Examination of Witnesses (Questions 80-99)
DEPARTMENT OF
HEALTH
23RD MARCH 2005
Q80 Mr Williams: But what is coming over
at PCT level and at network management team level is that the
co-ordination is not working. You say it is nothing to do with
organisation. Look at paragraph 2.44, the NHS foundation trusts.
There it says, "A workshop of key stakeholders, convened
by the Cancer Action Team in January 2004, identified NHS foundation
trusts as one of the high risk areas in terms of implementing
the NHS Cancer Plan". If you look at the previous paragraph
it says that 20 foundation hospitals were set up and they are
bound by a duty to co-operate with other NHS bodies, but—and
you signed up to this—"it is unclear what this means
in practice". That is just a year-old change and at the time
of this Report it was still not clear what that means.
Sir Nigel Crisp: Let me say I
would not have written that, and I had not spotted it and I should
not have signed up to that sentence, that it is unclear what it
means in practice.
Q81 Mr Williams: But, you know, Sir Nigel,
that really is not good enough.
Sir Nigel Crisp: No, it is not
good enough but I do not sign up to the fact that we do not know
what partnership means.
Q82 Mr Williams: Sorry; I have got to
emphasise this, Chairman. As far as this Committee is concerned
one of the ways we work efficiently is that we are not arguing
about the contents of your Report. It has been agreed in advance
and you are signing up to it. The fact that you missed it is in
fact a neglect on your part but it is what you signed up and you
are now telling us it is wrong.
Sir Nigel Crisp: Can I tell you
what I also signed up to? First can I accept the fact that in
looking at that on reflection I would have disagreed with those
words, but if you look at paragraph 2.44, which you quoted, you
may have noticed at the bottom of it it says, "On the other
hand the Department has stressed that there is no evidence that
NHS foundation trusts are having a destabilising effect on cancer
services", and indeed they pointed to several that had reasserted
their commitment.
Q83 Mr Williams: It says "several"
of the 20, not 20 out of 20.
Sir Nigel Crisp: Again, with respect,
my first answer to your Chairman said very clearly that we will
only be commissioning services for cancer patients from people
who are part of networks. That is what we are saying. It is not
in this report but that is the position we are taking.
Q84 Mr Williams: That is fine but we
are back on the other points. If 30% of the networks have not
got current plans for cancer services in their locality it is
not going to work very well, is it?
Sir Nigel Crisp: But all the PCTs
are commissioning primary care and cancer services, are they not?
People are getting cancer services. What we are saying is that
people will only get cancer services on the NHS if the services
they are being offered are part of a cancer network. It is that
simple. I have no doubt at all that people were concerned about
foundation trusts, as they were, for all kinds of other reasons,
about foundation trusts. The foundation trusts are part of cancer
networks.
Q85 Mr Williams: Can I switch away from
your direct response to me and maybe you do not want to comment
on that, to the activities of cancer charities? There are so many
of them, a plethora of them, and the public does not know which
are high quality, which are poor quality, which are jobs for the
boys and which are doing something worthwhile. Is there any system
of co-ordination of the role of these charities? Is there any
examination of possible waste through duplication?
Professor Richards: There are
a large number of different charities related to cancer. There
are three which are very large. There is Cancer Research UK, which
clearly focuses exclusively on research, Macmillan Cancer Relief
and Marie Curie Cancer Care. Those are by far the largest ones
but there are a myriad other smaller ones. Over the past four
years, as part of the Cancer Plan, we have been developing very
effective partnerships in a number of different ways, trying to
work with charities that have similar interests. For example,
those charities that are engaged in research are invited to be
members of the National Cancer Research Institute. This is a partnership
body between the Department of Health, the Medical Research Council,
Cancer Research UK and a range of other smaller research charities—the
Leukaemia Research Fund, Breakthrough Breast Cancer and so on.
Q86 Mr Williams: Did they all accept?
Professor Richards: Oh yes, and
they have been very active members of that. Equally, on palliative
care, clearly that is the hospices' area of interest along with
Macmillan and Marie Curie, and we have set up a national partnership
group on palliative care, which I chair, which brings those charities
together. We have done it with individual cancers so that for
lung cancer, for bowel cancer, for prostate cancer we have advisory
groups and we get the relevant charities, Beating Bowel Cancer
and Colon Cancer Concern, for example, to be members of the Bowel
Cancer Advisory Group. In that way we are working with a large
number of charities but in a way that meets what they want to
do and where our common interests lie.
