Tackling cancer in England: saving more lives (HC 712-i) Public Accounts Committee 16 Jun 2004

Evidence given by Sir Nigel Crisp KCB, Permanent Secretary/NHS Chief Executive, and Professor Mike Richards CBE, National Cancer Director, Department of Health.

Q45 Mr. Gerry Steinberg (City of Durham): Basically, exactly what Mr Trickett was saying baffled me as well. I read the report and came to exactly the same view, though, I have to say, I understood it less well than he did, because I read the paragraph about half a dozen times and it just did not seem to make sense to me. What did make sense to me was that it made very depressing reading for a Member of Parliament who comes from the North East of England. I looked through the report and, just quickly going through it, breast cancer, there is less incidence but there are just as high mortality rates in the North East. The survival after five years, you have a lot less chance of living than you have in the South East of England. If you have lung cancer, there is much more incidence and there are many more deaths. The same for bowel cancer. Colon cancer, you are more likely to die in the North East than you are in the South East. Prostate cancer, exactly the same. Going on to drugs. Eligible cancer patients prescribed Herceptin are amongst the lowest rates in the country. Death rates in the North East of England, in some cases, are twice those in the South of England. It appears to me, if Mr Trickett is correct in his assumption, which I think he is, that the more affluent areas of the South East of England certainly are looked after better than those in the North East of England, there is not much doubt about that at all. It seems to me that clearly we have a postcode service, in terms of cancer treatment. How would you respond to that?

Professor Richards: Firstly, if you take lung cancer, which is the commonest cause of death, the major factor there, by far the biggest factor, is the smoking prevalence. Smoking prevalence does vary across the country and is higher in the North East than in other parts of the country. In terms of other cancers, one of the key factors in whether people are going to survive is whether they present rapidly to their GP with their symptoms, and again there is some evidence that factor varies according to social class. Again, that is a major reason why we need to tackle that particular issue.

Q46 Mr. Gerry Steinberg (City of Durham): Do more people die in deprived areas?

Professor Richards: More people do die in deprived areas, yes, certainly.

Q47 Mr. Gerry Steinberg (City of Durham): Why?

Professor Richards: Because of smoking and also, almost certainly, because of later presentation to health services with their problems.

Q48 Mr. Gerry Steinberg (City of Durham): Would you agree that more people survive in affluent areas?

Professor Richards: That is also true.

Q49 Mr. Gerry Steinberg (City of Durham): Then the obvious question is, why are we not doing something about it?

Professor Richards: Certainly we are doing something about it.

Q50 Mr. Gerry Steinberg (City of Durham): My constituents have a worse chance of living than people in the South East of England?

Professor Richards: I think it is worth just pointing out that these figures on survival relate to the 1990s, and that is before the Cancer Plan came in, in the year 2000. We are acting on all the various different things that you have mentioned. We have taken action specifically on smoking and initially we targeted Health Action Zones. In fact, if you also look at the table which refers to Stop Smoking services, you will find that the North East comes out by far the best under Stop Smoking services, and I think that is an extremely welcome finding because in time that will reduce the rates of lung cancer, heart disease and other diseases. We are tackling it on smoking, we are tackling it across the country by making sure that we have got the services in place, the multi-disciplinary teams, which can make sure that care is provided to the highest quality wherever anybody is in the country.

Q51 Mr. Gerry Steinberg (City of Durham): You mentioned that, in fact, lung cancer was the worst sort of example in the North East and I would agree with you totally. When my wife became pregnant, 30-odd years ago, in the very early seventies, she stopped smoking because there was a campaign at that particular time and I stopped smoking along with her, so we have not smoked for 30-odd years. It has been known for 30 years that smoking is very dangerous, has it not?

Professor Richards: For 40 years, in fact, yes.

Q52 Mr. Gerry Steinberg (City of Durham): It has been widely accepted, is that right?

Professor Richards: Absolutely.

Q53 Mr. Gerry Steinberg (City of Durham): Is it vital that people are encouraged to stop smoking, regardless of their background?

Professor Richards: I do not think it is right that we should impose things on people, but it is right that we should advise them of the dangers.

Q54 Mr. Gerry Steinberg (City of Durham): You do not think it is right to impose things, so you do not think that, if something kills you, you should stop them doing it?

