we are getting to the
point now where we need to look in more detail. We also did a
lot of work at the time of the Cancer Plan looking at individual
cancers to look at the projected death rates through to 2010 but,
although that is not in the plan, it was part of our preparation
for the plan.
Q8 Chairman: Let us get down to key point
which is about targets. There is reference early on in the Report
at page 3, paragraph 10, to these two key targets that the public
really care about: one month maximum from diagnosis to treatment
and two months maximum from urgent referral to treatment. There
is again reference to this on page 15 of the Report, so this is
an absolutely vital target that you have to meet.
Professor Richards: Yes.
Q9 Chairman: The NAO says that these
pose significant challenges, which I am sure they do.
Professor Richards: Yes.
Q10 Chairman: I have to ask you and tie
you down, Sir Nigel: yes or no, are these targets going to be
met?
Sir Nigel Crisp: Yes.
Q11 Chairman: What more could we ask
for? Thank you very much. If you now look at page 27, paragraph
2.44, there is reference there to foundation trusts, and of course
we have got foundation hospitals and we have got independent sector
treatment centres. Are you certain that they are all going to
co-operate fully in your cancer networks?
Sir Nigel Crisp: Let me approach
this from two points. One is that I have no doubt that, as we
develop our planning and contractual arrangements, we will require
people providing cancer services to be part of cancer networks
because we believe that is the way in which you provide quality,
so they will not get paid for patients who are not being treated
as part of cancer networks. The second point is that foundation
trusts have a duty of partnership to work with others and a number
of them have announced that they want to do this in any case,
so I do not think this is going to be a problem. The only issue—and
I have very recently talked to network managers about this—is
the one that we have anyway, which is that with the number of
organisations co-operating there are always going to be some negotiations
and tensions within it, but I am confident that if foundation
trusts are going to remain in the business of providing cancer
services for NHS patients they will have to be part of networks.
Q12 Chairman: This plan lasts until 2010,
quite a long time. The NHS will be very different by 2010. How
are you going to update your plan?
Sir Nigel Crisp: We are almost
halfway through this 10-year period, as you say. Again, there
is a recommendation that we need to look at how we should update
it. We have not yet taken a decision as to whether we want to
merely issue some updating of some parts of it (I am assuming
you are thinking about the period from now to 2010 rather than
beyond) or whether we want to do a whole refresh of the plan.
I am inclined to think that we will probably go for the first
one of those and identify those areas that need updating and update
them, but the decision has not been taken yet as to exactly how
we will do it. It is midway through and we shall certainly review
it.
Q13 Chairman: I have a last question
on resources. Can I refer you please to page 25, paragraph 2.29?
Four of the 10 cancer networks who were visited by the National
Audit Office said that the level of resources that they had to
do their job was poor. I would like to ask you whether you are
reviewing if this applies to other networks and what you are doing
about it.
Sir Nigel Crisp: This is an issue
and we know it is an issue. What you can see around the country
is some variation. We provided some start-up costs for networks
and said broadly how we wanted them to work. We provided some
support and some co-ordination. Networks work best when they are
fully embedded in the local NHS because there are very few hospitals,
for example, that do not provide some kind of cancer service and
therefore the network needs to reach everywhere. What has clearly
happened over the last few years is some variation in how they
have been supported by the local NHS. What we are going to do?
This is entirely coincidental timing but I put out a paper last
week about how we are going to manage networks more generally
in the NHS and we will be expecting SHAs to be responsible for
ensuring that networks operate effectively. We are putting them
into a formal performance management model and part of that will
require assessment of whether they have got the resources there,
but I accept that at the moment some of them do not.
Q14 Mr Field: We published a Report earlier
called Saving More Lives and that showed that the poorer
you are the worse the outcome. How long do you think it will be,
if you think it is a realistic objective, before we will be able
to report that poor people have the same outcome if they are affected
by cancer as richer people?
