Examination of Witnesses (Questions 20-39)
DEPARTMENT OF
HEALTH
23RD MARCH 2005
Q20 Mr Field: So will part of the campaign
to be automatic screening for older women over 70?
Professor Richards: One of the
things that we have done is extend the breast screening programme,
which used to end for routine invitations at 64, up to 70; that
has been done over the past four years. That is a massive increase
in the screening workload; it is about a 40% increase, and we
have had to get more staff, such as trained radiographers to report
on mammograms. That is a very innovative programme, and that is
already having a major impact. Over the last two years the number
of cancers detected through the breast screening programme has
gone up by almost a quarter and we can be confident that that
will translate through into better survival rates because these
are small cancers that are being picked up.
Q21 Mr Field: But you suggested a moment
ago that the chance of getting breast cancer was greater over
70 but your programme stops at 70.
Professor Richards: The evidence
supporting breast screening over 70 is very thin indeed. We took
the decision to extend it up to 70 but I think we do now need
to review that and look again to see whether we should go on beyond
70. Equally, it is a question of what messages we give to people
when they have come to their final screen about the fact that
they still need to be aware of their own breasts and still need
to be aware of symptoms and, on top of that, that they are eligible
to come back for screening at their own request at three-yearly
intervals should they wish to. That has always been the case but
not many people take that up.
Q22 Mr Field: You denoted to me three
main categories as the causes of cancer. One was about income
and background, one was the effectiveness of treatment and one
was about awareness. The income one was related to whether people
smoke or not, what they do with their lives. I just wondered whether
you would be able to provide the Committee with a note, if we
were looking at survival chances, about to what extent you could
in a loose way blame the person for how they treat themselves,
which was one of the factors you located, compared to how important
the other two factors were that you located for us.[1]
Professor Richards: To a certain
extent this was covered in the first NAO Report. It matters critically
whether we are looking at the death rate or the survival rate,
and they are separate. If you look at the death rates from cancer,
which are obviously affected by how many people get the disease
as well as how well they do once they have got the disease, there
is no doubt at all that there is a higher death rate from cancer
in poorer people. The single largest contributing factor for that
is smoking. Secondly, it is almost certainly diet, so these are
the two factors in terms of their lifestyle and whether they are
likely to get cancer. There is also the fact that once they have
got cancer they have less good survival rates. That is almost
certainly largely due to the fact that they may present to doctors
later when their disease is more advanced and that obviously is
a problem in terms of being able to cure and treat it.
Mr Field: Both you and Sir Nigel kept
saying, "This came up in our last report". We are discussing
today a progress report on the Cancer Plan and my constituents'
lives do not easily fit into the reports that we necessarily do.
Q23 Chairman: A fair point.
Professor Richards: I agree with
that.
Q24 Jim Sheridan: I apologise in advance
if some of my questions are repetitive in the sense that I missed
the previous session. Following on from what Mr Field has already
said about poor and deprived areas, has there been any assessment
carried out of what the impact would be on cancer related deaths
of a smoking ban in this country?
Professor Richards: The first
thing to say about smoking is that it causes about one third of
all cancer deaths. We know there are a number of different things
that you can do to reduce smoking in the population and we have
a very comprehensive tobacco control strategy that includes things
like raising taxation, media campaigns, labelling of cigarette
packets, the Stop Smoking services, banning advertising, on top
of which banning smoking in public places is another important
factor. They are all factors. Interestingly, I was recently shown
a European study that had looked at tobacco control strategies
in 28 European countries. This was an independent study looking
at which ones had the most effective strategies. The UK came second
out of 28 countries with only Iceland ahead. In general terms
therefore I think we can be said to have an effective tobacco
control strategy. I have made it perfectly clear in the past and
I will make it clear again that I would support a complete ban
on smoking in public places because I think that would protect
the public and encourage smokers to give up.
Q25 Jim Sheridan: A complete ban in all
public areas?
Professor Richards: All enclosed
public places. That is my own advice and the Chief Medical Officer
has made it clear that that is his advice as well, but clearly
politicians have to take political decisions.
Q26 Jim Sheridan: Again focusing on some
of the more deprived areas, smoking is just one aspect of cancer.
There is another major aspect of cancer and that is industry related-diseases.