Professor Richards: I think there are elements of personal choice and I think it is very important to recognise - - -

Q55 Mr. Gerry Steinberg (City of Durham): You think it is all right to smoke yourself to death then, do you?

Professor Richards: No. I am ex-smoker myself and I have given up smoking because I recognise the dangers, and I would want everybody in the country to be aware of those dangers. It is the single largest cause of both cancer death and premature death in this country.

Q56 Mr. Gerry Steinberg (City of Durham): You would agree that it is sensible for Government to encourage people not to smoke, regardless of their social circumstances?

Professor Richards: I would, and over the last four years we have put in place the 'ban on tobacco' advertising, the large media campaigns on television, the notices on cigarette packets, which are words of warning, and the Stop Smoking services.

Q57 Mr. Gerry Steinberg (City of Durham): Was the Secretary of State given a copy of this report, do you know? Has he read it?

Professor Richards: I cannot say whether he has read it. Certainly he is aware of it.

Q58 Mr. Gerry Steinberg (City of Durham): Could you suggest that he reads it, because really his statement was quite ignorant, was it not? Do not answer that. I am saying that his statement was quite ignorant. People have known for 30-odd years, have they not, that smoking, and passive smoking, is bad?

Professor Richards: The dangers of active smoking became apparent before the dangers of passive smoking, but I think it is widely accepted now.

Q59 Mr. Gerry Steinberg (City of Durham): For how long would you reckon that passive smoking has been seen to be dangerous?

Professor Richards: Probably for at least a decade.

Q60 Mr. Gerry Steinberg (City of Durham): When I asked a Parliamentary Question in March 1999, "To ask the Secretary of State for Health if he will take steps to impose a legal duty on restaurants to provide non-smoking areas," what would you expect the answer to have been?

Professor Richards: Obviously, Government has to take a whole range of different factors into account. I have made clear my views on smoking in public places.

Q61 Mr. Gerry Steinberg (City of Durham): I will tell you what Ms Jowell said: "No." Then when I put the question, on 26 November, 2001, "To ask the Secretary of State for Health what proposals she has to ban smoking in the workplace and in public places," what was the response from Jacqui Smith? "We have no plans for legislation in these areas." Does that not show that Government just has not taken this problem seriously enough; and for Reid to say what he said is just encouraging people, who are likely to die anyway, to die a little bit quicker?

Professor Richards: I think the most important thing is that we have a major consultation, which is ongoing at the moment, about choosing health, where both smoking and obesity are major parts of that consultation. It is still in progress. I think it ends at the end of this month and there will be a White Paper in the autumn which will address issues to do with both smoking and obesity.

Q62 Mr. Gerry Steinberg (City of Durham): Do not get me onto obesity. It is rather funny, I always seem to get letters just before we have a meeting of the Committee of Public Accounts, which usually come in very handy. This is a letter from a Reverend, and I am not going to say his name because he has not given me permission to do so. This is to Sir Nigel. He says: "In 1998 my GP referred me to an ENT consultant. He required a CT scan to assist diagnosis. I had that scan just seven days later. Earlier this year a similar referral within the same NHS Trust resulted in a three-month wait to see the consultant. Again a CT scan is required, but this time there is a three-month waiting list." I will miss a lot out. "However, it would be encouraging during this long wait to be able to hope that things might improve and that one day the high standards of former years could be restored." That goes totally against what we are told, and really what we read in this report, that millions of pounds extra have been put in. Why do we get a situation like that?

Sir Nigel Crisp: If you get permission from the Reverend, I am very happy to look at the particular circumstances in the particular hospital. I will see what it says. I assume it is the same hospital. There will be some variation which goes the wrong way.

Q63 Mr. Gerry Steinberg (City of Durham): Why is it going the wrong way? It is in the North East of England, again. Is it the same in the South East of England, Sir Nigel? Do they have to wait three months in the South East of England?

Sir Nigel Crisp: Some of our waits are far too long. We have made big improvements in waits, on average, but clearly, in that particular instance, he got his CT scan in seven days, which is where we should be aiming, is it not, for the future?

Q64 Mr. Gerry Steinberg (City of Durham): Just give me an answer. You have not given me an answer as to why it is now three months when it was seven days?

