Examination of Witnesses (Questions 60-79)
DEPARTMENT OF
HEALTH
23RD MARCH 2005
Q60 Mr Allan: Is it ever the case that
somebody could go to a GP and the GP say, "I want to refer
them", and the PCT say, "We are not prepared to pay
for it"? Does that sort of thing happen because that is the
kind of thing people are going to be worried about structurally?
Professor Richards: Not to my
knowledge. I think that patients that need to be referred get
referred.
Q61 Mr Allan: In terms of the drug treatment,
again, is there a variation there? You said that there are variations
and in Sheffield we have got four PCTs, but is it ever the case
that out of two patients with exactly the same symptoms and the
same clinical needs in two different PCT areas one could get the
drug and the other not on the basis of a PCT decision?
Professor Richards: Emphatically
in that network that would not be the case because that is the
effective joint commissioning that they have agreed to. They have
binding rules. I think there are 13 PCTs in that network and they
collectively agree on what will be done so that you can be absolutely
sure in that network that everybody will get the same across the
board. That is the arrangement that Sir Nigel mentioned earlier
that is now going to be put in place across the whole of the NHS.
Q62 Mr Allan: From the patient's point
of view that is what you mean by a good network: it is one where
they are given consistent treatment?
Professor Richards: Yes, absolutely.
Q63 Mr Allan: But they could be in another
area and this might not be the case?
Professor Richards: Consistent
treatment and treatment that is in line with national guidance
which comes from the National Institute of Clinical Excellence.
Q64 Mr Allan: But there are other parts
of the country—and this is what your Report brought out—where
NICE have said that the drug should be available, somebody has
gone to their GP, and in Sheffield where it is working well they
would be getting the drug, but their GP is told by the PCT that
they will not pay for it.
Professor Richards: To be quite
honest, my Report actually showed that this was not a funding
issue. None of the networks told us that this was a funding issue
from the PCTs. There was a variety of other issues, often to do
with staffing and making sure that that we have the capacity in
the system in terms of pharmacists and chemotherapy nurses, and
also it is a question of making sure that doctors are giving the
very best treatments.
Q65 Mr Allan: I have to say, Sir Nigel,
as an observation that the whole PCT logic seems crazy when you
do not want a postcode lottery because you are talking about PCTs
allocating according to their local priorities but you have a
national plan that says, "We have a national priority for
cancer and you have all got to do it". You are saying, "Do
not have any variation", and there are lots of local bodies
who are supposed to do it—
Sir Nigel Crisp: I understand
the point you are making exactly, but what we are trying to get
to is what is unacceptable variation and what is appropriate variation
or reasonable variation. We have set up the National Institute
for Clinical Excellence precisely to say that these are the things
that should happen in a national health service. That is where
we do pick up the unacceptable variation, and there is some of
it, and some of it may be for reasons that, as Professor Richards
said, that some doctors do not necessarily agree with the recommendation.
There is some room for professional differences in some of this
as well which we have to understand but there are points when
we also have to be really quite rigid because we are clear the
evidence is telling us the answer.
Q66 Mr Allan: Another management job.
You are clear from the patient's point of view where you have
got National Cancer Plan targets and NICE group drugs that wherever
you are in the country they should meet the targets and the drugs
should be available? That is the instruction that is going out?
Sir Nigel Crisp: Those are the
specifics that we are saying are not negotiable.
Q67 Mr Allan: And they can vary upwards?
They can treat people more quickly?
Sir Nigel Crisp: That is perfectly
true.
Q68 Mr Allan: But not downwards. The
bit that seems to be missing, when we look at table 12 on page
23, and I know we are always going to pick out the slightly weaker
bits, is the local authority co-operation, where we read that
two-thirds of local authorities are described as having poor or
very poor co-operation with their Cancer Networks, and 34% are
adequate, none good or very good. Is that because it is not a
priority for them or they cannot be bothered? Do you have a view
on why that is not happening?
Professor Richards: I think this
is the stage of evolution which networks have got to at the moment.
The Primary Care Trusts and the acute trusts are the absolutely
critical partners in that with the strategic health authorities
taking the overview. The voluntary sector, the hospices, are also
smaller in terms of the amount of money they are contributing
but they are very important as well.
Q69 Mr Allan: They get a good write-up
here.
Professor Richards: Oh yes, very
definitely, and so they should. Over the next few years we will
see local authorities become more important partners in this,
particularly as people with cancer live longer, more of them are
elderly, they will have other illnesses to contend with, they
will need more social care support, and then it will be even more
important to have the local authorities involved. They are after
all very closely involved with the individual PCTs and where that
is working best is often where the PCTs and the local authorities
are coterminous. There is at that level engagement but they are
not at the moment engaging at the level of the whole network.
