HPS Transcript by iuu13646

VIEWS: 13 PAGES: 29

									                                                                         Item 3 Appendix A
                      Health and Public Services Committee

                                  28 November 2007

        Transcript of Item 4: Breast Cancer Screening and Radiotherapy



Joanne McCartney (Chair): Our main item today is breast cancer screening and
radiotherapy in London. Perhaps before I start I can just say a couple of short things about
why we undertook this investigation. It came to our notice that breast cancer screening
rates in London are lower than the national average. I understand, 62% of London women
aged between 50 and 70 actually take up their offer of screening, which compares with a
national average of 75%, so quite a difference in that. Also with regard to radiotherapy, we
understood that waiting times and delays may be longer in London than other parts of the
country as well. So that is something that we want to investigate today.

Before we do that, perhaps I could ask members of the panel who are here to help us today, if
you could just say who you are and what organisation you are from and then we can record
that formally in the minutes.

Maggie Alexander (Director of Policy and Campaigns, Breakthrough Breast Cancer):
Yes, I am Maggie Alexander and I am Director of Policy and Campaigns at the UK-wide
charity Breakthrough Breast Cancer.

Nikki Cannon (Screening Co-ordinator, Westminster and Kensington and Chelsea
Primary Care Trusts): Hi, I am Nikki Cannon, I am the Screening Commissioner and Co-
ordinator for Westminster and Kensington and Chelsea Primary Care Trusts.

Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): Mike Williams, I am Vice President of the Royal College of
Radiologists and Dean for the Faculty of Clinical Oncology, which basically means
radiotherapists. I am an oncologist from Cambridge; I have not treated breast cancer for the
last five years but I conduct national audits of radiotherapy services.

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): I am
Michael Michell. I am a radiologist based at King’s College Hospital. I am the Director of
the South East London Breast Screening Programme and I am representing the Royal
College of Radiologists for the purposes of breast screening radiology.

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): I am Kathie Binysh. I am a consultant in public health medicine. I am here
on behalf of NHS (National Health Service) London. I am the Director of the Breast
Screening Quality Assurance for London and I am also the Clinical Director for the West
London Cancer Network.

Joanne McCartney (Chair): Thank you. Can I thank you all for coming here today; we do
appreciate it. We had also hoped that a member speaking on behalf of general practitioners
could be with us today, but we have been unable to find a speaker. I know that some


                                              1
comments will be particularly relevant to that professional body, and we will take those on
board and we will seek to get their views of any issues that do arise today as well. They
have sent us a written submission, so we do have that evidence in front of us. I am going to
start by asking all of you: what do you think are the most important factors that explain why
the screening rates in London are well below the national average?

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): OK. I think things about the population in London that make it slightly
different to the rest of the country are, firstly, the mobility of the population that we have.
People tend to move in and out of London perhaps rather more rapidly than they move
around in the rest of the country. I think that we have higher levels of deprivation in
London and different people come to London for different reasons and move out of London
for different reasons. I think that we have generally got a lower socio-economic situation in
London. I think that our services in London are as good as those in the rest of the country,
so I do not think it is to do with the services that we offer. I think it is to do with the
population that we have. Another issue, which may or may not be associated with the
socio-economics, is the ethnicity of the people that come into London, particularly if they are
not born and brought up in this country. They may not be used to the concept of screening
and, therefore, not understand what it is about and what it is trying to do for them and not
understand the benefits that they might receive from it.

Joanne McCartney (Chair): Does everybody agree with that or is there anything extra
that anyone could add?

Maggie Alexander (Director of Policy and Campaigns, Breakthrough Breast Cancer):
Yes, I think we would certainly agree with those points about the mobility of the population,
about socio-economic status and sometimes the compounding factor of ethnicity. Also in
some of our work we have a campaign and advocacy network, which consists of about a
thousand women with personal experience of breast cancer and a number of organisations
and people with an interest in breast cancer. We have done quite a lot of survey work with
those and with the general public and what we also found is that misconceptions about
breast cancer and who is at risk from it and misconceptions about what the screening
process involves, also contribute to lack of take up. The other thing was that we carried out
a survey in 2004 and repeated it in 2006 and in the earlier survey we found that one in six
women were finding the time of the appointments and the location inconvenient. When we
resurveyed in 2006, almost one in four found that the appointments given to them were
inconvenient and that they cited this as a reason for not attending. So that obviously is quite
an important contributing factor.

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): I would like to
support those views, particularly about the lack of knowledge of breast cancer screening,
diagnosis and natural history, which we have found particularly in our local population as a
result of research done by Professor Amanda Ramirez (Director of the Cancer Research UK
London Psychosocial Group) who is doing some work on reasons for delay in presentation of
breast cancer, and this seems to be a major problem which is contributing to that as well. I
think that there is also work which we have been involved in, in Lambeth, Southwark and
Lewisham, where there is a particularly high rate of socio-economic deprivation, ethnic mix
and so forth, trying to understand the reasons for non-attendance, actually not taking up the
invitation for screening. I think that the reasons are truly multi-factorial and very complex.
Perhaps one of the things that may come out of today is support for further detailed
academic research to understand why non-attenders are not coming for screening.


                                               2
To just take up the point about convenience of appointments, which is a very obvious
potential reason that one might think about as a reason for not coming for screening, there
seems to be conflicting evidence on that. In the work by Professor Taket (Professor of
Primary Healthcare, London South Bank University), it did not seem to be a major factor in
whether a woman was going to attend for screening or not. Much more important factors in
her work were attitudes towards the screening process itself, whether an individual felt it
was important and potentially of benefit to her, rather than the inconvenience. We have a
very good example of that in our own part of South East London where in the Bromley area
we have a very high uptake of screening, well over 70%, like the rest of the nation. There we
have a small number of screening sites, so women actually have to travel quite a long
distance. It appears that for that group, if they decide that they are going to go for
screening, then they will attend, despite the inconveniences. Whereas in Lambeth,
Southwark and Lewisham, inner city area, very different type of population, where we have,
in contrast to Bromley, a larger number of screening sites potentially giving easier access in
terms of journey time, distance and so forth, the uptake is very much less. So I think it is
complex and I am not sure the accessibility and convenience is the whole story, although we
obviously accept in the programme we must make the accessibility as easy as possible of
course.

Joanne McCartney (Chair): I am looking at a response that Southwark Primary Care
Trust sent us, which says that one of the problems they have is that, because those non-
attenders do not attend, they cannot then do an audit as to their ethnicity, therefore they do
not know who are the non-attenders. I have to presume that is why you want some of the
academic work to be done on this, but do we have that data or any data? Is that a real gap
that we need to look at?

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): We are trying to collect ethnicity through the screening service, but it is
women who attend and not women who do not attend. The best data that we have to look at
women who do not attend is the general population data and you can look at the uptake
rates within a geographical area but then you have to make assumptions about those women
who have not attended or may not have attended. So we do not have the data on women
who do not attend.

Joanne McCartney (Chair): Ms Alexander, I understand that you have been awarded some
money to do pilot projects in London, could you just explain whether this will be looking at
some of these factors as well?