Sir Nigel Crisp: I do not know the answer. Are they seeing more patients? Seriously, unless you let me have a look at the letter and find out what the answer is, I do not know.

Professor Richards: Obviously, I cannot answer on an individual circumstance, but what I can say is that the demand for CT scanning has gone up very considerably, as it has been found to be useful in a whole range of different conditions for which we were not using it a few years ago. Over the last few years, I think since April 2000, actually we have increased the number of CT scanners by 87 %; that is bringing them up to 373 in the country by the end of this year. We have deliberately targeted those extra machines to make the provision more equal across the country.

Q65 Mr. Gerry Steinberg (City of Durham): Less equal in the North East?

Professor Richards: No.

Q66 Mr. Gerry Steinberg (City of Durham): It must be. If you have a scan in seven days and now it is three months, it has got worse?

Professor Richards: I cannot say what the circumstances are of that, but I do not believe, on average, they have got worse. I believe the demand has gone up. The capacity has increased and we are working extremely hard, through programmes like the Radiology Collaborative, which is part of the Modernisation Agency, to reduce rates in all aspects of diagnostics, particularly radiology. In those places which have been doing that we have reduced the waits very substantially.

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Q160 Mr. Gerry Steinberg (City of Durham): Professor, what is the percentage of mistakes made by doctors in terms of referring people as non-priority who turn out to be priority?

Professor Richards: It is very difficult to put a figure on that. I think one has to remember how difficult it is for a GP who sees probably only seven or eight new patients with cancer in a year but will see hundreds of patients who have symptoms which just possibly could be cancer. That is why we issued guidelines on referral, and those guidelines are being revised by NICE at the moment, and it is why we are working with GPs to improve decision support so that they can make the best decisions with patients about who needs to be referred urgently to hospital.

Mr. Gerry Steinberg (City of Durham): I have always had the feeling, since I came onto this Committee, that doctors are very arrogant.

Chairman: Unlike Members of Parliament.

Q161 Mr. Gerry Steinberg (City of Durham): Unlike Members of Parliament. I think I read in a report somewhere that, the information, the guidelines which had been given out, 50% said it was useless anyway. That is the attitude I would expect from a lot of doctors, that they always know better. Should there be a sort of national guideline, standardisation?

Professor Richards: First and foremost, I would like to defend my clinical colleagues against that charge.

Q162 Mr. Gerry Steinberg (City of Durham): I can give you lots of examples after the meeting.

Professor Richards: I am not saying there are no examples of it at all. I think that the culture amongst doctors has changed enormously during my working time, where we have moved very substantially from a period of paternalism to one of a great deal more of working in partnership with patients to do what is best for patients and what they want. We may not have gone as far as we need to on that, but certainly over the 25 years that I have been a doctor I have seen very, very substantial changes in that regard. I am not saying we have not got further to go, and certainly we are keen to work with doctors to help them to know when to refer patients urgently.

Q163 Chairman: You have closed your book, Sir Nigel. It is always a dangerous thing to do, because I have got one last one for you, following that marvellous speech from your colleague. When you come back in five years' time, do you expect to be able to tell us that our survival rates are comparable to the best in Europe?

Sir Nigel Crisp: I expect us to have closed the gap. Also it depends on where their survival rates are going. What is clear at the moment is that our survival rates are improving faster and we are starting to catch up. It is clear also, and maybe this gives me the opportunity to say just one thing to pick up on this, that the other thing I think we will see is patients with much more information. This is one of the underlying issues which I think has been around this Committee and also is part of the answer to Mr Steinberg. We do need people to understand the treatments which are available and the success rates, and I think that will be a force which probably you will be reporting on in five years' time, whether I am here or not.

Q164 Mr. Gerry Steinberg (City of Durham): Can I defend what I said. I had a constituency case where a lady was referred to a consultant not as urgent, and she contacted me and I told her to go back to the doctor. When he wrote the letter he had forgotten to put 'urgent' on it, so she went down the list and was not seen as an urgent case because he forgot to say it was a priority. Is that good enough?

Sir Nigel Crisp: No.

Professor Richards: No.

This is an uncorrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee. Neither witnesses nor Members have had the opportunity to correct the record. The transcript is not yet an approved formal record of these proceedings.