Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (Questions 1-19)




  1. Can I welcome Professor Mike Richards and Professor Sir John Pattison to our session today. We will be joined by Professor Sir George Radda. And can I say that this is indeed, in a sense, the follow-up session to a large inquiry we did in the last Parliament, by this Committee, and we thought it rather appropriate to have a follow-up a year or so later, to see how things were getting on and to see how we can oil the wheels. So perhaps I could ask Mike Richards just to say who you are and what you do for a living, and John Pattison too, please?
  (Professor Richards) Thank you, Mr Chairman. I am Professor Mike Richards. I am the National Cancer Director, charged with first developing and now implementing the NHS Cancer Plan.

  (Professor Sir John Pattison) John Pattison, Director of Research, Analysis and Information, at the Department of Health, here really from the R&D point of view, in terms of your report.

  2. You are very welcome. You have been here before and you have helped this Committee progress things, and we have been very grateful for that. Let me start by lobbing a nice easy one at you, really, as you would expect. You have done your first report and you have said there are very encouraging signs in the cancer services arena, and yet we read, in other areas, other reports coming out, not least in the media, which we do not react to immediately, that there is another side of the story, that the system is failing patients, and so on, particularly those present in emergency. So there are two pictures coming over, in a way. How do you square those two situations, that the public hear about, the good news and the bad news?
  (Professor Richards) I think it is very important to look at the sequence of timing. The NHS Cancer Plan was published at the end of September 2000, a couple of months after the NHS Plan itself, and, as you say, just over a week ago, we were able to make our first annual report, in effect, the "Making Progress" report, which I believe has been given to Committee members. The various reports that have come out recently are, in effect, useful baseline measures against which to measure progress, because the National Confidential Inquiry into Perioperative Deaths, which was published last week, covers the period 1999-2000, the financial year, and so, in effect, is the period just before the NHS Cancer Plan was published, and the report yesterday from the Commission for Health Improvement and the Audit Commission covered the period autumn of last year, that is when they did their field work, so, again, a useful baseline measure against which to measure progress. I would be the first to say that we have still got a long way to go; we are making progress, and I can tell you about that progress if you want, but I would be the first to say we have still got a long way to go.