Maggie Alexander (Director of Policy and Campaigns, Breakthrough Breast Cancer):
That is right. Yes, exactly those kind of issues. I think I completely accept the point that
the issue of convenience can be a compounding factor. We would never suggest it was the
only or most significant factor, but it clearly needs further explanation. I think one of the
problems is that the research that has been done to date has been very patchy and then often
the lessons from that have not necessarily been applied. We are very pleased to have been
awarded a Department of Health grant [under the Section 64 Scheme] to run and evaluate a
pilot, fairly comprehensive, breast cancer education and awareness campaign in two areas, in
Camden and also in Westminster and Kensington. That will give us a lot of the kind of data
that will answer these questions but that work is only just beginning and although there is
quite a bit of literature to support the direction of the study, we will not have answers from
that for the next couple of years, but we would obviously be very happy to feed in any early
findings, wherever they can be useful. It will explore issues about understanding and


                                               3
awareness of signs and symptoms, the benefits of breast awareness and screening. It is
always going to explore all those issues and the barriers.

Joanne McCartney (Chair): That could be helpful. What is your timescale for that piece of
work?

Maggie Alexander (Director of Policy and Campaigns, Breakthrough Breast Cancer):
Year one, which has started, is doing all the preliminary work and identifying the
geographical areas and setting up the project advisory group. Year two, which starts in
February next year, is to roll out a pilot education campaign and evaluate that early, so that
the major project can take account of the pilot work.

Joanne McCartney (Chair): Given the knowledge you have so far, could you say anything
about the inequalities that exist in London with regards to the take up of breast cancer
screening? Have you identified certain communities or certain areas of London?

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): It goes from inner London to outer London. So it gets better in outer
London and is worse in inner London and that is consistent across both the breast and
cervical screening programme. That is the most consistent pattern. It also is associated
with socio-economic deprivation and equally with population turnover; how fast it turns
over, which all goes together and makes it very difficult to disentangle exactly which of
those factors is what it is that is causing the particular problem in lack of uptake of the
programmes. I was also going to say, there are some Primary Care Trusts within London
who have also done work at a much more localised level - within their own local PCT
(Primary Care Trust) area. They have also found similar things, so the pictures that we are
seeing across London we are seeing locally, so it goes with social deprivation and
particularly with ethnicity, but as I say, you cannot really work out which of those factors it
is that is causing them not to come.

Joanne McCartney (Chair): One further general question before we get into some more
detailed questions. Across London we have 31 PCTs. Do all of those offer a similar service,
or does it vary drastically from one to the other?

Nikki Cannon (Screening Co-ordinator, Westminster and Kensington and Chelsea
Primary Care Trusts): PCTs basically commission the screening service for eligible
women from one of the six breast screening units in London. For instance I am part of a
consortium of six Primary Care Trusts, the Commission for the West of London Breast
Screening Programme, and throughout London that setup is the same. Obviously the
service they provide is rigorously quality assured by the QARC (Quality Assurance
Reference Centre), so I would say there is very much an equitable service provided for
women.

Joanne McCartney (Chair): The same letters, invitations, go out to the same people?

Nikki Cannon (Screening Co-ordinator, Westminster and Kensington and Chelsea
Primary Care Trusts): Yes.

Joanne McCartney (Chair): One of the responses we have had says that there should be a
London network of breast cancer screening and I know that when we did our work into
neonatal care, the establishment of networks greatly improved some of the service. I am just
wondering whether that is something that --


                                               4
Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): Well, can I come in on that? Basically the services are the same. They are
provided to the national specification and the London quality assurance team quality assures
the service to make sure that they are performing to those standards. However, within that,
particularly because of the issues around poor uptakes, different PCTs have tried different
things to try to reach their local populations, either in terms of publicity materials, looking
at different ways of inviting women; whether they give them timed appointments or ask
them to ring in to the service to make timed appointments and the flexibility of those sorts
of things, and the type of material that is available. In certain areas they will particularly
offer to have an interpreter on the mobile van so that that is available for the woman when
she comes for her screening. So, whilst it is basically the same service everywhere, there are
some local variations to try to meet local needs.

Joanne McCartney (Chair): One of the things which we have found that the Network for
Neonatal Care did very well is that they shared best practice.

Nikki Cannon (Screening Co-ordinator, Westminster and Kensington and Chelsea
Primary Care Trusts): In terms of network, each PCT has a screening commissioner.
Screening commissioners meet quarterly which is hosted by the QARC. So there is that
network of commissioners. Then there is also a health motion group that meets with
representatives from screening departments and screening commissions. There is an awful
lot of London focus work. At the moment the QARC and the PCTs have jointly funded a
two-year project manager post to look at some centralisation work, on which
Kathie [Binysh] is probably more up to speed than I. But I think there is a real awareness
in London - I have got a huge pile of the different initiatives that we are trying through
London.

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): Perhaps it is just
worth adding that I think that at all professional levels, administrative, radiology,
radiography, there is a very good network across London with very good communication, so
there is sharing of best practice that exists, but I think the problem here is that all those
little bits of best practice that have been tried locally in different programmes, differences in
the invitation and so forth, none of them has been shown to have a substantial, sustained
effect on the uptake for screening. What we are looking for is to go from 60% to 75% rather
than the 60% to maybe 65% with a huge effort.

Maggie Alexander (Director of Policy and Campaigns, Breakthrough Breast Cancer):
I was just going to advocate, as well as sharing best practice within the London network, of
looking further afield as well because there has been some very interesting work done with
Breast Test Wales, particularly on increasing access for people with a range of disabilities by
having information in a range of formats, minicoms. They have done a fairly systematic
review of some of the access problems and those with physical difficulties in using mobile
screenings, which they rely on more. So there is quite a lot of data there and we have
compiled a dossier of some of the best practice we have heard about, either from our network
or from other screening services which again, we would be very happy to share. So I think
there are some quite useful tips.

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): Yes, I think that sharing best practice is not just confined to London; it goes
much more broadly than that.


                                               5
Peter Hulme Cross (AM): It follows on just to ask if you have any suggestions or opinion
on what further work needs to be done to understand why there is poor uptake and how we
can improve upon it. You said you are looking for something which will go from 60% to
75%. That sounds like a sort of silver bullet solution which there may not be, or there may
be. From what you have said, in Bromley you have got high uptake, yet there are few
centres. Lewisham and Lambeth and so on, low uptake but lots of centres, but very different
populations. You also said yourself that the reasons are complex for not doing this and also
it looks as though it is difficult to understand why there is low uptake, because you can only
look at those people who actually come. Those people who do not come, you said yourself,
you are using assumptions. Clearly there are gaps in all this and there does seem to be some
more work needs to be done to try to find out if there is a more comprehensive solution.
Have you any suggestions?

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): Absolutely, I
have. I think that there needs to be some fundamental, basic research done to look at the
non-attenders and what it is that is making them decide not to come for screening and that
may be related to cultural, religious, health beliefs; all sorts of complex things which need to
be unravelled and I do not think that that basic work has been done yet. It is only when that
has been done that we will be able to look at what is the appropriate intervention in the
population.

