Examination of Witnesses (Questions 40-59)|
WEDNESDAY 12 DECEMBER 2001
40. So you expect them to continue their work
and be well-funded and you would not see a diminishment in the
range of areas that are being covered by the existing range of
(Professor Sir John Pattison) I think that is right,
because they are often smaller because they are very focused and
distinctive, sometimes geographically, sometimes on a particular
aspect of looking after a particular cancer, and I think there
will always be the sort of opportunity to raise research funds
in that manner.
41. So you believe it is a beneficial move that
the two charities have made, by merging, with few downsides for
the cancer research?
(Professor Sir John Pattison) That is my view, yes.
(Professor Richards) It is a view I would share, too.
42. The charities have consistently been contributing
twice as much as Government to cancer research and development,
and there is a ministerial commitment to level this up by 2003;
but at the end of 2001 we should be able to see at least the first
year's progress on that, can you tell us about it?
(Professor Sir John Pattison) This is always a contentious
issue, is it not, because we would make the case, I think with
justification, that you need to look at the indirect costs of
supporting this research as well as the direct costs; and, very
often, and I was present earlier on at the MRC Council today,
where one is looking at trials in this area where the indirect
costs are at least as large as the direct costs of doing a piece
of work in the National Health Service, sometimes actually larger.
If you take that into consideration, and we cannot yet give you
exact figures but we would be happy to do so, it looks to us,
on a first pass, as if the charitable sector input and the Government
sector input are about the same, it looks to us to be about 50-50.
43. Is that going to be published somewhere?
(Professor Sir John Pattison) I do not think we are
intending to do it, but we can.
(Professor Richards) I think one of the important
things to say here is about the National Cancer Research Institute,
and what it is doing as one of its first priorities.
44. We are going to come on to that in a minute.
(Professor Richards) Which is identifying the cancer
research that is going on in the country, and that will make this
task a great deal easier.
Dr Turner: I think the public would want to
be able to see, up front, that it is actually matching the charities'
45. Could I ask for those figures to be to be
made available first to us?
(Professor Sir John Pattison) They will have to come
with health warnings, because they are not entirely validated.
46. Did you mean for last year or for this year?
(Professor Sir John Pattison) For this year.
Chairman: This year; thank you, Sir John.
47. I think you mentioned audit, Professor Richards,
that 19,000 patients have benefited from the ending of the postcode
lottery. I understand that there are 13 anti-cancer drugs going
through NICE at the moment; can you give some indication as to
when they will come out from the other end, as it were, and what
sort of areas they are intending to treat?
(Professor Richards) Well, 11 drugs, or drug indications,
have already been approved, so if I just run down what those are.
For ovarian cancer, we have both Taxol and Topotecan; for breast
cancer, we have Taxol and Taxotere; for lung cancer, we have Taxol,
Taxotere, Gemcitabine and Vinorelbine. For brain tumours, we have
Temozolamide; for pancreatic cancer, we have Gemcitabine; and
for chronic lymphocytic leukaemia, we have Fludarabine. Those
are already in the public domain. There are a number of other
drugs where decisions from NICE are pending. Those include Trastusumab
and Vinorelbine, for breast cancer; Rituximab, for follicular
lymphoma; and three drugs for colorectal cancer, those are Irinotecan,
Oxaliplatin and Raltitrexed. So that is the current state of where
we are with the NICE appraisals.
48. And how long is it taking NICE actually
to appraise these drugs?
(Professor Richards) It varies, depending on the drug,
and the complexity and the number of times there are, in some
cases, appeals against the judgment, either at the provisional
appraisal determination or the full appraisal determination stage;
and so some of those ones that are still pending, it is because
they are subject to appeal at the moment.
49. Are you happy with the progress they are
making on appraising drugs?
(Professor Richards) I think what I would say there
is that all parties have been on a learning curve, and I say that,
including the Department of Health, NICE themselves, the clinical
research community, patient groups and the pharmaceutical industry.
