Examination of Witnesses (Questions 101-124)
Q101 Mr Bacon: I take
Sir Robert's point that there is always going to be a leading
edge. Presumably, Sir Robert's point is going to affect decisions
later, because somebody else in a hospital in a different part
of the country will hear what Sir Robert's hospital has been doing
and will say two or three years down the road, "I want a
bit of that." You have to control that, don't you? But let's
get back to the original question.
Professor Sir Mike Richards:
The specifications that individual hospitals will need will differ.
There is the leading-edge question and I welcome the fact that
PET-MRI, as an example, is beginning to come into this country,
and I welcome the fact that it will be happening at Sir Robert's
trust. That's fine. There will then be highly specialised trusts,
such as neurological or cardiac services, that may need the high
end of a CT scanner, for example, for heart services, and MRI
scanning for brain and neurological services.
There will be differences between trusts, but
there will be workhorses as well. What we can do is provide advice
on when the leading edge and the highly specialised ones are needed
and when the standard ones are completely okay. If we can provide
that advice—I think we have the clinical experts, the physicists
and others who can help us provide it—and we can also say
that we now think the indications for a particular form of radiotherapy,
such as stereotactic body radiotherapy, or whatever, are this,
you will only need one of those machines per five million people,
because only a narrow group of patients will need it. That is
what I think we can do.
It may well be—Sir David may want to comment
on this—that the commissioning board can do that in the
future. It is a potential role for it. We can give that advice
so that when a trust is making up its mind, it can determine that
for the indications of what it will need, it seems the right sort
of machine. It can then go to the supply chain to get the best
deal.
Q102 Mr Bacon: But it
is one thing for you to offer the guidance and the advice, but
it is another for the trusts to listen in the conversations that
they are having with Mr Brown. Mr Brown, do you think that trusts
use spec as an excuse for not engaging, or is this not a problem?
Andy Brown: No, not at all. Our
framework deals cover all specs. There may well be one or two
brand new modalities, like PET-MR, which were not around four
years ago when we did the framework in 2007. We are doing another
framework now, which will be launched in November, because they
are four years long. That framework will take account of any technological
changes in that period of time. We will have the latest technology
on there as well. Furthermore, we future-proof our contracts,
to ensure that should a supplier bring out a new technological
change in the contract period, that automatically gets on to the
framework.
Q103 Chair: How many
suppliers have you got framework agreements with?
Andy Brown: For this level of
machines there are four manufacturers. It is pretty much four
worldwide.
Q104 Mr Bacon: Can you
just remind us who they are?
Andy Brown: Siemens, Philips,
Toshiba and GE. For linear accelerators, there are three manufacturers:
Elekta, Varian and Siemens.
Q105 Austin Mitchell:
I just want to move the discussion on from the prices paid for
the stuff to the use of it. First, I was struck by something issued
by the Department of Health since the report came out about waiting
times for scans. I want to ask you, Sir David, why, apart from
the election of a Conservative Government, the waiting time for
scans has got longer since 2010?
Sir David Nicholson: The waiting
times generally across the whole board are relatively stable,
but they go up and down during any year or any seasonal arrangement.
There is a great danger in people picking out particular months
and particular years and trying to compare them against each other.
It is almost limitless what you can do in that environment. We
think that they are low and stable. If you look at them, the average
is still some 1.8 weeks for MRI. There is stability.
Q106 Chair: Some 1.8
weeks. The NAO is always a little bit out of date, so what is
your latest data on waiting times?
Sir Mike Richards: The median
wait for CT scans is 1.4 weeks. For MRI scans, the wait is 1.8
weeks. Those are stable.
Q107 Chair: What were
they a year ago?
Professor Sir Mike Richards: I
haven't got the figures for a year ago, but I can tell you what
they were four years ago, when they were three times as long for
MRI, and for CT scans they were about twice as long.
Q108 Chair: Can you let
us have a note as to what they were?
Sir David Nicholson: They were
broadly the same this time last year, but that is against a background
of an increase in activity of nearly 5% over the year.
Q109 Chair: So these
terrible stats in here, which I did find a bit shocking, that
50% of people who have a stroke do not get a scan within 24 hours,
has that changed?
