Examination of Witnesses (Questions 40-59)
DEPARTMENT OF
HEALTH
23RD MARCH 2005
Q40 Mr Steinberg: Is this money ring-fenced
for cancer?
Sir Nigel Crisp: No. A very small
amount is ring-fenced.
Q41 Mr Steinberg: That is disappointing.
Sir Nigel Crisp: We are working
on the outcomes, not on the inputs. We measure them on things,
as the Chairman asked me, such as waiting times.
Q42 Mr Steinberg: In the Report there
are the usual remarks that they do not get enough resources and
you always expect to get remarks like that from the National Health
Service. Could it be argued, if that is the case, that some PCTs,
if it is not ring-fenced, are not passing it down the line and
it could be spent on something else?
Sir Nigel Crisp: Over the period
of this plan we changed policy slightly. We started off at the
beginning of the NHS plan allocating direct sums and ring-fencing
them so we did ring-fence some additional money for cancer. In
the next spending round we decided it was better to give as much
money as possible to the local community so that they made the
decisions but we nevertheless have indicative amounts of money—
Q43 Mr Steinberg: Would you name and
list those PCTs who are receiving the extra money for cancer networks
and are not using that money where it was intended to be spent?
Sir Nigel Crisp: As Professor
Richards said a moment ago, he is going to be producing a report
on how the extra money has been spent, because it is £570
million on top—
Q44 Mr Steinberg: That is not quite what
I am asking though, is it?
Sir Nigel Crisp: — and that
will undoubtedly identify the areas.
Q45 Mr Steinberg: When will that be published?
Sir Nigel Crisp: Not at PCT level.
It will identify it at cancer network level, which covers a number
of PCTs.
Q46 Mr Steinberg: But if the cancer networks
are not getting the money from the PCTs how can you then blame
the cancer networks?
Sir Nigel Crisp: I am not sure
we are blaming anyone on this particular thing.
Q47 Mr Steinberg: What I want to know
is which PCTs are not handing down the money that they are supposed
to hand down? Could we have a list of those PCTs?
Sir Nigel Crisp: I do not think
we break down PCT expenditure by cancer. We break it down at the
larger level, ie, at the cancer network level.
Q48 Mr Steinberg: In terms of spending
the money, and again Jim touched on this, you could get a load
of money and you could spend it, as you think, very wisely but
at the end of the day you might not be doing that because, for
example, you could have X amount of new scanners and not have
the staff to use those scanners. Have you got any evidence to
show that they know how they are spending the money and if they
are spending it wisely?
Sir Nigel Crisp: Part of Professor
Richards' role as the National Cancer Director is supervising
the activity that is going on across the entire country. The plan
is trying to knit together all the features you need to get a
really good cancer service. He does have a supervisory role and
an oversight of all of that, but perhaps he could give you the
level of detail he will be able to produce.
Professor Richards: We are collecting
that information at the level of the cancer networks and the networks
largely map onto Strategic Health Authorities, not exactly but
largely. What we also do is collect information on the number
of scanners that are in each Strategic Health Authority so that
we can convert that into the number of scanners per million population,
the number of radiotherapy machines per million population. We
also look at the workforce and so we are in a position to say
which parts of the country have relatively more or relatively
less, and over the last few years our plan has very deliberately
been to even things up. Where we have seen, for example, that
there are not as many CT scanners from the money that was allocated
to CT scanners in the Cancer Plan, we have targeted those deliberately
at the areas that had the least.
Mr Steinberg: I do not want to sound
like the Prime Minister at Prime Minister's Question Time and
in the thrust of politics one never knows whether the statistics
are correct. My view has always been to look at the NAO and see
what statistics they have given and they are usually correct.
If you look at page 17, figure 8,975 extra consultants in post
by 2004, a 36% increase in training places, £1.3 million
invested in three training centres, £400 million invested
in new facilities, 668 MRI scanners. You can go on and on. This
has got to be an excellent record.
Jim Sheridan: Vote Labour.
Chairman: That is enough of that.