Peter Hulme Cross (AM): And who should do that work?

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): I think an
organisation with the appropriate skills to analyse that sort of complexity and we have a
grant application currently to Breakthrough [Breast Cancer] for that work to be done with
Professor Amanda Ramirez and her group.

Peter Hulme Cross (AM): I suppose it means contacting those non-attenders and either
phoning them or sending them some sort of letter to try to find out why they did not go?

Nikki Cannon (Screening Co-ordinator, Westminster and Kensington and Chelsea
Primary Care Trusts): That type of work has been done in the past, but as you would
expect you get a very poor response from it. We have done it through West of London and
the return rate was so tiny. One of the elements we have not mentioned yet, and I do think
it is hugely important - when you talk about going from 60% to 70%; one of the ways we
have managed to do that is we are doing a very in-depth study in two practices.
Westminster and Kensington and Chelsea, I am sure you are aware, have areas of huge
deprivation and huge affluence. It is a very interesting area for us to work in, but our breast
screening rates are the same across all wards and areas; there is very little variation, very
small percentages in terms of the affluent areas and poorer areas. So that is very interesting
for us. Also, when we look at our incidence of mortality, they are no higher than nationally.
Now that starts to need to lead to questions of, if 50%, and our uptake is under 50%, is that
low, then surely we should be seeing a higher incidence of mortality, because we should have
women presenting with later breast cancers. That does not appear to be happening. We are
talking about reasons why women do not come, and they are all very valid. I have been
working on this for the last 13 years and this work needs to carry on.




                                               6
I think one of the big areas we have not mentioned yet, is an issue of data, it is an issue of GP
lists. I do not think the picture is that clear, it is not that 40% of women are sitting there,
receiving an invitation and making a conscious decision not to come. I really very strongly
believe this. It is really disappointing that we do not have a GP representative here, because
I think if we are looking for a gap that we have not looked at, that is your black hole because
that is where all the data initiates from, that is where the invitation first … That
information comes to the breast screening services via the GP; if that is not working then we
are off to a false start. There are no incentives at the moment for GPs to do any work on
breast screening; it is not a target that they are paid for, it is a target the PCTs are
monitored on, but not the GPs. So it makes it very hard for us to do work with them unless
you do get some motivated GPs but they have so many other calls on their time.

Peter Hulme Cross (AM): Are you saying actually that for somebody to get a letter to
come to a screening, they have to be registered with a GP?

Nikki Cannon (Screening Co-ordinator, Westminster and Kensington and Chelsea
Primary Care Trusts): Yes.

Peter Hulme Cross (AM): Because there are loads of people who are not registered with
GPs and who cannot find a GP, come to that. They move around and so on; they are just
not registered.

Nikki Cannon (Screening Co-ordinator, Westminster and Kensington and Chelsea
Primary Care Trusts): Absolutely. Yes. Registered women is the very start point. In
London, with mobility and the transient map, that is when it becomes very complicated.

Peter Hulme Cross (AM): Yes. Thanks.

Maggie Alexander (Director of Policy and Campaigns, Breakthrough Breast Cancer):
Yes, just two quick points there. I completely share your views about that and I think there
are also real missed opportunities with GPs, because what we have found in our survey work
is that a vast majority of women over 70 are not aware of the fact that they can request a
screening appointment. So, although the age range is going to be extended, obviously that
is going to take some time to implement. In the meantime the women who are at greatest
risk are not necessarily requesting appointments and we see great opportunities from their
regular encounters with practice nurses and GPs, those women that are registered, for GPs
to be asking, “Have you had your screening appointment?” or if they are over 70, “Shall we
request an appointment?” There is a very low level of awareness of their increased risk and
real opportunities being missed. I did hear of one little piece of very good practice, I think it
was in Cornwall, where the practice nurse used to put a red dot on the card… I think they
were still using cards, or on the computer screen of people who were either due a screening
appointment or who were over 70. When they came in for anything, for an asthma clinic or
diabetes clinic or anything like that, she would use that opportunity to raise their awareness
of their right to screening. That was one thing. There is another example, in terms of
interventions which have actually worked to increase uptake. There was the 2002
University of Kent report, which links to something that was said earlier about women’s
intent to go for screening and planning it. They found that actually the thing that made the
difference was helping women to actually plan to go for screening and to plan to take time
off if they were in work. When that happened, that actually raised the uptake of screening
by 11%. I thought that was quite interesting and I do not know if that work has ever been
followed up but it does rather link into another finding, that if people do not attend for their
first screening appointment, they tend then not to go for subsequent ones. So, if you can get


                                               7
them into the programme and planning to attend the first time they are called, then there is
greater chance of them being seen as their risk increases.

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): I was going to pick up and say actually we are following up on the work
from University of Kent and we are getting some projects done within the London screening
units to see if that does make a difference. I was also going to follow up on the matter of
general practitioners. That I think is a very important issue. It does link back both to the
mobility issue about how they manage their lists and how accurate the registers are, and also
we are looking at undertaking a survey of GPs to understand their attitudes towards breast
screening. As we have already heard, it is possible for them to encourage women to come
forward, either before they have had their invitation, and indeed there have been some
practices and some Primary Care Trusts have sent letters out on behalf of GPs to women to
say, “You are about to receive your invitation and I would very much encourage you to
participate in this screening test” which appears to have a small effect. It is not the magic
bullet that we are looking for. So we are trying to encourage general practitioners to
participate and support the programme and they are of course notified by the screening units
when women do not attend, when they have been invited. They then have that information
so that they can, and indeed some of them do, put on red dots or red stickers or flags on their
computer systems, so that if the woman does come in for some other reason they can then
say, “I note you did not go along; it would be a good thing if you did.”

Joanne McCartney (Chair): Nikki [Cannon] you said about your borough, affluent areas
and poorer areas. I am just wondering, given that you represent Westminster, Kensington
and Chelsea, I would think that quite a few of the women there would perhaps go for private
treatment as well. I am wondering whether you have done any work on that or there are
any figures that show whether women are not counted because they do actually access
private screening.

Nikki Cannon (Screening Co-ordinator, Westminster and Kensington and Chelsea
Primary Care Trusts): Private mammography, some of it goes round and round London
commissioners and it gets discussed a lot and there have been several attempts at trying to
gather that data because we cannot count private mammographies because they are not
quality assured; they are not part of the national programme. The work we are doing at the
moment, which unfortunately is not completely finalised, is looking at two practices, one of
those is in a very affluent area and we know they have had a basic uptake rate of 48%. We
have gone into that practice and we have gone through every single one of those women’s
notes and we have contacted every woman that we do not having a screening record for and
it is a very interesting piece of work. We have never unpicked it at quite such a level and
actually 72% of that practice’s women have had a mammogram of some form or another,
whether it has been private or whether they have self-referred themselves. So they have
fallen outside of the screening round; where all the eligible women in that practice get called
to have their breast screen. It is much more of a data issue than the very bald statement it
appears to be.