Here I am talking about asbestos-related diseases of which millions
of people have died and yet most of the people who have died depended
on charity organisations giving them information and advice as
opposed to the government or established bodies. Why is that?
Professor Richards: Asbestos-related
diseases are important. In terms of cancer, the cancer that asbestos
causes is called mesothelioma and that currently causes about
1,800 deaths a year in the UK. That number is still going up and
will peak at about 2,100 in a few years time according to the
latest estimates. That is because that is related to asbestos
exposure 30 years or more ago and it is a cancer that takes a
very long time to develop. We are working hard through our 34
cancer networks to make sure that services available for people
when they do get mesothelioma are as good as they possibly can
be. It is a very difficult cancer to treat. It is a cancer that
has a lot of problems in terms of pain, breathlessness and fatigue.
It is a very nasty cancer.
Q27 Jim Sheridan: In a lot of industries,
the shipbuilding industry, for instance, I have seen people die
of this horrible disease, not only the people who worked in the
industry, but their families as well were very distressed. What
I find really frustrating from my point of view is that people
who are diagnosed as having asbestosis-related diseases are now
depending on a charity to advise them and give them information
about benefits, about how to claim compensation. Why is there
not a government department which deals with that, or is there
a government department that deals with that?
Professor Richards: We work very
hard with the charities, with the British Lung Foundation and
a whole range of other charities. There was a summit on mesothelioma
just a couple of weeks ago at which I was the invited speaker
from the Department of Health, and we all agreed that we needed
to work more closely together on this. We are doing so. We have
an advisory group at the Department of Health, which I chair,
which brings together the charities interested in both lung cancer
and mesothelioma with people from the NHS as well in order that
we can make sure that for the cancer-related diseases and asbestos
we do as well as we possibly can.
Q28 Jim Sheridan: Where was the summit
you have just referred to held and how were people expected to
get there? What was the cost of the conference? Usually those
will just be for professionals or consultants to have a blether
amongst themselves.
Professor Richards: It was held
in central London.
Q29 Jim Sheridan: As usual. How many
shipyard workers or engineering workers work in central London?
Professor Richards: Not very many,
but there were representatives there from trades unions, there
was really quite a large number of widows of people who had had
mesothelioma.
Q30 Jim Sheridan: How many charities
were there?
Professor Richards: I cannot remember
the number of charities but there were several charities and one
of the things that they were doing was agreeing amongst themselves
that they should work more closely together on this and also that
they wanted to work with me and the Department of Health on this.
Q31 Jim Sheridan: How many representatives
of those who have suffered from asbestosis were at the summit?
Professor Richards: I cannot give
you a number. There were quite a number of people who had been
directly affected, mostly, it has to be said, as widows, because,
as you know, people who have got the disease are often very ill
and the length of time that they survive is often quite short,
so it is not surprising there were not very many of them at the
meeting.
Q32 Jim Sheridan: So was the question
of benefits discussed at this summit and how best to impart that
information?
Professor Richards: It certainly
was.
Q33 Jim Sheridan: How are you going to
do it?
Professor Richards: This is where
we need to work very closely with the cancer teams across the
country, the teams that look after lung cancer and mesothelioma.
They need to be the first port of call, of saying, "These
are the people you need to go and deal with". They need to
be able to signpost people to benefit services through Citizens'
Advice Bureaux and through other services as well. For example,
in my own hospital, St Thomas's, we have an arrangement where
people from the Citizen's Advice Bureau come and do sessions in
the hospital so that patients who have got conditions like that
can get excellent advice straight away.
Q34 Jim Sheridan: You will be aware therefore
of the Macmillan Better Deal campaign. Is that a campaign that
you wholeheartedly support?
Professor Richards: We mentioned
this on Monday and it is a campaign that I strongly support. Again,
on Monday we acknowledged that in the past I do not think the
Health Service has done well enough in terms of signposting people
to the services they need in order to make sure they get their
financial benefits.
Q35 Jim Sheridan: I have to say that
I still remain unconvinced because even in this day and age people
who have suffered injuries as a result of industrial diseases,
as a result of carrying out their everyday work, are still now
dependent on charities to advise them. I still find that somewhat
frustrating. Why is money given to the Primary Care Trusts as
opposed to giving it directly to the cancer networks?