Q49 Mr Steinberg: This Report makes excellent
reading. Coming on to the points Mr Field made, I come from the
north east of England where we have probably got similar records
in terms of deprivation to Merseyside. What I was disappointed
about in this Report was that there was no indication at all of
any priority being given to our areas in specific terms. They
were mentioned as disadvantaged areas but there seems to be no
priority plan. I am not asking that we should get more resources
but there should certainly be a plan set down. What disappointed
me as much as that was that in the NAO Report itself—and
it is not often I criticise the NAO—when I looked at Appendix
2, for example, and where they have gone to do their research,
it was Birmingham, Manchester, Humber, London, Peninsula (wherever
that is), Surrey, Sussex and West Hampshire, South West London
and West Anglia. There is not a mention of the north east of England.
I would have thought that would be one of the prime areas you
would have gone to.
Dr Robertson: The way we selected
these cancer networks to visit was in consultation with the Department.
Q50 Mr Steinberg: So they did not want
you to go there?
Dr Robertson: No: we were taking
a view as to those which were regarded as being particularly effective,
those that you might regard as in the middle and those that might
be viewed as less effective. Our primary requirement was to get
a range of networks in terms of their performance and that is
what we did.
Q51 Mr Steinberg: It is a shame that
you did not go to the north east. When you are talking about cancer,
everybody knows from that last Report that we did a few months
ago that it clearly said disadvantaged areas were the ones that
had the worst cancer records and then we come to this Report and
there is no real plan to specify and prioritise the areas that
are the worst sufferers. That I find disappointing.
Professor Richards: With regard
to the two networks that cover the north east, one is the Northern
Cancer Network, which is based on Newcastle but covers a large
swathe of the north of the country, and the other is the one for
County Durham and Tees Valley, the Cancer Care Alliance there.
They are both very effective networks and they are particularly
putting effort into things like smoking cessation because they
recognise that that is such a problem in the north east.
Q52 Mr Steinberg: What about the report
that came out from somebody at Newcastle University which said
that you were failing miserably on your targets to stop people
smoking and you could not achieve your targets?
Professor Richards: If I can be
bold, I think it was an entirely mischievous report and it absolutely
failed to recognise what is going on in tobacco control in this
country. It was saying we will not achieve targets by smoking
cessation alone. We have never said we would. We have always said
that was one part of a six-strand tobacco policy, and I mentioned
the other parts earlier, and also as I said earlier, we are rated
second out of 28 countries for our tobacco control strategy, so
I think we are doing a lot. They are effective but they are only
one part of the solution. There is work being done on taxation
and on media campaigns. I am sure you are all aware of the media
campaigns. You will have seen the advertisements that show a cigarette
with fat in the middle of it looking like a coronary artery. You
will have seen the ones about second-hand smoking of children
blowing out smoke sitting at the bottom of stairs. Those have
been seen by vast numbers of the public and they have been very
effective campaigns.
Q53 Mr Steinberg: If you look at page
16, figure 8, it says under "Improving treatment", "NICE
appraisals of cancer drugs to end the postcode lottery".
Can you give us a list of the postcode lottery? I would be very
interested to know which PCTs distribute the drugs and allow their
practices to do so and those who do not.
Professor Richards: Again, what
we can give you is information at the cancer network level, because
in June of last year I wrote a report for the Secretary of State,
on the variations in use of drugs. We looked at all 16 drugs that
had been appraised by NICE. We reported on the variations. I made
recommendations on what should be done to reduce the variations
and I am pleased to say that Ministers accepted my recommendations
and those are now in action. We can send you a copy of that report.
It is probably in the House of Commons library anyway but we will
send you another copy.[2]
Q54 Mr Allan: Sir Nigel, as politicians,
when we talk about the Health Service we like to talk about managers
and bureaucrats being bad and doctors and nurses being good, but
when I look at the NHS accounting department it seems to be a
success. Would it be fair to say that this is an example of managers
and bureaucrats carrying out a tremendous job of work in terms
of improving the effectiveness of doctors and nurses?
