Select Committee on Public Accounts Minutes of Evidence


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.


 
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