Sir Nigel Crisp: I think we discussed
this to some extent at one of the earlier PAC meetings but can
I ask Professor Richards to pick it up?
Professor Richards: What we know
is that cancer death rates are falling both for more affluent
people and for poor people, and they are falling roughly speaking
in parallel. What we are trying to do is accelerate the decline,
particularly in the more deprived groups. The issue there first
of all is smoking. We have got some good news on that, which is
that the Stop Smoking services have been targeted particularly
at those areas which have high smoking rates, which are the more
deprived areas, mostly in the north of the country, and they have
the highest quit rates of the country. Places like Hartlepool,
Easington, Liverpool are among the star performers on that. Equally,
what we need to do is try to get patients, when they do develop
symptoms, to come forward quickly and we know that that is an
issue again in more deprived groups. They are more likely to delay
seeking medical advice and we have an innovative programme that
we are working up with the Healthy Communities collaborative to
try to get those messages through to people in the community about
what the symptoms are of cancer and what they need to do about
it when they get them.
Q15 Mr Field: When Sir Nigel was asked
by the Chairman whether the targets about the length of time from
diagnosis to treatment beginning would be met, the Chief Executive
very confidently said yes. To what extent, if those targets are
met, would that begin to reduce the difference between rich and
poor, and to what extent are they the other issues which you have
already touched upon?
Professor Richards: To be quite
honest, I think the differences between rich and poor are not
in those waiting times. With regard to those waiting times, from
the time that people get into the system to being referred onwards,
I am not aware of any evidence that there is a difference between
rich and poor there. It is the wait before they go to see a GP
which tends to be longer for more deprived people, as indeed are
the smoking rates higher. The two are separate. They are both
important. We need to tackle the wait after people have been referred,
and I agree with Sir Nigel that we have to do that by the end
of this year and get that cracked, but we also need to look at
the earlier period.
Q16 Mr Field: You seemed to be suggesting
earlier that it may be that poorer people are less aware of what
the symptoms might be. I have to say that I have not gone around
Birkenhead trying to hoover up information but I have never seen
a piece of information anywhere in a doctor's surgery or in a
public building which would tell me what the symptoms are, so
what is the campaign?
Professor Richards: There are
a number of different approaches being taken. You may have read
in the paper today about the information on skin cancer and the
Sun Smart campaign that is being run by Cancer Research UK but
funded by the Department of Health. That is £400,000 funding
over three years and this is the beginning of the second year
of that programme. That is one example.
Q17 Mr Field: The data shows that poorer
people are less inclined to get skin cancer, are they not?
Professor Richards: They are less
inclined to but—
Q18 Mr Field: So it is a campaign which
is not aimed at them.
Professor Richards: No, but they
may be more likely to delay seeking medical advice and that is
extremely important in skin cancer in terms of what the outcome
is likely to be. The evidence in breast cancer, for example, again
is that it tends to be the elderly and the relatively poorer people
who are more likely to delay before they seek medical advice.
One of the things that we did shortly after the Cancer Plan was
published was to commission research in this area, and one of
the reasons we have not been able to take it forward faster is
that we needed to wait for that research to find out what people
did and did not know so that we could plan our campaigns most
effectively. That research has now come in. We held a workshop
on it just over a month ago and we are now planning the campaign
in order that we can target the right people in the community,
who are the poorest people and the elderly.
Q19 Mr Field: When you refer to an example
of the differences on breast cancer does the approach differ from
younger women in my constituency compared with pensioners on screening?
Professor Richards: Yes. The situation
with breast cancer is that there is a lot of misinformation about
at what age people are most likely to get breast cancer. Partly
that is because if you look at the media or listen to any soap
opera, they tend to give breast cancer to people aged 30 or 35
which, although it can happen, is very unusual, whereas breast
cancer is much commoner in women over 50 and in fact is commoner
over the age of 70. That is a message that we need to get through
to the public and we now know that it is something that the public
do not fully understand and that will be part of our campaign.
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