The other practice we are looking at in a more ethnically diverse and deprived area actually
also is showing, I think it is about 6% private mammography uptake. So it is quite
interesting that there is a significant issue and it is something I know London as a whole has
been looking at and it is a problem for London.

Joanne McCartney (Chair): So in fact the rates might not be as low as we believe?



                                               8
Nikki Cannon (Screening Co-ordinator, Westminster and Kensington and Chelsea
Primary Care Trusts): No, and that is where I am at the moment, I really believe that to be
the case.

Elizabeth Howlett (Deputy Chair): Sorry, can I just say, we did a scrutiny on childhood
immunisation, we found exactly the same, same area, that there was a low take up and yet
there did not seem to be outbreaks of measles. So quite the people were actually going to
private practice but, unfortunately, it is not necessary for them to inform whoever it is, even
if it is just numbers, and a quantity of numbers have actually now had vaccinations or have
had screening.

Nikki Cannon (Screening Co-ordinator, Westminster and Kensington and Chelsea
Primary Care Trusts): I think it is really important before we start to put massive amount
of money into promotional campaigns, that we actually work out what the real problem is -
where do we need to put our emphasis. Because it may not be, and I do not think that it is
the whole; it is a very complex thing; I think there is no one big answer, but it may not be
that is quite the terrible uptake rate that it would appear.

Elizabeth Howlett (Deputy Chair): There were a number of submissions that we had that
called for national and pan-London awareness raising campaigns. Do you think that would
help the situation?

Nikki Cannon (Screening Co-ordinator, Westminster and Kensington and Chelsea
Primary Care Trusts): I do. I used to chair the London Health Promotion Group for a
number of years and we have been campaigning for years and years for a London campaign
and we are on the point, hopefully, of securing some funding. I do not know if we know
whether that has come through yet. I do, I think it would be an excellent thing because I
think there are so many screening units. Although we talk to each other; we do awareness
campaigns; I have done bus adverts and various things; but there has never been a really co-
ordinated London approach and we know that works, but it very expensive. So if we can get
a significant amount of money together, I do think that would be fantastic. I think we
approached the Mayor’s office once, a few years ago. A London campaign combined with
some really focused GP work to get them engaged in the programme and we are looking at
offering them money, which we can do through locally enhanced schemes, and I think that is
probably our best opportunity in London.

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): Can I just add to
that, we would absolutely support that. I think part of the message that we would very
much like to come across is that this is a very, very high quality programme. It is robustly
quality assured; it is probably the most scrutinised part of health practice in the UK at the
moment; it certainly feels like it from where I am sitting. I think that there is a very positive
message; we have been doing this since 1990; we are very good at finding tiny cancers and
we are very good at sorting them out.

Nikki Cannon (Screening Co-ordinator, Westminster and Kensington and Chelsea
Primary Care Trusts): Absolutely.

Maggie Alexander (Director of Policy and Campaigns, Breakthrough Breast Cancer):
That is certainly borne out by some of our survey work. There is a very interesting group,
it is actually outside London, but 121 women who were surveyed in collaboration with a
local newspaper about attitudes to screening and so on and a lot of the remarks were about


                                               9
finding out about it and understanding it and saying, “Explain risks and how screening
could help.” I think if the messages explain what the value is…

In terms of working with GPs, during breast cancer awareness month, we produced this
poster with the awareness of the Touch, Look, Check message and we have sent that to
every GP in the UK and we are just starting to follow up now on the results and the
responses but we also sent it to the practice nurses. So we are hoping this will help to
encourage awareness and encourage GPs and practice nurses to draw it to the attention of
their patients.

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): Can I just come in on that? I would support and indeed we have been
working with Nikki [Cannon] and all the other PCTs in developing the idea of a pan-
London campaign. Alongside that we are also undertaking a piece of work to look at
whether we can have a single centre for calling women for their breast screening, and that
would enable women who live in one area and work in another to be able to go to another
part of London to actually have their screening. So they would not have to go back home
and take time off work to do that is what we would like to be working towards. Alongside
that, we would like to have a single telephone number for London for women to be able to
ring up and to change their appointments and we think that a pan-London call and re-call
programme to underpin all the services would help women to access it.

Maggie Alexander (Director of Policy and Campaigns, Breakthrough Breast Cancer):
I think that would be incredibly helpful and well valued and certainly would meet some of
the aspirations of people we have talked to.

Joanne McCartney (Chair): Is that a realistic possibility do you think?

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): I think so. We are working on it. We have got somebody working on it
within the QAR Centre (London Quality Assurance Reference Centre).

Joanne McCartney (Chair): Would it be a question of funding as to whether it got off the
ground?

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): Well it will obviously take funding, yes.

Joanne McCartney (Chair): Could I just ask a question about the quality assurance,
because I was not aware for example, that if people have got private healthcare and they
went to get their own screening, that it might not be quality assured. Is that a risk that
people are taking? I do not know who could answer that.

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): Well, I think we
have got to be careful. There is a technical quality assurance which is absolutely mandatory
for anybody using ionising radiation, so that wherever a woman goes for her X-ray
mammogram, there should be quality assurance of that machine so that there would be an
assurance that the quality of the images would be appropriate or high quality. From the
point of view of other aspects of quality assurance, for example, how good the team is at
detecting cancers, which is what it is all about; in the NHS screening service we are dealing
with huge numbers and we are rigorously measured in terms of our ability to have a high


                                              10
sensitivity and also a high specificity and all the associated measurements of that. In private
practice there is no such quality assurance because the numbers - the system - simply does
not allow it and I think that that is a weakness of the private practice type mammography
that is offered to women.

Nikki Cannon (Screening Co-ordinator, Westminster and Kensington and Chelsea
Primary Care Trusts): I guess also with your NHS mammogram, you get double view and
it is double read, double checked, so you have no idea whether that would happen privately.

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): Yes. Absolutely.

Nikki Cannon (Screening Co-ordinator, Westminster and Kensington and Chelsea
Primary Care Trusts): Which is then extra, better quality.

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): The other area that is quality assured is about the information that the
woman is given about her screening, which is looked at within the NHS breast screening
programme but is not necessarily quality assured within the private practice.

Peter Hulme Cross (AM): In that last answer, did I hear you say that in the NHS the
image is checked independently by two people? Is that right?

Speakers: Yes.

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): That is virtually
standard practice across England.

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): Yes.

Peter Hulme Cross (AM): Standard practice across England?

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): Yes.

Peter Hulme Cross (AM): Right.

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): England and
Wales. Yes.

Peter Hulme Cross (AM): England and Wales.

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): Yes.

Peter Hulme Cross (AM): Whereas in private practice, presumably, it would not be, it
would be looked at by…...




                                              11
Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): It would be
variable. Some do and some do not.

Peter Hulme Cross (AM): Right. OK. That does seem quite significant, if you are looking
for small cancers. It is obviously better to have four eyes looking than …

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): It makes a
difference in sensitivity of between 5% and 10%.

Peter Hulme Cross (AM): Really?