Professor Sir Mike Richards:
That is an area that, undoubtedly, we still need to do work on.
We are monitoring that, and there is the stroke audit that gives
us the figures. There is variation between trusts. At the highest
end it is 97% of patients that are being scanned within 24 hours
and at the other end it is about 28%, so there is variation. We
have to work on that, but that is not, of course, just about machines;
that is also about the work force. It is about seven-day working,
and, as you are probably aware, there is a lot of effort going
into looking at how we can get hospitals in general to move towards
seven-day working.
Q110 Chair: Is it also
true that 15% of cancer patients who would benefit from radiotherapy
do not have access to that therapy?
Professor Sir Mike Richards:
Can I explain those figures? There were some international figures
that suggested that over half of all cancer patients would require
radiotherapy—about 52%—and we are currently somewhere
nearer to the 37% mark. There are concerns about whether that
international benchmark is right, and we are doing further work
with our experts, which we expect to publish later this year,
on what the demand really is. I am sure that we will need more
patients being treated with radiotherapy. The next question is
where are they and why are they? It is not that they are being
denied radiotherapy now. I personally think that a proportion
of this is due to the fact that we still have a problem with late
diagnosis in the NHS. We have made no pretence about that. It
is a major part of the cancer strategy that we want to reduce
the problem of late diagnosis. The main thing being that if these
patients are diagnosed late, they are no longer suitable for curative
radiotherapy.
Q111 Chair: I understand
that, but what the Report actually says is that 15% of patients,
presumably those who have been diagnosed with cancer and for whom
radiotherapy might prolong their life, are not accessing that
therapy.
Professor Sir Mike Richards: I
think that is based on the figures that 37% are currently getting
it and this international figure of 52%.
Q112 Chair: When are
you publishing this research?
Professor Sir Mike Richards:
I believe that the new demand figures for radiotherapy are going
to be published in November or December.
Q113 Mr Bacon: You mentioned
that there is still a lot of further work to do. You will know
that this Committee has twice looked at stroke, and this, I suppose,
is really a question for Sir David, because I would like to know
how much more work there is to do. You have quoted 90%, down to
sort of 20-odd per cent.
Professor Sir Mike Richards:
28%.
Mr Bacon: One of the things that was
very clear from the National Audit Office work on stroke five
years ago—we have looked at it again more recently than
that following the progress report that they did—is that,
because the costs of treatment after a stroke for those who survive
are so huge—higher than cardiac I seem to remember—the
mantra "always scan" actually saves you money. Yet,
five years later, we are still talking about having a lot more
work to do. When will we get to the point when the work is done?
Sir David Nicholson: It will never
be done in the sense that new arrangements will come into place
and new techniques and new technology will allow us to do even
better, so it not something that you ever reach, but we have a
stroke improvement strategy, we have a plan, we have a whole set
of people out there working on improving stroke services as we
sit here today. When we came last time, we said that, over the
next three years, we would expect to hit most of those issues
that we identified in that strategy, and we are continuing to
do that work.
Professor Sir Mike Richards:
As an onlooker, stroke is not my area of responsibility, but there
is absolutely no doubt that progress is being made in that area.
Having a stroke strategy, and what has happened since then, really
is making a difference. That does not mean that we do not have
a lot more to do, and both Sir David and I would agree on that.
Q114 Austin Mitchell:
You have bought this expensive equipment and part 3 of the Report
reveals some worrying discrepancies about its use. Figure 12 shows
wide variations in the "Average number of fractions per machine".
Figure 13, "Opening hours", shows surprising variations.
They are like pubs. Figure 14, "The percentage of people
in each trust waiting under two weeks", shows fairly steep
variations. Figure 15, "The percentage of people in each
trust waiting under two weeks from referral to a CT scan"
also shows variations. The Comptroller and Auditor General's Report
states: "From our visits we found variations in the average
number of scans per CT machine per trust varied from around 7,800
to almost 23,000 in 2009-10." What are you doing centrally
to ensure more consistent usage across the NHS? How will that
be ensured once the independent foundation trusts each start playing
their own game?
Sir David Nicholson: We publish
information nationally and individual organisations benchmark
themselves against it. We provide support and advice.