  3. Please do say a few words about what you see as the progressive things we have done, and you, John Pattison, may want to join in and say also about the improvements you would like to see, that everybody learns as they go along, and please pitch that in, too?
  (Professor Richards) The Cancer Plan deliberately set out to be a comprehensive strategy, it is the first time we have ever had a comprehensive strategy on cancer in this country, including elements about prevention and screening, as well as the service elements for those who have got cancer, and, indeed, with the necessary infrastructure, in terms of building the workforce, developing the facilities that we need, and putting in place the systems that we need actually to drive this in. And, of course, most importantly, making sure we have also got the funding that we need to make these changes. So actions across the whole spectrum. And I will just highlight a few of those, if I may, but I think what I can demonstrate is that there is progress across the spectrum. For example, on prevention, we now have smoking cessation services in every health authority across the country, we set ourselves an initial target of 40,000 people not only attending the services but setting a quit date and having quit four weeks later, and, in fact, in the first year, we exceeded that by a 50 per cent margin and it was nearly 62,000 people that quit; and in the first quarter of this financial year, the number is 28,700 who had quit at the four-week point, which, again, is well ahead of target, almost double what our target was. On the other aspect of prevention, which is improving diet, we have the `school fruit scheme,' which is now at the pilot stage and is involving 500 schools and is going extremely well, with high satisfaction rates both from teachers and from pupils. And we have also got the wider, five-a-day pilots, looking at how we can best raise awareness of the importance of eating fruit and vegetables, in order to reduce the incidence of cancer; and I have just been at a meeting, earlier this afternoon, hearing about the progress of those pilots, and it is extremely encouraging. On screening, one of the key things that we set ourselves to do there was to extend the breast-screening programme to involve people aged 65 to 70, and we knew that that would take three to four years to roll out that programme, because we need more radiographers and radiologists to run the programme, but in the first year we set ourselves the target that 10 per cent of units would have managed to roll out the screening to the older age group, and we are actually hitting 12 per cent. On cervix and colorectal cancer, we have large-scale pilots going, in cervix cancer, of new technologies, the liquid-based cytology, for example, and, on colorectal screening, the faecal occult blood testing. With prostate cancer, we have taken a different approach; we do not have the evidence from randomised control trials that PSA testing saves lives, but we have decided that this is, and should be, a matter of empowering the public to make their own decisions, subject to them having appropriate information. So we launched the Prostate Cancer Programme last year, and also, with that, we have developed the information material so that people can actually make up their minds and see whether having a PSA test is right for them. On Primary Care, which is an area where I think there has been a great need for development, in terms of cancer, we are now working with Primary Care Trusts, and we have appointed lead clinicians, this is a project which we are doing in association with Macmillan Cancer Relief, and we now have 300 lead clinicians for Primary Care appointed. We also have district nurse training programmes in Primary Care, that are now up and running. One of the key areas that people have been worried about is waiting times, and, on waiting times, a first target was to reduce the waiting time from referral by a GP to the first hospital visit, and for those who are deemed urgent by their GP, and that is being achieved in almost 92 per cent of cases; that is across all different tumour types. We are now working hard on reducing the waits from first getting to the hospital to getting through to treatment, and the Cancer Services Collaborative Project is a very important part of the implementation there, and they are working at the local level, looking at what the obstacles are, what the blockages are, and how we can best reduce them. And what we are finding, in practice, is that, in a lot of cases, where the waits were months we have been able to reduce them to weeks, and where they were weeks they have been reduced to days. Now we have got a long way to go on that, but I think we are definitely making progress. Clearly, we need to expand the workforce and to have the new facilities that are coming on stream at the moment to complete that task, but we are making progress. And, the NICE appraisals, we now have a whole range of appraisals that have been done, and we estimate that around 19,000 patients a year are now benefiting from that, in terms of being able to get access to drugs, that previously were subject to the postcode lottery of care. We have published National Standards for cancer this year, and we have had a very successful process of peer review visits across the whole country, so that every cancer service in England has been visited by a team of clinicians and managers, and the standards of care have been appraised using the National Standards; and every trust that has been visited will have received a report from the reviewers, and each trust is then expected to produce an Action Plan to show how it is going to remedy any deficiencies. And I am currently getting reports in from the eight regions, an overview of those peer review visits, but the ones I have seen so far have been extremely encouraging. Work on Cancer Registries is another important area, and there are two main things to say there. First of all, that we now have the Action Programme for Cancer Registries, which committed £2 million extra yearly for the next three years to Cancer Registries, really to help modernise the Registries and to help them work closely with Cancer Networks, and we have had those plans back in from the Registries, we have assessed them, and very soon we will be able to make announcements on how that money is actually going to be spent. Obviously, the other issue that I know has been of concern to this Committee in the past relates to the confidentiality issue.

  4. We will come to that later.
  (Professor Richards) And we have had the Health and Social Care Act, so we will come back to that one later. On improving patients' experience of care, I think that is a very important component of the Cancer Plan. We are producing, through NICE, guidance on support and palliative care; that work is in progress. Alongside that, the Cancer Service Collaboratives are working with patient groups, at the local level, actually seeing what the problems are, is it about getting access to written information, is it that the shower does not work in the inpatient unit; those things can then be fixed, and that is happening in practice. The Cancer Information Advisory Group is looking at all the written materials that are available, and looking for gaps, so that we can fill those, but also looking at quality criteria, so that, hopefully, we will be able to kite-mark information so that patients can be assured that it is both understandable but also contains the right information. On palliative care, we have awarded eight Beacons this year, particularly for palliative care services that are demonstrating that they are working in partnership with others, and we are building Palliative Care Networks alongside the Cancer Networks, and the New Opportunities Fund is also running a "Living with Cancer" programme, which we are co-operating with closely, and there is obviously in the Cancer Plan extra funding specifically for palliative care. Probably the biggest single area of difficulty, which we acknowledged in the Cancer Plan, is with the workforce; we need more doctors, more nurses, more radiographers, every single aspect of the cancer workforce. I am pleased to say that we are making improvements there. We estimate that by the end of this financial year we will have over 400 more consultants than we had in 1999, we are certainly getting more nurse specialists in, for example, in lung cancer and gynaecological cancer, there has been a marked expansion in those areas in the last year or so, and we have got dedicated training programmes related to endoscopy, histopathology, radiographers, all of which are specific problem areas. I think we are doing well, in terms of the replacement of obsolete equipment, and now some 30 per cent of all CT scanners in this country are new since January 2000, and the equivalent figures for MRI scanners is 23 per cent, and for the linear accelerators used for radiotherapy it is 19 per cent, and there is more to come over the next couple of years. Maybe I will skip the research one, because Sir John may want to take that point.