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): Cancer
detection, yes.

Maggie Alexander (Director of Policy and Campaigns, Breakthrough Breast Cancer):
I think that anecdotally we would be fairly confident that women who go for private
screening are not advised of that difference.

Also we have heard anecdotally that women who make their own appointments for private
screening are not necessarily given any information at all, so in some ways you could say it
is an inferior service.

Peter Hulme Cross (AM): In relation to the perceived lack of screening units, some of the
submissions we have had argue that a lack of screening units, of women having to travel
long distances, may be a reason for low take up, but clearly not in Bromley, according to
what you said. But if there were more screening units provided, do you think that would
increase the take up rate? It seems a silly question but …

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): No, I think it is
an absolutely crucial question because we need to bring into this changes in technology.
Within the next few years we will go from using film to using digital machines, so all of the
screening services, virtually all in the London region at the moment are on film, as it is in
the rest of the UK. As we go to digital, first of all the difference in the cost of a machine is
very great. So the cost of a digital machine, capital cost, is about three times that of an
analogue or film machine. So in planning how we provide the services in the future, we have
to take into account the cost of digital units.

I think, from what I have seen, in my own programme, going across the whole of South East
London, there is not convincing evidence that having a large number of units spread out
through the community is an effective way substantially to improve the uptake - having said
that, clearly we need to have the screening sites in reasonably accessible places. I think if I
could just use the example; we had for many years, for about ten years, a very successful
screening site in Camberwell, which was in a shopping precinct. I think the attraction of
that is that it completely takes the screening experience out of any hospital, clinical,
healthcare setting. It is in an environment which women are used to being in; it is part of
normal, healthy living, if you like. I think another example of that would be in South West
London, with the screening site which is in Allders store. That seems to be another very
good example of having it in the right, convenient and appropriate environment.


                                              12
Peter Hulme Cross (AM): That is very interesting, isn’t it? The, “Oh, I am going
shopping” and I just pass a screening and I thought, “Oh, I will pop in for a screening.” It is
convenient.

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): I think it should
not be an inconvenience for the individual woman for the simple reason that 99.5% of them
are completely normal and, therefore, the test that we are offering should not be
inconvenient. It should not inconvenience their lives.

Peter Hulme Cross (AM): But also, as you said, there is not the atmosphere of a hospital.
Hospital equates to being sick; equates to possibly dying or whatever, whereas shopping is
quite different, so mentally it is a much more positive sort of thing.

Joanne McCartney (Chair): We had a focus group with some women who had gone
through the process of screening and breast cancer and one of the things they said; they had
very mixed reaction to the screening process, some had been treated ten or more years ago,
some quite recently, but they all said it was the atmosphere in the mobile unit or the centre
that was important; whether the staff were friendly, whether the equipment looked new and
clean and it was a conducive atmosphere. I know both of you two wanted to come in, I
wondered whether you could address that as well.

Nikki Cannon (Screening Co-ordinator, Westminster and Kensington and Chelsea
Primary Care Trusts): I wanted to agree but also, I am afraid, disagree with
Michael [Michell] because in Westminster and Kensington and Chelsea we have done a
very big piece of work in the last two years and we have got rid of our two mobile units, one
of which was in a large supermarket car park, because they were vandalised and broken into
and broke down, but the women did not like them. With the best will in the world, and I
take on board everything you are saying; it is a test for well women and these are not sick
women, but you are having a fairly invasive medical procedure and actually the women in
some of the parts of London where we had our mobiles, which are not the most pleasant of
parts, felt quite vulnerable. You cannot see a unit and walk into it; you have to have an
invitation. So that element of convenience is not quite as it would appear because you do
have to turn up for your appointment at a given time and date and have to make that trip
there. Yes you could finish your appointment and pop into the shop perhaps but our focus
groups, and we did a wide public consultation, focus groups, questionnaires; the women
wanted their unit in St Mary’s Hospital and that is where we have put the unit and the
women love the unit. Our uptake rate at the moment has not followed, but we have done a
lot of follow-up with the women because they feel safe, they feel anonymous, they feel that
not everybody knows what they are going to have done. So I think it is dangerous to
assume. I think throughout London, siting of mobiles is one of the biggest headaches - the
criteria that you have to fit, the security and having the power and how much it costs
whenever somebody steals a wheel, which happens more often than you would imagine.
There is a move in London towards static units that also can be there all the time, because a
mobile unit will only be in a certain area for maybe up to three months is the longest usually
and then it will move away to another area. You would have to wait until that mobile came
into your area again, whereas if you have a static unit … Our populations are so densely
populated that nobody has to travel very far; you can promote that unit all year round; you
can be more flexible opening early or late or offering Saturday morning clinics and to my
mind it enables us as a locality to own that unit and pop in and build up a better relationship
with the local population.


                                              13
Maggie Alexander (Director of Policy and Campaigns, Breakthrough Breast Cancer):
I think both those points are illustrative of the fact that you actually ideally need a range of
different opportunities for different people and I think a lot of these things could be
addressed by the concept of a pan-London service whereby you could go to somewhere close
to your work. We have had reports from our CAN (Campaign and Advocacy Network)
members in London, that even though geographically it might be quite a short distance, if
they are carers of elderly parents and young children actually getting even relatively short
distances across London are an obstacle. If they could go to a place near to their work or
something like that, it would be very helpful. I think the other comment about Butterfly
Walk; it was not a mobile as I recall.

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): No, I am saying
it was a static site. It was a shop.
Maggie Alexander (Director of Policy and Campaigns, Breakthrough Breast Cancer):
I believe people could self-refer, but I could be wrong about that. I think at one point. So I
think we may need a menu of options, but certainly we have had some reports from people
about the kind of anxiety about mobile units because of privacy and location and so on and I
think whether it is in a hospital or outside of hospital, safety and dignity and places to
change … People have talked about changing and them being stuck in hospital gowns in
rooms full of men and things like that and that is clearly unsatisfactory. It is probably
happening less now.

Peter Hulme Cross (AM): Can I go back on your point about the move from analogue
units to digital units and the associated cost? Presumably the cost of digital anything starts
off high and tends to come down quite rapidly.

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): Yes indeed, and
of course there will be many reasons why the cost of the total package of screening will
become less in some respects, so we will not be using film and so the cost of a film and all of
the associated costs of processing, handling, storing, moving film around, will mitigate
against the increased capital cost of the digital units.

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): Nevertheless, we
will have to make sure that the digital units that we buy and put into service, we use
efficiently and fully. So we cannot be using one digital unit for two days’ screening a week.
I think that would be an appalling waste of tax-payers money. We will have to use them for
five days a week and possibly think about extended hours, evening; look at extending hours,
weekend, to offer perhaps more flexibility in terms of the appointments we can offer,
particularly for those who are working.

Peter Hulme Cross (AM): The weekend might be very acceptable for some people.

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): Yes indeed.

Peter Hulme Cross (AM): But a digital unit, is that going to result in a sharper image; a
clearer image?