Q115 Austin Mitchell:
Is that a name and shame strategy?
Sir David Nicholson: Yes. And
there is a series of tools that we use to help them manage their
demand and the way they use their machines. We provide all that.
Q116 Chair: I know that
we are going over old ground, but you provide information. The
idea is competition, but the good burghers of Barking and Dagenham
do not have that choice. If they do not have a car, they have
to go to the local hospital and the waiting list may be long.
The PCT now suggests reducing the extended hours of opening to
meet the financial system. There is no choice. The information
does not drive better services for the individual—unless,
like you and me, they are middle class and can wander across the
capital or the country.
Professor Sir Mike Richards:
You are talking about information being given to patients, which
I fully support, but information being given to commissioners—
Q117 Chair: That does
not help. If our commissioners in Barking and Dagenham buy services
from Sir Robert's hospital in the centre of London, my guys will
not go because they cannot afford to travel there.
Professor Sir Mike Richards:
That is not the point that I was trying to make. I was saying
that your commissioners can then really work with the local provider,
if they were not at the most efficient end of the scale, because
they would have that benchmarking information.
Chair: "Work with" is just
not tough enough. Jo is not here, but you have the two with the
worst hospitals—we go over this time and again—and
you have been working with them since I became MP there in 1994.
I have not seen any substantial improvement. What I get as a resident
and a citizen in London is unfair, given what my constituents
get.
Q118 Austin Mitchell:
That would apply in Grimsby as well. What powers do you have,
apart from collecting information—presumably naming and
shaming—and pushing up the performance averages to some
kind of decent consistent average? How will those powers operate
when they are all foundation trusts?
Sir David Nicholson: The major
way in which we do that is through the contractual arrangements
and the payment system that we have in the NHS. We have a national
contract with a series of incentives and penalties, and we have
a payment system.
Q119 Austin Mitchell:
If that works, why are the variations still there?
Sir David Nicholson: First, there
will always be variation. Indeed, variation can be a good thing;
that is how you get innovation and the leading edge. You don't
want everyone to be exactly the same; you want people such as
Robert's organisation to get ahead.
Austin Mitchell: It is also how you get
dead people.
Sir David Nicholson: What you
tend to find in these graphs—they are very interesting—if
you look at the top and the bottom, which is what we tend to do,
we would say, "Who are the two or three at the bottom, and
what are the factors that affect them?" You tend to find
that they are normally special cases, that particular things have
happened in those environments. You should look at the totality
of this. I know that you have taken some 5% off each end; nevertheless,
the variation is not quite as big as it appears when you quote
the worst and the best, because there are often separate and different
issues there.
Professor Sir Mike Richards:
May I say what my team and I do with this data? We do follow it,
and we know exactly which trust is which. For the radiotherapy
centres in figure 12, we know exactly which ones are where, and
there are usually reasons for why they are at the lower end of
the scale. For example, one of those at the lower end of the scale
is a radiotherapy centre that had only just got going during this
period, so it was perhaps not surprising. It was still building
up its work load, but that radiotherapy centre means that patients
have to travel a whole lot less across Somerset in that particular
case. That is one reason. We identified work force issues in
another case. We are now working with that trust and it is working
on resolving them.
Equally, at the top end there are unsustainable
services where they are putting too many patients through those
machines, and that is not desirable either. The benchmarking
enables us to say, "Those are the places that probably also
need an extra machine to be able to give a sustainable service
and they should then be working with NHS Supply Chain."
Q120 Ian Swales: You
have twice mentioned work force issues. We sat in this Committee
a few months ago and heard about £50 million fighter planes
that were on the ground because they didn't have pilots. That
seems a crazy way of running the economy of the RAF. Is the real
situation with the scanners that aren't used as much that they
are actually short of people and that we are trying to save money
on people while staring at expensive machines that aren't used?
Professor Sir Mike Richards:
You have to take each hospital and trust on its own. In one case,
it is work force for radiotherapy. In many others, it is not.