Q87 Mr Williams: Being frank about it,
every advanced country in the world is carrying out massive research
into cancer, as they are into arthritis too but with limited success.
This is a genuine request for information. How far is the charitable
contribution to actual positive research significant and how far
might it be better if perhaps they concentrated to some extent
(as some of them do) on the educative side, a point which several
of my colleagues have mentioned, making people aware of what the
symptoms and hazards are?
Professor Richards: I think the
contribution of an organisation like Cancer Research UK to worldwide
research is indisputable.
Q88 Mr Williams: That is one.
Professor Richards: That is by
far the largest one. Equally, I could look at others like Breakthrough
Breast Cancer, which is much smaller but doing a very good job
in research, have excellent laboratories but work very closely
with us, and the Leukaemia Research Fund as well. I personally
think they have a major contribution. I ought to declare an interest
here. I was funded by the predecessor body of Cancer Research
UK for 14 years in my clinical research that I conducted into
cancer before taking up my current post. I think they have played
a major part and what is happening now is that they are doing
it much more effectively in partnership with government, the Medical
Research Council and the Department of Health through the National
Cancer Research Institute, and in the last three years the number
of patients going into clinical trials for cancer have more than
doubled. I do not know of any other country that has got as rapid
an increase and I can tell you that when I talk to colleagues
in the United States about that they are very impressed and quite
envious.
Mr Williams: That is a reassuring answer.
It was a genuine search for information. Thank you very much.
Mr Field: Professor Richards, Mr Williams
at one point emphasised the effect that reorganisation can have
on delivering the plan, and there is a rumour that if the Government
is re-elected it will reorganise PCTs; there will be fewer of
them. When the Strategic Health Authority was established covering
the area which I represent, an early move on its part was to suggest
that the oncology centre at Clatterbridge would be merged with
the one across the river and a huge amount of the time of the
centre went in fighting that proposal. Because we are interested
in influencing what the policy might be, do you think it will
be more difficult to achieve these targets if the Government goes
in for another round or reorganising than not?
Q89 Chairman: If you want to plead the
fifth amendment on that, that is a rather unfair question.
Professor Richards: It is not
for me to speculate on what will happen. What I would say is that
the document that came out from the Department of Health last
week called Creating a Patient-led NHS was very important
in reaffirming the need for networks. Actually, I think that is
true whatever organisation we have—Primary Care Trusts,
including health authorities—because networks match the
natural flow of patients from primary care to secondary care to
tertiary care. I believe that networks are fundamental to this
and will continue.
Mr Field: I just wanted it on the record
for when we come to our Report. That is very, very helpful. Sir
Nigel, we had a submission from Macmillan Cancer Relief and one
of their points was that the Government should do more to tell
patients about the benefits to which they may be entitled. I know
this is another Department. All of us would salute the work that
the Macmillan nurses do but I just think they are wide of the
target on this issue, that really the person who is probably best
placed to tell patients about their benefits would be Macmillan
nurses. Should they not take on the task? Even if they are not
completing the forms they would be the ones to say "You are
probably eligible for DLA. You are probably eligible for Attendance
Allowance", even if somebody else then helps them fill in
the forms.
Q90 Chairman: Again, I do not really
think—
Sir Nigel Crisp: We did discuss
this on Monday, so it is in the record there, but not specifically
about Macmillan nurses. What we are saying is we do think frontline
staff, including Macmillan nurses, the people who are actually
dealing with the patients, need to know enough at least to signpost
people and we do not think they do enough of that at the moment.
Q91 Mr Field: Can I try and get this
last question in order then. Gerry mentioned the incredible increase
in staff and equipment. I was in a hospital—not in my constituency—looking
at the scanning equipment which ceases to work at five o'clock.
Do you have any printouts at all on how many hours a day the new
equipment that we are all so proud of is used?
Professor Richards: We do not
have central information on that. What we do know is that the
new generation of CT scanners take the scans a great deal faster
so the number of people being scanned per day on one machine is
a lot higher than it was in the past and the picture quality is
better as well. We are making a further major investment in diagnostic
equipment and in staff. I think I mentioned at one of the other
meetings that in terms of the radiographers, who are the staff
who actually operate the scanners, we have doubled the number
of radiographers in training. That will enable us to work longer
hours. A lot of the thing that is holding this up at the moment
is not having enough staff. We cannot expect them all to work
12 hour shifts every day, so what we need is more staff. We set
that in motion as part of the Cancer Plan, so those extra staff
have been going through training—it takes three years—and
from this summer we should start seeing substantial increases
in numbers. That will take two or three years to build up but
we have put the foundations in place with the extra training.