                                               14
Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): The research
that has been done shows that the digital image is certainly equivalent to the film image,
which we are very used to and we know is very, very good. For the group aged 50 plus the
accuracy is probably about the same. For the group which are aged less than 50, and of
course we are looking to extend the programme down to inviting from 47, and for high risk
family history screening for women in their 40s, digital is more accurate in terms of
detecting cancers.

Joanne McCartney (Chair): I have got a question on this. I do have a question from the
audience on the roll out of digital, to say that, “Have the IT (information technology)
systems got sufficient capacity to store the data and all the images that you will be
handling?” Because there seems some anecdotal evidence as to whether the IT capacity will
be sufficient. I do not know who could answer that.

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): There is a
problem at the moment which is about the linkage between the proposed digital systems and
the computer recall system for the screening service and work is ongoing to sort out that
linkage and obviously in terms of running the programme as a whole that linkage is critical
to be able to run the service efficiently and accurately.

Joanne McCartney (Chair): That is a technical issue is it?

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): That is a
technical issue. It is being worked on and I would hope very much that that would be sorted
out imminently.

Elizabeth Howlett (Deputy Chair): It just occurs to me I realise, reading all our briefing
papers, that actually some men do suffer from breast cancer, so where do they go for their
screening?

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): OK. So
screening is not offered routinely to men.

Elizabeth Howlett (Deputy Chair): No. Quite.

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): Because there is
no evidence that it is of benefit, as far as we know. About 1% of breast cancers occur in men
and always present symptomatically and the usual clinical finding is of a lump in the breast.
And, yes, they can certainly undergo X-ray mammography and they undergo exactly the
same other tests in terms of workup to make the diagnosis .

Joanne McCartney (Chair): Before we move onto radiotherapy, one of the things that
came through loud and clear with our focus group of women, was the importance and the
value of a breast care nurse and there was a range of opinion as to whether people actually
knew about them, they were told about them. Some had found out about them very late and
thought they were absolutely wonderful and it made the whole journey through screening to
diagnosis and treatment a lot better. It was as if they had someone who was within the


                                             15
system that they could talk to independently as well - extremely important. Not all of the
women were aware of the services. So what is the information that is given to women? Is
there a standard information pack which should be given throughout, to everybody and at
what stage that information? Who actually manages that individual’s care pathway? Who
is responsible for it?

Maggie Alexander (Director of Policy and Campaigns, Breakthrough Breast Cancer):
We have a very close association with the RCN’s (Royal College of Nursing) breast care
nurses all around and we have contact with all breast care nurses in the country. Generally
speaking, they are not involved in the screening service. It is for women who have a
diagnosis of breast cancer that they would in almost all cases, and certainly ideally, be seen
with a multi-disciplinary team, but would have a key worker who would normally be a
breast care nurse. Certainly the women that we talk to, almost universally, report that
where they have had regular contact, ideally with the same breast care nurse, it certainly
improves their experience of the patient journey. We have done some very interesting work
which we have called a Service Pledge project, where we have worked with breast care units
to raise the standards by creating a partnership between breast care nurses and patients who
have been through the unit and interviewing them about their experience and the things
that would make a difference. Sometimes they are very small things about the service, the
organisation, the waiting room; sometimes it is about post-surgery, having a specific breast
care bay, as opposed to being on a mixed ward. So people generally report very positive
experiences of their contact with breast care nurses but it is generally not as part of the
screening service, it would be post-diagnosis.

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): I think that
there is quite a lot of variation actually in the role of the breast care nurses within the
screening service. I think in my own screening service, and I know in others in London, the
breast care nurses play an absolutely crucial role in the care of the patients, particularly at
that very difficult time for them, when they are called back from the screen, the expectation
is that they are normal, because of course they have not felt anything at all, and to have a
skilled, properly trained, breast care nurse, in the assessment clinic at that time, I think has
been an immense help to many women. Then to have the continuity of having the same
breast care nurse present at the follow-up visit, when they get the result of the biopsy (
“Very sorry, this is the diagnosis”), I think is also an immense amount of comfort. Then the
patient is transferred to the care of the appropriate treating multi-disciplinary team and this
should be a seamless transfer of the nursing care from the screening nurses to the nurses
within the treatment team. I think that that works very, very well indeed.

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): I think that is right. Obviously, when women who are well go for their
initial mammogram, they will not have any contact and may not, at that stage, be aware that
there are breast care nurses associated with the screening service and it is when women are
called back, which of course makes them very apprehensive, because they have been
convinced that they have cancer, and that stage is when they really want their hand held.

Joanne McCartney (Chair): We also heard from them that the range of information that
was given to them was very different from initial diagnosis, like what treatments could be
offered; what the side effects of treatment were, or when they were put on medication,
knowing information about the side effects of that medication. Is there a standard
information pack that could be drawn up, or is drawn up, that could be given to women
embarking on that journey?


                                               16
Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): We are slightly straying into treatment realm here. What is happening
across cancer services in general terms is that people are looking at standardising the
information packs and information that is available to patients who have cancer, not only
breast cancer patients. Also particularly the specialist nurses are looking at what stage it
appears most appropriate to give a patient what sort of information. Just dumping them
with a large pack when they get their diagnosis is not the best way of doing it. It depends
on what treatment that patient is likely to undergo. To give them that information or tell
them about the possible options to help them to come to a decision about the treatment that
they would like and the pathway they would like to follow.

Joanne McCartney (Chair): I suppose part of the danger that we heard about from them is
that they are going to lose that anyway.

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): Yes.

Joanne McCartney (Chair): And they often get worried.

Maggie Alexander (Director of Policy and Campaigns, Breakthrough Breast Cancer):
I think we have come a long way from a survey done about 15 years ago which found that
94% of people with cancer wanted good, accessible, appropriate information compared to
17% who were getting it. Things have moved on. I am eagerly awaiting the launch of the
cancer reform strategy next week which, we are reasonably confident, is going to recognise
the importance of good, not just information, but communication. That means a partnership
with the patient in assessing, with them, what information they would like and need at
particular points in their cancer journey. I think we have gone a long way, but there is still
more to do and I think achieving some sort of consistency is going to be very key to that.
Obviously the charities have a big role to play as information providers.

Nikki Cannon (Screening Co-ordinator, Westminster and Kensington and Chelsea
Primary Care Trusts): I do think, Joanne [McCartney] that we are talking about
promoting the service and being very positive about the quality of it and I think this is an
area as well, where because it is quality assured, because it is a national breast screening
programme, that second stage of screening, where women are called back, that system is so
well in place, I wonder if some of the women you are talking about perhaps have presented
symptomatically which obviously a vast number of women do each year. I think the process
for women who have been called for screening, is very -- I cannot speak for every screening
unit in London, but most of the ones I know and have some personal experience of, is
fantastic. I have never heard of a woman in a screening scenario who has not been given a
named breast care nurse. I think that process, because it is established, because it is
acknowledged as a quality standard, is there in screening services. If women are going to
other services, then perhaps we cannot guarantee that quality.

