House of Commons - Science and Technology

Select Committee on Science and Technology First Report

V PEOPLE AND EQUIPMENT

NHS Staffing

38. Human resources have been identified time and again as a major problem in delivering cancer research and cancer care in the NHS. Professor Nurse said "the major issue is one to do with resource, getting people out there to be able to actually treat this disease".[78] Professor McVie gave us details: "we are 400 or 600 medical oncologists short, 200 clinical oncologists, we have not got an academic pathologist within a mile of most of these cancer centres, radiologists are stretched".[79] He explained "I do not think we have just got a unique problem in oncology, it just happens that cancer research has been remarkably successful in the last ten or 15 years and we have got much more to offer and, therefore, the demand has suddenly gotten there because there is far more opportunity to improve the outcome of patients with common cancers".[80]

39. The Cancer Plan committed the Government to funding an increase in medical staff by 2006. By that time there should be nearly 1,000 extra cancer consultants. The Cancer Plan contains a table showing the anticipated percentage increase of consultants in their respective fields.

Table Two: Anticipated Consultant Numbers (Medical, England only)[81]

1999
2003/4
2005/6
Increase 1999-2006
% increase 1999-2006

Histopathologists
836
913
968
+132
16

Radiologists 1,507 1,840 1,767 +260 17

Clinical Oncologists 305 420 453 +148 49

Medical Oncologists 110 192 265 +155 141

Haematologists 510 639 659 +149 29

Palliative care Physicians[82] 94 164 221 +127 135

Total
3,362
4,169
4,333
+971
29

Source: 1999 consultant numbers - DoH Workforce Census, September 1999

The Christie Hospital however reported a bleak picture: "we are lagging well behind the proposed timetable for increases in numbers of consultants. We started below the national average and are falling further behind".[83]

40. Consultant numbers are not the only problem. The Committee's Report highlighted the worst areas. There was a shortage of specialist cancer nurses; pay and career structures for non-medically qualified staff, such as laboratory scientific officers and radiographers, were poor and staffing levels overall are low. The Committee's Report stated "pay and career structures for essential non-medically qualified professionals, notably medical laboratory scientific officers and radiographers, are inadequate and enhanced training and recruitment programmes are required. Without such staff effective treatment is impossible".[84] The Christie Hospital told us "the most crucial problem currently is recruitment and retention of therapy radiographers".[85]

41. When we asked about the numbers for staff other than consultants, Professor Richards told us "the difficulties are, for example, with cancer nurses, that they have never been previously separately identified as such, but they are just within the nursing workforce".[86] We asked Professor Richards what progress had been made in recruiting extra staff. He highlighted other disciplines which were short of staff: urology, cancer nurses, radiographers and therapy radiographers, and told us "I cannot 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".[87] He argued that there was no easy way of setting targets for staff, as requirements and responsibilities change over time.

42. Professor Richards told us that the National Cancer Research Networks would each produce a Service Delivery Plan once established, giving details of what they would be doing and how. Part of this Service Delivery Plan will be a Workforce Plan. He felt that it was important for the NRCNs to be involved in decisions on staffing: for example "it may be that you need one extra consultant between two hospitals, working as a Network you will be able to see that".[88] We asked the Department of Health for any staffing targets so far identified by NCRNs but they were unable to provide them. Eighteen NCRNs had submitted Service Delivery Plans, but these outlined current staffing requirements only.[89]

We are concerned at the Department of Health's inability to provide real targets or figures on NHS cancer staff, even for those in training. Without current staffing figures and targets, progress cannot be assessed in future. We urge them the Department to publish its staffing goals and to provide regular updates on their progress. Funding posts is not enough: the Department must ensure that there are enough staff in training to fill these posts. We find lack of measurable progress in addressing staffing problems disappointing.

NHS Equipment

43. The Committee's Report expressed concern at the lack of equipment available in the NHS for both diagnosis and radiotherapy. It recommended that "the Government and the National Screening Committee evaluate high speed and precise techniques with a view to commencing large-scale trials for CT [computerised tomography] cancer scanning. This would require the NHS to purchase state-of-the-art diagnostic equipment".[90] It also recommended that intensity-modulated radiotherapy (IMRT) and three-dimensional conformal radiotherapy (3D-CRT) equipment should be made available in all cancer centres together with trained personnel.[91] Equipment for both of these new, smaller-dose radiotherapy systems was not commonly available in the UK, although such systems are obtainable in other countries.

44. The Government Reply said that almost £200 million had been invested in NHS equipment and that by 2003-04 two hundred new CT scanners would be available in the NHS. Central radiotherapy investment through the NHS Plan would result in 101 linear accelerators (IMRT machines), both new and replacement, becoming available by 2003-04. The Reply also said that additional funding, at an unspecified level, had been provided for 3D-CRT equipment.

45. The December 2001 NHS Cancer Plan Progress Report contained information on new equipment bought so far through central NHS programmes.