  5. I will just say, I am glad you got a chance to get all that off your chest. It is very impressive that many things are happening, and yet is it one more big heave just to keep it going, or have you identified areas where we could really improve? For example, I went to a meeting yesterday of the King's Fund, the talk was entitled "Where has all the money gone?", and they had their graph, as you probably know, deficits being paid off, and so on; but they also talked about management, a style of management that can make things happen. Do you feel the frustration sometimes, that it could have gone faster, over the last year, or so?
  (Professor Richards) I think, over the last year, it probably has gone about as fast as it could. I think one of the key elements there, in terms of the management, is setting up the Cancer Networks across the country, many of those were not in existence a year ago, now we have 34 Networks across the country. They are young organisations, but they all have a lead nurse, lead clinician, lead manager, and we are getting those structures in place, which actually is very important, because, for cancer care, patients start in the community, they go to a district general hospital, many of them need the services of a specialist centre, many of them need palliative care services, you have got to get all those services working together; and that is why we need the Networks, and they are becoming stronger and stronger all the time.

  6. But you would expect me to ask, do you have a timetable for all this, when do you expect El Dorado, when can you retire, having done it?
  (Professor Richards) I can tell you that I have been asked if I will do the job for a total of five years, and I have done it for a total of two now.

  7. So three more years and that is it; no more cancer czars?
  (Professor Richards) No, I did not say that, and I believe emphatically though it has to be progressive improvements, but we are making a step change at the moment, in terms of actually accelerating the pace of change.

  8. And if somebody, you know, another Paul Nurse, came up with some marvellous new technology and development and understanding of the process of cancer cell formation, would the system be able to be flexible enough to handle that and move it quickly into the clinics?
  (Professor Richards) I believe it would. I think the value of Networks is that because they integrate primary, secondary and tertiary care, we will be able to transfer technology from the centres to units, and to the community, when that is appropriate, but that will also leave the centres in a good position to take on new technologies and new treatments, as and when these are developed. And I think we are looking at a period of massive change in terms of our knowledge about cancer, and therefore about the treatments that we will be offering over the next few years.

  9. Welcome, Professor Radda; it is nice to see you. And if you and Sir John want to chip in and add, please just indicate. Is there anything, at this point, you would like to add, before we move the questioning round the table?
  (Professor Sir George Radda) I think there is an automatic lead-in, from what Mike has just said, into R&D, and just perhaps to add I think some notable progress that we have made. First of all, in establishing the National Cancer Research Institute, and, secondly, in establishing the National Cancer Research Network and the National Translational Research Network. It is still, obviously, early days.

  10. We will be getting into those questions later on, so you will have a chance then.
  (Professor Sir George Radda) Thank you; and the prostate cancer has already been mentioned, and privacy and confidentiality, which is a major issue, you say you want to come back to as well.

  Chairman: Yes.

Dr Murrison

  11. Could you just add on that, Sir John? It has been suggested that perhaps our priorities and attention to other areas might be being disadvantaged by our focus on cancer, I am thinking particularly of neurology, for example. Have you any observations on that?
  (Professor Sir John Pattison) I think that there is a right and proper emphasis on cancer. It is impossible to do everything all at once, and I think that it is quite clear that the priorities are cancer, cardiac disease, mental health and older people; and that is not to say that it is diminishing in any way our commitment to neurology, rheumatology, orthopaedics, etc., but it is giving a boost to cancer. And, of course, one of the reasons that the concept of the National Cancer Research Network received support was that we would put that in place, evaluate it and see if it is a model for a network approach to other things. And there are two others that have already been mentioned, and there is quite strong lobbying from the research community about; one is neurology and the other is cardiac surgery, as a matter of fact, devices and procedures in that area. Personally, I believe it will be a good model and it will bear fruit for neurology and others in due course.

  12. Professor Richards, back to money, I am afraid. It has been put to us that perhaps the money allocated under the Cancer Plan has not yet percolated to the coal face, and I was wondering if perhaps you could make some comments on that?
  (Professor Richards) Well that comment has also been made to me, over the course of the year, and what I have said to people is that where they are concerned about that would they kindly send me evidence about it because then I can look into it. I think there are some cases where that has been the case, and that is why I am very pleased to say that from next year some of the cancer funding is actually earmarked, earmarked being a very much stronger word than hypothecated, as was used this year.

  13. It is also being put to us that perhaps some of the release of money was done in perhaps a precipitous or premature fashion, and that that has led to an ad hoc use of those funds, and therefore that they have been less effective than they might have been. I suspect you would refute that?
  (Professor Richards) Interestingly, I am not aware of that as being a concern, and in my travels around the country I would have expected to pick that up if it were a real concern. What I can say is that the Networks this year, now that they are in existence, have been developing Service Delivery Plans; these are plans which, roughly speaking, are saying, "where are we now, where do we need to get to, to achieve the national targets, therefore where are the gaps," and, from that, they can identify their priorities for investment. And, I think, done on a Network, therefore, that will actually make it a great deal easier to make sure that the real priorities are being met.