Some changes have already been made to the NICE process, this
does not apply just to cancer, it applies more widely. For example,
NICE bring interested parties together now at an early stage of
an appraisal process, to solicit views at that point. I think,
for cancer drugs, it is worth thinking about them in two different
groups. We have one group that I would call the legacy drugs,
those that have actually been licensed for several years but were
subject to the postcode lottery of prescribing drugs, such as
Taxol, which was actually licensed back in 1993, and, there, we
tend to have quite a lot of data, because, obviously, there is
more data now than there was when they first got licensed, and
often it is randomised control trials have been done subsequent
to that, earlier in the course of the disease. And now we have
a new set of issues that arise, as we get the new drugs being
licensed, because with cancer drugs, and this is different from
most other drugs that come on the market, cancer drugs frequently
get their European licence, and therefore their licence in this
country, on the basis of non-randomised data, on the basis of
phase 2 trials. That presents problems for NICE, who are asked
to, or they are tasked to, assess the effectiveness and cost-effectiveness
of new drugs, and obviously there is not a control arm in those
trials. That does not mean we cannot evaluate those drugs, because,
in many cases, we can look at historical controls and we can,
obviously, get information from non-randomised trials on the quality
of life and on costs. I think we need to learn from the experience
we have had to date, and I have been talking with colleagues at
NICE about that, and we are proposing to hold a workshop early
in the new year, actually bringing together all the parties that
I mentioned at the beginning, to look at how it has worked, what
lessons we can learn from it, and how we can improve it in the
50. Can I press you on NICE and the length
of time it is taking for NICE to come up with its recommendations,
because it is actually a subject that does exercise the minds
of patients. You rattled off a list of drugs. I wonder if you
could give us some indication of the timescales that you are working
to, and particularly how long it is going to take for the drugs
that you have mentioned from the start of the investigation to
a report finally being made?
(Professor Richards) As I said, it does vary. There
is a basic minimum at the start of the process, where the pharmaceutical
industry, I think, are given approximately four months, after
we have decided that that drug should be appraised, to prepare
their case, and I think that is only right and proper, that they
must be given the time to prepare the case adequately, and equally
that that also gives patient groups and others and professional
groups the opportunity to submit their evidence, too. Then there
is necessarily a detailed evidence review process, and that necessarily
takes time; then, based on that, the appraisal committee looks
at the evidence review and the initial submission from the pharmaceutical
industry and they make their provisional determination, then there
has to be a process of feeding that back to the stakeholders,
for that particular treatment, getting their comments in, and,
in some cases, modifying the appraisal in the light of that, before
the final guidance comes out. So it does, inevitably, take some
time. What we are trying to do, particularly now that we are moving
onto new drugs that are not yet licensed, we are trying to run
the NICE process in parallel with the licensing process; that
is easier said than done, because it is very difficult to judge
the pace of the licensing process, even the drug companies sometimes
are surprised when things go faster than they had expected, and
we have had one example of that recently, with a drug called Glivec.
But we are attempting to run those two processes in parallel.
51. In the report, you say that `we are ending
the postcode prescribing lottery;' but how do you intend to eliminate
(Professor Richards) I think we are saying we are
ending it because we cannot yet say that we have got through the
whole backlog of drugs, but we have got through, in patient numbers
terms, a very significant number. What we have also done is made
it clear in the Cancer Plan that, where NICE has determined that
drugs should be given, the funding is available for those patients
that are eligible for that treatment to receive it.
52. One of the things I am aware of locally
is that PCGs, in my case it would seem to be a PCT, decides its
drug budget at the start of the year, based on drugs that NICE
have approved at that point, and it does not review that list
until the next budget-setting process. What can you do to make
sure they review their list of approved drugs on a more regular
(Professor Richards) I think this is where it is so
important for PCTs to work as full partners within Cancer Networks,
because within Cancer Networks the information will be available,
the expertise is there, they know what drugs have been sent to
NICE for appraisal, and obviously we all have to make guesstimates
of what NICE is likely to say about a particular drug. But we
have put money aside, there is money in the extra funding for
cancer, that will allow for these NICE appraisals, again, based
on our best estimate of what NICE is likely to say about them.
53. So we need perhaps to do more to push PCTs
to link up to Cancer Networks to do that?
(Professor Richards) I think it is very important
that PCTs are full partners in Cancer Networks. I think, when
Networks started, after the Calman-Hine report, they focused mainly
on secondary and tertiary care, that is changing rapidly now.
I mentioned the appointment of the PCT lead clinicians, but PCT
chief executives getting involved as well is very important, so
that these important decisions about commissioning of services
are made appropriately as well.
54. Professor Radda, please be patient, we will
get to you in a minute.
(Professor Sir George Radda) I am listening with interest.
55. Professor Richards, to improve cancer services,
I think it is very important that we have the extra staff in place,
and I think the Government certainly made a commitment to that.