Table three: new and replacement equipment bought under the Cancer Plan since Jan 2000

Number of new and replacement equipment since January 2000
Percentage of equipment new since January 2000

MRI Scanners
21
23%

Linear Accelerators 22 19%

CT Scanners 52 30%

The Department of Health has provided us with a list of exactly what equipment has gone where.[92] We questioned the Department about the decision-making process involved in distributing the new equipment and whether hospitals offered new machines might have to turn them down for lack of space or trained personnel to operate them. Professor Richards assured the Committee that the Department of Health undertook extensive consultation before deciding on the placement of equipment: "officials within the Department of Health have very, very close contacts with hospitals across the country and we talk both at the Trust level, we talk to regional cancer co-ordinators, we consult widely about where the greatest need is and what machinery is actually needed there".[93] He was not aware of any cases in which a hospital had had to refuse equipment. He concluded "there is the extra funding going into the Health Service, and into cancer, and if the problem is about needing extra staff to run that new equipment then I would hope this extra funding can be used for that purpose".[94]

46. When asked about the staffing requirements for operating these new machines. Professor Richards stated that the balance between new and additional equipment had been decided with the staffing problem in mind, and that the replacement machines were faster and would not require any considerable immediate additional staffing. He did not foresee a problem when capacity was expanded with additional equipment. "We are seeing a rise in radiographers to operate these machines; and we have estimated the numbers that are required per extra CT scanner, so that we will be able to do that".[95] The National Association of Laryngectomee Clubs told us that "due to lack of trained staff, premises and up to date equipment, delivery of the NHS Cancer Plan is being compromised". They were particularly worried about the need for a new radiotherapy unit for Head and Neck cancer patients in one Service Network: "even if funding and premises were to be made available to improve the situation there would be difficulties in staffing this unit".[96] Professor McVie told us "the human resource is not yet in place that has been promised. There are machines ordered all over the country, new radiotherapy machines, but it is a six month installation time and you will be lucky if this time next year much has changed in terms of waiting time for even palliative radiotherapy".[97] The situation at the Beatson referred to in paragraph 30 is an illustration of the low morale in cancer care units. We note the Department of Health's confidence that equipment is being provided on time and in the right places, with adequate staff support. Morale in hospitals and among patients will plummet if there is not the staff on the ground to be able to make full use of new equipment.

Patient access

CLINICAL TRIALS

47. The Committee's Report examined two aspects of patients' access to clinical treatment: participation in clinical trials and the approval and availability of anti-cancer drugs. The Report recommended that "increasing the number of adult cancer patients entering clinical trials must become a high priority".[98] The Report was also firmly in favour of a database of current clinical trials, accessible to patients and clinicians, which would enable patients to put themselves forward for trials. The Government created the NCRN with the aim of doubling the number of patients in clinical trials within three years. Professor Sir Paul Nurse told us that he did not think there had been any improvement of patient access to clinical trials in the period since the Committee's Report was published. Several memoranda also conveyed the impression that the situation had not improved. As mentioned in paragraph 24, figures for patients enrolled in trials will be available in summer 2002. There is a database on the Cancer Research UK website, but the Department of Health has not been active in this area. We are disappointed at the lack of progress in the admission of cancer patients into clinical trials. We urge more rapid progress towards the development of extensive and accessible clinical trials databases to inform both researchers and patients and look forward to seeing a rapid rise in the number of patients entering clinical in trials in the near future.

ACCESS TO DRUGS

48. Patients' access to anti-cancer drugs has been described as a "post-code lottery", with different drugs being available in different NHS Health Authorities, owing to budget restraints. The Committee's Report condemned this as "unacceptable",[99] and recommended that the Government "require all Health Authorities to provide anti-cancer treatments which are approved by NICE where the patient's consultant regards them as clinically appropriate and prescription is within the guidelines set by NICE".[100] The National Institute of Clinical Excellence (NICE) is the body which is responsible for the approval of drugs and for determining which drugs are cost-effective for use in the NHS. The Government Reply promised that extra funding would allow all Health Authorities and Primary Care Trusts to "be able to meet any additional costs arising from the provision of anti-cancer drugs recommended by NICE".[101] The Minister told us "what we need to do is make sure that as new drugs come on stream those are picked up and that no post-code lottery develops as well".[102] She reassured the Committee that "whenever we have any query raised with us that a particular area might not be funding a particular NICE drug or assessment properly, we certainly do investigate that and follow that up, because that is clearly extremely important".

49. We were made aware of serious concerns about the work of NICE by Professor Gordon McVie. He told us "they are still taking a phenomenal time to do the review and they are still not starting the review until some months, and sometimes years, after a drug has been passed by the regulatory authorities as safe. This is causing real, serious frustration. There is also a serious question of the competence of the so-called experts on NICE. There is not a known oncologist or anybody who is known to have been vaguely trained or familiar with the problems of oncology or cancer drugs or cancer techniques".[103] We received a rebuttal of this criticism from NICE which stated "as part of its appraisal process, the Institute seeks advice from relevant health professionals (including oncologists in the case of anti-cancer drugs) and patient/carer organisations (eg CancerBACUP)".[104] It also said "the Institute's appraisals are conducted vigorously and fairly, taking into account both clinical and cost effectiveness".[105] We do not intend to comment extensively on the drug approval process as NICE is currently the subject of an inquiry by the Health Select Committee. We have drawn that Committee's attention to the evidence we have received on NICE. We remain to be convinced that the problems of timely patient access to drugs have been solved, and in view of strong criticism expressed to us in evidence on the National Institute of Clinical Excellence, we look forward to the Health Committee's Report on NICE with interest.

78 Q 114 Back

79 Q 114 Back

80 Q 116 Back

81 Table from NHS Cancer Plan, p 74 Back

82 Palliative care physicians working in hospices who do not hold NHS contracts are not included in these figures Back

83 Ev 61 Back

84 HC 332, para 89 Back

85 Ev 62 Back

86 Q 71 Back

87 Q 55 Back

88 Q 67 Back

89 Ev 21 Back