We have done a great deal to expand the work force on the diagnostic
side and on the treatment side—the radiotherapy side. Does
that mean we have gone far enough? Have we all the numbers we
need? No, we haven't. But we have seen a steady increase. One
of the things that we did several years ago was to double the
number of therapy radiographers in training because we knew that
we needed that. In fact, it was not until they came out of training
that we could start seeing some of the benefits.
Q121 Chair: The attrition
rate is shocking.
Professor Sir Mike Richards:
This is partly why we have had to create more training places.
I am not in any way complacent about that either.
Q122 Ian Swales: My question
is around the point that Sir Robert raised earlier. You may not
have the power to demand various things of trusts, but you do
have a lot of power as a commissioner. To what extent can you
set performance standards and so on as part of the commissioning
process? You may not be able to demand that they do certain things,
but you can demand outcomes. You can demand what the figures
should be, surely. In terms of accessibility to scanners, for
example, can't you do more in mandating that as part of your commissioning
process?
Sir David Nicholson: I am sure
that we can do better. We can identify performance standards
and we can put financial penalties against people who don't deliver
them. Mike and his team are working on that. We have improved
the contract every year so far. We've got better at doing that,
and will undoubtedly get better in the future. Commissioning
can do that.
Q123 Ian Swales: Sir
Robert's point was a good one as well. At that point, he was
talking about data. You quite often sit in front of this Committee
saying you are not that happy about the data you've got. Well,
can't you just decide what you need and then get it as part of
the commissioning process?
Sir David Nicholson: We can. There
is a process for us to go through. We are going through a process
in relation to the data set for diagnostics at the moment because
we don't believe we have the data available. There is, of course,
a whole set of other people who say to us that these are unreasonable
demands on front-line organisations to create more and more data.
There is a process that we have to go through, which we are going
through at the moment. We have to define the data very carefully.
It is a very complex thing. You are absolutely right. Over
the next few years, you will see an explosion of data in this
regard.
Mark Davies: Since 2009, the national
radiotherapy data set has been a mandatory requirement, so better
data is now emerging on radiotherapy. There is still some distance
to go in scanning data, in terms of utilisation.
Professor Sir Mike Richards:
Can I tell you what we are doing? I agree with that comment,
which is why we are establishing a diagnostic imaging data set.
It is about 19 separate items of information. We are trying
to simplify for the NHS how we collect the data.
An awful lot of this data is collected in so-called
radiology information systems in individual hospitals. Our approach
is to say, "Can we extract from those existing IT systems
and pool it nationally so that we can give a national picture
and feed it back to people and can look at the variations?"
That is the work that we are doing at the moment. I am leading
on that work, and we are hopeful that we will get all the permission
through so that we can start collecting the information from next
April.
Sir David Nicholson: Then we can
mandate that to individual organisations.
Amyas Morse: So we are not actually
publishing that data right now. That is something you are developing.
Professor Sir Mike Richards:
We haven't got it yet, but we will.
Amyas Morse: On the whole subject
of interpretation of information and the discussion that we have
just had about outlying factors, it is interesting to know what
you think meaningful ranges are. We produced this information,
but you are constantly looking at the information. Of course,
we could produce examples of things with good reason why this
and that was starting up or whatever, but what is interesting
is whether you think the range is acceptable at the moment or
not. What is your opinion on it?
Professor Sir Mike Richards:
I think we need to look separately at the extremes, for which
there are sometimes good reason and sometimes not, and the variation
of what you might call the "middle section". I have
looked at lots and lots of these figures over the years with respect
to cancer, and I tend to look at the 90th centile and the 10th
centile. A working rule is that, if the ratio between those is
more than two, I really need to look into it.
For example, without opening up a whole other
can of worms, in the past we have looked at cancer drugs and we
have seen those variations. What we have seen over time is that,
every time we measure it, the variation gets less. But, to begin
with, that variation was considerably more than two and really
meant an unacceptable variation to me. I do have that metric
in my own mind, which I personally think is quite a useful one.
It seems to apply whatever you look at.
Q124 Chair: Thank you
very much indeed. That was a useful exchange. We look forward
to coming back to this and other issues. No doubt you are coming
to us next week again on something else.
Sir David Nicholson: I think that
the foundation trusts is my next visit.
Chair: I'm looking forward to that.
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