Maggie Alexander (Director of Policy and Campaigns, Breakthrough Breast Cancer):
There is just one other quick point; we have heard through work with the RCN breast care
nursing forum that there have been, certainly in the last year, threats to some of those
specialist nursing posts and that has caused considerable anxiety amongst our members. It
would be great to have assurance, given the clear value of those posts. We would like to do
some robust research on being able to demonstrate that value in a way that is widely
acceptable but certainly anecdotally we know that there is a very great value to patients. I


                                              17
do not know what the final outcome of this review is, but it would be very reassuring to
know that those posts would be secure and that they would continue to play a significant
role in providing a comprehensive breast cancer service.

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): I think just
going back to the original question posed for this session; the breast care nurses also have a
very clear role in going out into the community and effectively explaining to women’s
groups, liaising with primary care nurses and so forth, about the screening service.

Peter Hulme Cross (AM): Asian communities - those sort of communities that …

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): In my own area
we have been to the Asian communities, Afro-Caribbean communities, Muslim communities,
Black Cancer Care and every group that one can think of in the community.

Peter Hulme Cross (AM): Really? Because that is really important I think because I
suspect that some of these communities do not have access to the information. There are
also cultural barriers and all sorts of things. Face to face contact is just so valuable; time
consuming admittedly.

Nikki Cannon (Screening Co-ordinator, Westminster and Kensington and Chelsea
Primary Care Trusts): Yes, in all areas of community work. We have commissioned a
theatre and health education play which is done by a Midlands theatre group but very much
aimed at Asian women or women from black minority ethnic groups and we have toured. It
comes to London every October. Most PCTs take the opportunity to use that; go out into
community groups in partnership with breast care nurses who are there obviously to answer
clinical questions and allay women’s fears. There is an awful lot of that work that does go
on. You are right, it is important.

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): Then the other side of that is also the education that they do with
professional groups. They will educate GPs and practice nurses and tell them about the
breast screening service so that when they have contact with women that they can provide
them with accurate information as well.

Elizabeth Howlett (Deputy Chair): We are going to move on to radiotherapy treatment
waiting times. They do vary across the capital. I wondered if there is any reason for that.

Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): Well first of all I should explain that our work on radiotherapy
waits has gone on over ten years and we have audited in 1997, 2003, 2005 and we are doing
it again at the minute. It has not been broken down to look specifically at breast cancer, nor
have we looked at individual providers. At the moment the assurance under which we
collect the data, and we have 100% data from 57 radiotherapy units in the whole UK, is that
we will not divulge individual results. So I do not look at individual results, so that then I
cannot say the wrong thing. So I cannot tell you about what goes on in individual parts of
London. If you want me to try and explore that, I can go back to the London providers and
say, “Would they agree to their data being released to you in some form.” We could see if
that is possible and the data would then be very current because it has been collected in the
last week of September.


                                               18
I give you a generic answer as to why things differ. So radiotherapy really, how services are
provided, depends on how the provider interacts with the commissioner and how much
investment they get. So some people do well and other departments go downhill and I think
that has been a problem. We have been working nationally to try and raise the profile of
radiotherapy waits for all patients. We have said since 1993 that all patients should start
treatment within 28 days of decisions being made with them to be treated. If you look at one
of the papers that came round from one of the breast care charities, which I have now lost in
this pile, this one, you have longest waits up to 103 days in here. They do vary on the self-
reported data quite widely. So I think it is really about taking a national perspective and
trying to make it a priority, not only for the provider, but also for the commissioners of care.
I will come onto some of the other questions about how we could do that, but I am very
pleased to see someone here from NHS London. My view is that NHS London, as we have
heard, the NRAG (National Radiotherapy Advisory Group) report, which was the National
Radiotherapy Advisory Group, looking at this problem nationally and making a set of
recommendations to ministers. So that was a statement of the problem and some plans to
take things forward, but it is going to be taken forward, we hope, in the cancer reform
strategy, which we are all rumoured should come out next week. I hope that we will see
radiotherapy and its under-provision admitted as one of the major errors of the Cancer Plan
2000. The way that is going then to be addressed is there will not be a handout from the
Department of Health, it is going to have to be prioritised by commissioners and that is
going to be a local discussion between commissioners and providers. I would like to see
NHS London taking a lead and convening a meeting to look at radiotherapy services across
the board; that there are national benchmarking data going to come out in the next week,
looking at radiotherapy activity; they will be sent to the provider and they will be
benchmarked, they will know where they are in a range of activity waiting times and other
data, but the commissioners and NHS London will be able to ask them to come and share
that data and look at who is where against national benchmarks.

Elizabeth Howlett (Deputy Chair): So that is benchmarks and guidelines, not necessarily
targets? Because we find in the NHS if it is really targeted the service improves.

Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): Yes, I agree with you that the effective thing in the NHS has
been to have a target. I think the question is whether targets have had their day, politically
and in other ways, but certainly it has had a big impact on radiotherapy services. There are
31 and 62 day targets, where the 31 day target is when the patient and the doctor agrees
that a cancer treatment is required, it should be given within 31 days. That only applies if it
is the first treatment and the 62 day target is from when you were referred by your GP to
when you actually get something done, should be within 62 days. Again, it is only the first
treatment. So radiotherapy is most commonly given as a follow-up treatment after surgery
and particularly for 95% of breast cancer patients, they will have had either a mastectomy or
the lump removed and radiotherapy is a follow-on treatment which therefore is not subject
to targets. So it has basically been excluded from the way that targets are written at the
moment. One of the things that we have argued for is that all radiotherapy should be given
within 31 days of the decision to treat. That would be a huge undertaking to actually deliver
that, but that is what we believe would be best for patients.

Joanne McCartney (Chair): Does NHS London agree with that analysis?

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): Yes. I would also like to say that we are intending to invite the cancer


                                              19
networks to work together; that they have agreed to work together on a pan-London basis
to look at the radiotherapy services across London because they do have quite a big impact
on each other and a single service cannot be seen in isolation. I know that you are
specifically looking at breast cancer and talking about the variation in that. Of course, breast
cancer gets treated, as everybody heard, within the wider radiotherapy department, so they
obviously have to prioritise the overall resources that they have in order to fit in all of their
workload, of which breast cancer patients are a part.

Elizabeth Howlett (Deputy Chair): From my area I know that there is one hospital where
they admit to 90 days, that is 3 months, it is extraordinary. What a worry that must be for
someone who has been told, “You have breast cancer.”

Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): Well it is completely unacceptable --

Elizabeth Howlett (Deputy Chair): It is.

Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): -- because we know that it will increase the recurrence rate. So
in the paperwork that I sent you, we have documented evidence that if you wait longer than
eight weeks for your breast radiotherapy, the recurrence rate goes up by 60%. So there is a
significant increase in the risk of the cancer coming back in the breast. So that is evidence
based, in the medical literature. It is not something that needs researching; it is something
that we know. The most recent patient who got extensive publicity was nursed in
Maidstone who was told she had to wait 16 weeks and complained. It was on Prime
Minister’s Question Time and got prioritised locally, but that kind of thing is a disgrace.