Sir Nigel Crisp: I hope that is
what we try and do anyway. This is a very clinically focused Report,
as it should be. You will be aware that there are now something
like nine equivalents to the Cancer Plan, national service frameworks,
whether for coronary heart disease or for mental health or whatever,
and in all of those cases what you will find is very good close
working between a senior clinician, who is taking the lead, which
is very important for dealing with the credibility in respect
of his or her peers, and a good infrastructure of people who are
bringing in all the different expertises you need, some of which,
frankly, are about managing money. This is a Health Service that
spends £2,000 a second. It is remarkably important that we
manage that money very well. This is the forerunner of all those
other plans and I think people have done exceptionally well.
Q55 Mr Allan: What you have done, because
patients' outcomes are so much better now, is that you have taken
a service which was under-managed or poorly managed before and
are managing it more effectively. Is that fair to say?
Sir Nigel Crisp: What happened
before this Plan was in place was that everyone did their own
thing and some of what they did was fantastic and some of it was
not and it was not joined up. One of the things that we all understand
about the Health Service is that almost no institution provides
health services by itself. It is primary care and the secondary
hospital and the tertiary hospital and that is even more true
in cancer.
Q56 Mr Allan: You have moved, or rather
we politically have decided to move all the pieces around the
Health Service board to suit the plans. I just want to go into
it a little bit to understand these relationships. For example,
the PCTs have had them before. Can I be clear, and I will take
my own area of Sheffield? At Weston Park Hospital the Cancer Network,
which is kind of a creep from the acute sector, which seems to
predominantly live there, has made sure that there are clinicians
there so that when somebody in Sheffield presents they get the
treatment in the timescales that you are now setting out.
Sir Nigel Crisp: Can I give a
layman's view of this and ask someone who is more directly involved
to answer? What we have tried to do in the network is to say that
people with cancer use services in a whole lot of different institutions,
almost more than any other group of patients. We need to get that
group of people together so that we understand that they are using
the same data, that they are communicating with each other, that
they have got protocols to help patients move between them, that
they have audit happening and so on, and that there is some coherent
cancer planning going on for the area. That is why we have created
networks. That is a very simple lay perspective.
Q57 Mr Allan: I am specifically speaking
about the diagnosis and treatment bit, which is the bit which
for most people is the crunch point. They have gone to a GP, there
is a suspicion, they want to get into an acute unit to get diagnosis
and treatment very quickly, and the plan seems to be doing that
more effectively. I am just wondering whether the PCT is at all
relevant in a sense, that if that person goes to their GP they
are going to refer them. There is no difference between one PCT
and another as to whether or not they are going to pay for it,
is there?
Professor Richards: If I can take
the network in your area, the North Trent Network, and in fact
it is mentioned specifically on page 26, figure 14, as an example
of effective collective commissioning, that network is not just
for Sheffield; it is also for places like Doncaster and it is
very important that for patients who come in through Doncaster
as their local hospital get seen there, a lot of their diagnosis
will be done there, some of their treatment will be given in Doncaster,
and then for radiotherapy, for example, and complex chemotherapy
they will need to come on to Weston Park in Sheffield. It is extremely
important that Doncaster and Sheffield work closely together and
that the PCTs that cover those two areas also work together so
that they can make sure that the resources are in place both for
the local treatment that they need in Doncaster and for the treatment
they need to have in Sheffield.
Q58 Mr Allan: Does it matter to the patient
which PCT they are in? Is it ever going to matter if they are
in the same cluster? Everyone is prioritising on the grounds of
clinical need. Does it matter to the patients?
Professor Richards: It should
be invisible to the patient.
Q59 Mr Allan: Is it in reality?
Professor Richards: I think it
is in reality, yes. What matters is that the PCTs work effectively
together so that they can plan, let us say, effective radiotherapy
services in Sheffield for the whole of that population, which
is about 1.8 million that that network serves and, as you can
see, it is an example of where a network is getting it right.
2 MACDONALD, S., et al., Department of Health Research
Programme: Cancer Symptom Profiles and Referral Strategies for
Primary Care, 2004. Factors influencing patient and primary
care delay in the diagnosis of cancer: a database of existing
research and its implications for future practice. Back
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