To what extent they need to do that if they are really engaging
well locally I think we can debate as time goes on.
Q70 Mr Allan: But at the moment very
good progress has been made.
Professor Richards: Yes.
Q71 Mr Allan: And they are still thinking,
"This is for the NHS. This is nothing to do with us, guv"?
Professor Richards: Largely I
think that is true.
Q72 Mr Williams: Like Mr Steinberg, I
welcome the extra resources and the obvious commitment that comes
out in this Report. The thing that worries me is how far, despite
the commitment and despite the resources, is delivery being impeded
by reorganisation overload?
Sir Nigel Crisp: During the course
of the Cancer Plan, which has been in existence for five years,
I think we have had one reorganisation that is relevant, which
was the creation of PCTs, and that did change the circumstances
but that is now three years old.
Q73 Mr Williams: You see, this is at
deviance from what the NAO have told us in the background briefing
where they say that with the abolition of the health authorities,
the creation of new strategic health authorities, the PCTs and
foundation trusts, the plan is looking increasingly dated. This
is very different from the impression you were giving in the answer
earlier.
Sir Nigel Crisp: I am not sure
of the reference.
Q74 Mr Williams: No; this is in the briefing
we have received.
Sir Nigel Crisp: I see. We created
PCTs in 2001. The plan came out in 2000. The old health authorities
disappeared at the beginning of 2002 and the new ones came in
and that did make a change.
Q75 Mr Williams: Look at paragraph 2.37
which explains it: "Many individuals we spoke to in PCTs
told us that they were finding the planning process for commissioning
cancer services difficult". That was the PCTs. The SHAs are
responsible for amalgamating the PCT plans and they say that the
quality of PCT planning documents varied considerably and that
the local planning process was an ongoing learning process, so
you are making it up as you go along.
Sir Nigel Crisp: No. Let us be
clear. When this was created there were a hundred health authorities
and no PCTs but something called PCGs, so it was a different world.
There were still a lot of organisations there which cancer networks
needed to work with. We have created 28 Strategic Health Authorities
which almost map onto the cancer networks but not quite, and then
we have created PCTs. That did happen three years ago. You are
quite right: with any new system the first year of planning will
not be as good as the second year or the third year. This was
part of my answer to the Chairman right at the start, that we
think the networks have done a very good job but we do think they
need some strengthening.
Q76 Mr Williams: But we are three years
on now. The SHAs said, and it is spelt out in the Report, that
the process was disjointed and unsatisfactory, paragraph 2.37.
Sir Nigel Crisp: But that is why
we are changing it. It is not really reorganisation. It is a change
in process here.
Q77 Mr Williams: Did the process not
in part have to be amended because of the reorganisation?
Sir Nigel Crisp: It did but it
had only been going for a year if you look at those dates, so
I am not sure that reorganisation is an issue here. I think the
issue is the bigger issue, which is that you have a number of
organisations working together and how do you make independent
but linked organisations work together effectively, how do you
get joint decision-making and so on? What we have done is, having
made good progress, we are now making the strategic health authorities
directly responsible for ensuring that networks operate effectively
by monitoring and managing them.
Q78 Mr Williams: We did not start from
scratch. It was not as if there was nothing in existence before,
no process, no system, and yet we are told in paragraph 2.32 that
30% of network management teams that were visited had no current
plan for cancer services in their locality. That is abysmal because
surely, as I say, they are not starting from scratch.
Professor Richards: The early
cancer networks started in the mid to late 1990s and that showed
us what could be achieved by networks and that is why we adopted
the network model in the Cancer Plan. That gave us the grounds
for knowing that that would work. I think there was some degree
of hiatus when you have got to change from health authorities
to PCTs. They had a lot to do to get their own house in order,
if you like and there was a degree of hiatus. I believe that one
of the things that the networks have been doing is educating the
PCTs about cancer. When I ran the South East London Cancer Network
in the 1990s, which was one of the early ones, I saw part of my
job as educating the health authorities (as they then were) about
cancer. I used to go round giving what I called my O-level cancer
lecture.
Q79 Mr Williams: It worries me, you see,
that you had to do it at O-level.
Professor Richards: It is important
to do it and the networks that have been successful have brought
their PCTs on board, have brought them up to speed and have got
them seeing how important this is for delivering what is important
to the individual PCT. If you look at the individual PCT they
have a lot of people with cancer and a lot of people dying from
cancer and it is, as I have said before, a national priority but
also a local priority.
| 