Sir Nigel Crisp: Because that
is how we distribute money in the NHS. We give it to the local
body that has responsibility, which is what Primary Care Trusts
do, for looking after the health needs of their whole area. Therefore
they get the money and therefore they need to make decisions which,
as you very rightly said just now, will depend on the health needs
of the local population, and they take that overview which will
include cancer but will also include services other than health.
Q36 Jim Sheridan: Surely the cancer networks
are best placed to decide where that money should be spent?
Sir Nigel Crisp: Cancer networks
only look at cancer whereas PCTs look at the health of the local
population which goes much wider than that and that is the process
that we use to try and get local decision-making related to local
needs. As part of that they obviously fund cancer networks but,
more importantly, in funding cancer networks they fund cancer
services and their local facilities according to how they see
the local needs within a national framework of which Professor
Richards is the director.
Professor Richards: It is also
very important to say that Primary Care Trusts are part of the
networks, that the networks are partnerships between the organisations
which hold the purse strings, the primary care trusts, and those
that are providing the services, the acute trusts, the foundation
trusts, etc, and so the Primary Care Trusts are part of those
networks. The body that brings them together is the network and
so through the network they do their planning for cancer and then
the Primary Care Trusts determine what funding is then needed
to make sure that they achieve the national standards.
Q37 Jim Sheridan: Again, from my own
experience one of the imponderables of life is the work that local
hospices do and if the National Health Service are to pick up
the bill or the tab for carrying out the work that hospices do.
They are mainly staffed by volunteers and charities. A personal
frustration of mine is the National Insurance that hospices have
to pay. I have been campaigning for that to be removed. Would
you support any campaign for that or is that a legitimate argument,
for hospices to be excluded from these payments?
Professor Richards: What we have
said is that we recognise that the voluntary sector, the hospices,
are shouldering too much of the financial burden of hospices.
That is in the Cancer Plan and that is why the Government made
a commitment in the Cancer Plan to provide £50 million extra
for specialist palliative care services, including the hospices,
and that has been done through a central budget but with the local
cancer networks determining where the need was greatest at the
local level. They submitted their plans for how they wanted to
spend the money and a committee, including the voluntary sector,
then adjudicated on those plans. The money has been given out
and I can assure you that the money has got through to the front
line.
Q38 Jim Sheridan: I am not denying for
a minute that the money has got through. What I am saying is that
people go out collecting in cans and having jumble sales, whatever
it may be, and that money just goes back to the Chancellor of
the Exchequer.
Professor Richards: In terms of
what those arrangements are, that is beyond the Department of
Health. That is more a matter for the Treasury. Having said that,
I support more money going to hospices. They do an extremely valuable
task and the Department of Health has put more money into that,
which of course has come from the Treasury, if you like, so it
comes from the taxpayer.
Q39 Mr Steinberg: I have got to say,
Sir Nigel, that this Report was a huge disappointment to me. It
is probably my last Committee of Public Accounts and I was fully
hoping that I could really put you under pressure for the last
meeting as something to remember me by, but I have to say that
this is probably the best Report that I have read in the last
five or six years that I have been a Member of this Committee,
so I am not going to be able to do that. The more I read the Report
the more I looked to see what I could have a go at and there was
very little. This Committee is never very political but I have
to say I was rather proud when I read this Report of the achievements
that we have made over the last seven or eight years. I think
anybody who denies the fact that this is being well and truly
handled now is very churlish. Everybody on this Committee knows
that where criticism is due I am quite happy to give that criticism,
so it is good job we are not talking about the CSA or helicopters
or something like that this afternoon when I could have gone out
on a really good note. The Report is a first-class Report. Can
I just follow on from what Jim said? He questioned you on the
allocation of resources to the PCTs and the cancer networks. I
was not certain whether that money went via the PCTs or straight
to the networks. Clearly it goes straight to the PCTs and not
to the networks. Is this money on top of money that the PCTs would
have got anyway for dealing with cancer, or anything else for
that matter?
Sir Nigel Crisp: Can I make two
responses to that? First, I very much appreciate your comments
about this Report. It is very significant that we have had Professor
Richards dealing with this for the last few years and this is
due to an enormous amount of work by a number of people, including
several behind me, from around the NHS. A great deal of effort
has gone into this, as indeed you know. On the PCTs, this is the
money that goes out to PCTs. As again I am sure you know, we want
to make sure that we have got as much as we can of the money that
is voted to the NHS going to the local community so they make
the decisions.
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