But how does that actually work on the ground; are we getting
extra staff, can you tell me how many new staff there are training
and what they are actually training in, are they the right consultants,
do we have enough people in chemotherapy, or do we have mismatches
sometimes, where we might have a lot in radiotherapy but it might
not balance up? And also, throughout the country, do we have people
in the right places?
(Professor Richards) The answer is, there is no single
element of the cancer workforce where I can put my hand on my
heart and say I think we have got enough of them; and that is
whether it is doctors, and that involves radiologists, pathologists,
clinical oncologists, medical oncologists, palliative care specialists,
haematologists, general surgeons, urologists, you know, I could
go on and on and on, the whole lot of those, we have not got enough
of any of those. We have not got enough specialist nurses in cancer,
nor have we got enough radiographers, who are absolutely critical,
in terms of both running diagnostic x-ray departments and also,
obviously, the therapy radiographers, who operate the new accelerators.
So across the board we need more. But in each area there are different
problems; and what we have been doing, over the last two years,
is to identify with the professional groups what those problems
are, whether they are problems, for example, if you take therapy
radiographers, one of the real obstacle areas, working with them,
making sure that we raise awareness amongst school-leavers about
the profession, making sure that we get the university education
in place, making sure that we then make the working life attractive,
with opportunities for career advancement thereafter, so that
we will actually build the workforce. We are doing better, but
it is a slow process, because it takes time to train people.
56. Yes, I can appreciate; you have highlighted
all the problems that I think we are aware of. But what about
the solutions; can you be specific as to how many extra staff
are actually training at the moment, what steps forward we have
(Professor Richards) I cannot, off the top of the
head, give you numbers in training for each of those different
disciplines, but what I can say is the number of trainees has
increased, and we are set to get a larger number of consultants,
say, in each of those areas. The numbers that we will get in some
of the specialties is still going to be too small, for example,
in radiology and pathology, because of historic problems of the
numbers of specialist registrars being recruited, that will take
several years before we get extra consultants out at the other
end. What we are doing there is to make sure we address what those
problems are. For example, in pathology, we have actually set
up dedicated training schools at the senior house officer level
so that we have got a feeder grade to come into the specialist
registrar grade, and those are operating in Leeds, Leicester and
Southampton, and they are extremely popular with the SHOs that
are going through the process, and they will feed into the system.
So we are taking different approaches in each area, depending
on what the problems are.
57. Do you have the figures that you are short
of in different areas; is that published anywhere?
(Professor Richards) It is very difficult, at this
stage, to say what the target numbers should be, in the longer
term; and one of the reasons for that is that we are really looking
with great care at who should be doing what jobs, we are looking
at new ways of working and skill mix opportunities. For example,
if we took gastroenterologists and colorectal surgeons, if they
have to do all of the endoscopy, the colonoscopies and the flexible
signoidoscopies themselves, and the gastroscopies, we will need
a larger number than if that can be taken on by others, such as
nurse practitioners, and we are actually training nurse practitioners
in that field. And so the absolute number of consultants that
we will need in the longer term is somewhat diminished by that,
but, of course, we need more than we have got now, there is no
question about that.
58. So you do not have the real figures at the
(Professor Richards) We are working towards coming
to those target figures, working with the professional groups,
but I cannot give you a list of those figures now, no.
59. The National Cancer Plan talks about new
equipment promised for hospitals, and, just moving back to staffing
again, do you have any idea how many trained specialists you are
going to need to operate this equipment, because I think that
is important; you must have some idea of how many people you are
going to need to operate the equipment that you are planning on
(Professor Richards) Yes. When I was talking about
the equipment, at the beginning of this session, I mentioned that
we were getting rid of a lot of the obsolete equipment first;
now one of the reasons that we have decided to do that, rather
than going for additional equipment, was precisely because of
the problems that we have got with workforce. In other words,
where there was a CT scanner that was 11 years old, or 15 years
old, we decided to replace that with a state of the art CT scanner,
because that does not require any extra staff immediately, but
those machines are quicker, they can scan more patients in a day
and do a better job; so the early phases of our facilities programme
relate mainly to replacement equipment. The second phase, obviously,
is about expanding the capacity, with new, additional equipment,
but that is based on the fact that we are seeing a rise in radiographers
to operate those machines; and we have estimated the numbers that
are required per extra CT scanner, so that we will be able to