Mr Hoban

  14. Can I ask you what mechanism you use to track the money that has been hypothecated to deal with cancer, because it sounds as if we are not quite sure where it has ended up; what reporting-back mechanism is there?
  (Professor Richards) Within the year, we do not have mechanisms for knowing that, but at the end of the year there should be a reconciliation of that, that is my understanding anyway, of the system. But what the allocation document that came out last week made clear was that there was earmarked funding for cancer, £76 million, in order to bring the total being spent up to an additional £407 million, over and above the year 2000-2001, that may not be the exact wording of it but that was the meaning of it. So that is what we are working to.

Dr Murrison

  15. I think, if I drill down slightly on that, there are concerns perhaps that there might be a temptation to use some of the funds allocated to reduce debt on the part of trusts, and you are saying that you do not have a strong handle on how the funds are being spent?
  (Professor Richards) Within this year, no; as I say, at the end of the year, there will be a reconciliation, and what also I can say is that the money for next year is earmarked, and therefore we will make sure that that is spent up front, if you like, on cancer. The other point to make is, obviously, there is a great deal more money going into the NHS in this coming year, and that is extremely welcome, and that the planning guidance that came out last week makes it very clear what the priorities are, and Sir John has already mentioned these. But the priorities are for emergencies, for waiting times and for the clinical priorities of cancer, coronary heart disease, mental health and older people, and so I think that is a very clear message to the Health Service of what the priorities have got to be for this coming year.

  16. So you have no real idea at this moment in time how those funds are being spent, on the ground?
  (Professor Richards) No, I cannot give you an answer at this time to exactly how those monies are being used. I can tell you how the centrally-allocated funds are being used much better, because that is obviously under our central control. Some of the additional funding, for example, for extending the breast-screening programme, for the Cancer Service Collaborative, for some of the new equipment, that is centrally allocated, and the reason that we are doing that, for example, with the equipment, is that then we can make sure that the linear accelerators go where they are most needed.

  17. Does that leave you with a sense of unease at all? It would worry me, I think, if I were in your situation.
  (Professor Richards) I have already said that I have heard a lot of concerns from around the country that the money is not getting through, and that is why I am pleased that the arrangement for next year is a lot stronger.

  18. Thank you. How do the spending commitments for the Cancer Plan help to move us towards meeting the European average on health spending?
  (Professor Richards) One of the key things that we did in the run-up to the Cancer Plan was to look very carefully at the Eurocare data, which is the data that shows that the survival rates in this country have been worse than the European comparator countries. That, you have got to remember, was survival rates for patients treated in the late 1980s, but we looked at that data, and there were two important conclusions from that. The first was that we had to accept that the differences, to a large extent, were real, we might argue about individual countries, but, certainly, for example, if you compare us with Scandinavia, there was no doubt in my mind that in the late 1980s we had poorer survival rates. But there was a second important conclusion, which was that people in this country tend to have more advanced disease by the time they get to treatment, and that is one of the reasons why we are giving such high priority to tackling waiting times. Now the Eurocare report cannot tell us exactly whether it is the patient delay that is the bigger problem in this country, whether it is delay at the primary care stage, or at the secondary care stage, but we know that there have been long waits at the secondary care stage, and we are tackling that as a matter of urgency.

  Chairman: Do you want now to move on to Cancer Registries?

Dr Murrison

  19. Yes. I think Professor Sir John Pattison mentioned this in passing, this is something that we are quite concerned about. Our understanding is that the General Medical Council has placed a one-year moratorium on the registration of cases of cancer because of matters to do with confidentiality. We have a body called the Patient Information Advisory Group, that was set up in May 2001, and yet we understand that it met for the first time on 10 December. I was wondering if you could comment on that?
  (Professor Richards) I think the first and most important point is that we now do have Section 60 of the Health and Social Care Act which actually enables us to put regulations in front of Parliament to secure the future of cancer registration, which was a commitment that was made in the NHS Cancer Plan. So that was the first and most important step. The next step is obviously drafting those regulations, and it is the Patient Information Advisory Group that then comments on those regulations and advises the Secretary of State. My understanding is that at their first meeting on Monday they did look at the draft regulations for cancer registration and that they were broadly supportive.

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