Q92 Mr Field: But it is Sunday trading
hours at the moment, is it not, with use of equipment?
Sir Nigel Crisp: Not always but
too much.
Q93 Mr Williams: In view of what was
pointed out earlier on the difficulties of the PCTs in commissioning
cancer services, how hard is the addition of the element of choice
going to make it for them to commission? It must be a complicating
factor for them, or it may be the other way. What is your recommendation
on that?
Professor Richards: Going back
to commissioning generally, the first thing to say is that some
parts of the country—we talked about Sheffield a little
earlier—have clearly cracked this, so it can be dealt with.
What we are now doing is making sure that problem is dealt with
across the country.
Q94 Mr Williams: Can you let us have
a note on that so we can put it in our report?[3]
Professor Richards: Certainly
we can let you have a note and we can also point you to the pages
in the new document from the Department of Health that specifically
mention what we are doing on networks, I think that could be helpful.
In terms of choice, clearly we want patients with cancer to benefit
from being able to make choices the same as other patients. I
think there is also a case where if you want to make sure that
patients are seen and dealt with very fast within the two week
rule that we have, it may not always be possible to offer people
a choice of five hospitals where they can be seen within two weeks,
so for the time being we have said the priority is to make sure
that people are seen at a hospital that has got a properly appointed
team but within the two weeks. For the time being, the choice
of five hospitals does not apply to those who are being referred
earlier.
Q95 Chairman: It is a bit of a meaningless
choice, is it not: you can be seen at five hospitals but if you
want to be seen within two weeks you have to go to hospital A?
Sir Nigel Crisp: May I make a
variation on that. That does not mean to say there is not choice
in the wider sense. There is a great deal of discussion about
choice of treatment, for example, and a whole range of other things
like that which are very important to patients. We do recognise
that in cancer services, perhaps more than in most other services,
it is important to be part of a whole joined-up system.
Chairman: It looks like choice may be
somewhat more limited than we might have hoped.
Q96 Jim Sheridan: Picking up one of the
points that Mr Steinberg made about PCTs in areas where there
is a high level of cancer being diagnosed, as I understood it
I think you said that many resources that go in cannot be ring-fenced
to deal with cancer treatment. Am I right so far?
Professor Richards: What we have
said is that we have set standards for the outcomes that we are
looking for from cancer networks and, indeed, from individual
PCTs.
Q97 Jim Sheridan: Any additional resources
cannot be ring-fenced to deal solely with cancer treatment?
Sir Nigel Crisp: I do not think
it is "cannot be ring-fenced", we do not ring-fence
as a matter of policy.
Q98 Jim Sheridan: I am trying to see
if we can get a handle on these PCT areas where there are high
levels of cancer-related diseases. I am trying to get a handle
on just how much has been spent in these areas compared to others
and the additional demands on PCT areas where there is a high
level of cancer treatment. What also concerns me is if other government
departments which are charged with the responsibility of advising
people of benefits, et cetera, do not allocate additional
resources to explain to people what their benefits are when they
have cancer, that kind of thing, how will they know about it?
Sir Nigel Crisp: There are two
things. Firstly, how do we decide how much money each area gets
anyway. We have a formula for allocation to PCTs, and we have
recently revised the way the money goes into that system, which
tries to pick up need in areas which will not only pick up the
need for cancer services but for other services as well. The latest
figures were announced about a month ago and there was considerably
more investment in what we call spearhead PCTs, those areas that
we saw as having the greatest need. That is available to you if
you want to see that. What is also true is that different areas
have higher incidences of different cancers, which is the other
point that is worth noting, so we will see more breast cancer
in the South, for example.
Q99 Jim Sheridan: How do the general
public know how much resources are going in there over and above
the general medical bill for PCTs? How much more financial resources
or otherwise are going into the PCT areas where there is a high
level of cancer? How do we know that is happening?
Sir Nigel Crisp: I am not entirely
sure that there are PCTs that you would necessarily say were a
high level of all cancers, I think it is just one of the features
of—
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