Elizabeth Howlett (Deputy Chair): Yes. It is. Are there enough radiologists or is it the
equipment; what is it that is missing here?

Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): Right. Well, again I would refer you to the NRAG report which
is available and I sent the web reference1. There is a summary report of 35 pages, I am
afraid, and 6 other underpinning reports; there is a whole lot of detail, so it is there if people
want to look at it. To make a long story short, essentially it is due to 10–15 years of under
investment in everything; in equipment, but also in staff and in training. So the most
obvious deficit is in radiographers, who are the people who actually lay the patient on the
couch, position them and turn the machine on. There is an 11% vacancy rate nationally in
radiographers; of posts that are advertised and cannot be filled and the dropout rate in their
training programmes is about 35%. So it is a three-year degree course and a third of them
never get to the end. There are a lot of reasons for that which have been looked into,
probably relating to selection; to the fact that you take 18 year olds, then you only see cancer
patients from day one, which does not apply to nursing and medicine. Also it is a very
stressed working environment. So one solution that came out of the NRAG report is to
have a virtual training environment, where they have created a … it is like a computer game
in 3D projection and you can have a virtual machine, which you can control with the
manufacturer’s handset, that you have a virtual patient who you can see inside, you can see
where the tumour is; you can set them up, you can see where the rays are going to go. So we
think that that will be a very helpful training device, where you can learn to use the machine,
when you have not got an expensive machine you can break and you have not got a patient

1
    http://www.cancer.nhs.uk/nrag.htm

                                               20
you can hurt, because you do it wrong. £5 million nationally has been invested in that and
it has been taken up by 95% of radiotherapy centres. So we hope that that will help with the
radiographer issue.

Training positions were doubled, about five years ago now, so more radiographers are
starting to come through. So that was a decision taken by the National Cancer Director,
who said, “Well that is the obvious problem; let us double the number of places.” The
problem is that the output has been less because of the attrition. Similar things apply to
physics, which are the people who maintain the machine, measure its output, work out the
dose and so forth. Again there, there are unfilled vacancies, the vacancies are filled at a
lower grade by people who are not sufficiently qualified and probably overall the knowledge
deficit is about 50%. So again, the biggest part of implementing the NRAG report would be
to address the workforce issues.

Machines are also an issue but more additional ones are being commissioned and we have
recommended that they have advanced technology so that they can do much more shaped
fields and that they can also image the patient at the time. So, certainly even with breast
cancer, the dose distribution within the breast is critically important to late affect, so that
planning the treatment in a more sophisticated way will produce better long-term outcomes.
I think the difficulty with implementing that again is about staff, particularly in physics and
radiography, that these things take longer and need more staff time. You also need more
medical time because you are doing a more complicated plan. So there are staffing issues
across the board and I think bringing in advanced radiotherapy is going to be a big
challenge for the NHS, so we have set up an implementation board across the professions to
try and assist with this and it will depend on funding innovative treatment that are half
research and it will be about what the drivers are and the contracts as to whether this kind
of treatment should be funded by the NHS. In the States already 30% of patients get that
kind of advanced radiotherapy because the insurers will pay for it. So the incentives are
going to be key to how radiotherapy develops.

Elizabeth Howlett (Deputy Chair): Yes. Quite. Do you know what the vacancy level of
radiologists in London is? You said 11%, I think.

Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): That is radiographers.

Elizabeth Howlett (Deputy Chair): Radiographer. I beg your pardon. Yes. Yes.

Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): There are not many vacancies for consultant radiotherapists but
a lot of them see many more patients than they should do. So the recommendation is 315
patients a year; I have yet to meet one who sees that few and a lot are running at about 600 a
year. So we have not got vacancies but we would say that we are understaffed because of
overwork.

Maggie Alexander (Director of Policy and Campaigns, Breakthrough Breast Cancer):
Could I just mention I think we would all agree with everything that you have said. Just to
add to it, certainly we have done some work in collaboration with Breast Cancer Care with
women about their radiotherapy experiences and it sort of bears out the consequence of the
service that is terribly under pressure and people describe their radiotherapy, feeling like a
separate service and it needs to be better integrated into the rest of the breast cancer
treatment pathway. They do not get communication about the waiting times and the causes


                                              21
of the waiting times and what is going to happen, so the women worry about the
consequences and the likelihood of recurrence because they have been told that they should
be being treated and they are not. Some of the things that people have thought about -
obviously those who run the service can say more about it - is things like pre-booking
appointments, before surgery and the possibility of extending where the equipment is, in
sound condition, where its use can be extended beyond the current hours. Obviously that
also depends on staffing.

Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): Yes. I think you are right, that having extended hours; we have
done a survey of 1000 patients and shown actually not many want to come after hours,
probably about 20%, but that is enough to fill the time and the difficulty as you say, is having
the staff. I think that the difficulty with pre-booking, so you are having your operation and
will book your radiotherapy, is that you are then prioritising breast cancer patients over
other patients and what you have to do is to solve the problem for everybody.

Within our department we now treat everyone within 31 days, for all indications, because
we have got enough staff and we have got enough machinery and we do not have to start
playing games with saying who we are going to prioritise and, “We will book your
radiotherapy because we know when your appointment is.” I think nationally that has been
considered by many to be inequitable. I agree you can pre-plan breast patient’s care, but in
fact probably the clinical need is greater for a bowel or neck cancer that had just arrived.

Elizabeth Howlett (Deputy Chair): Right. That is excellent.

Joanne McCartney (Chair): Often some acute trusts do not have those services, so they
have to be referred and I am assuming that that creates further delay as well. Is any work
done on how that could be seamless?

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): I think , particularly driven by some of the waiting times targets, that
hospitals are much slicker and the MDT (Multi-Disciplinary Team) co-ordinators in
peripheral units have single points of contact within radiotherapy centres or cancer centres
as to where those patients are referred and they are encouraged to refer at an early stage. So
for breast cancer they do have advance warning that these women will be in line for
radiotherapy treatments. Then of course the other thing is that the clinical oncologists, the
doctors, also go out to the peripheral hospitals and then go back into the radiotherapy
centres so that they have got information coming back from local units to the centres.

Joanne McCartney (Chair): Does NHS London have any data on vacancy rate for
radiotherapists?

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): They have looked at the vacancy rates of radiotherapists and there has been
quite a lot of work done across London. Radiotherapy centres where they have particularly
struggled with high vacancy rates have had quite a lot of initiatives to recruit, including
looking overseas as well, when necessary, to try to fill those. Unfortunately, there are still
vacancies, but they are much fewer than they have been, but it will need people in training to
come through to actually ensure that it is possible to continue with full staffing.




                                              22
Joanne McCartney (Chair): I do not know if you can tell us, but we have heard that there
is an 11% vacancy rate nationwide. Is that comparable in London or are we better or worse
than that?

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): I would have to go back and check those figures.

Joanne McCartney (Chair): Quite useful, I think, if you could do that.

Geoff Pope (AM): Well, Mr Williams gave us a very good description of some of the issues
around the waiting lists, so it does seem as though we understand what the problem is.

By the way, apologies for missing some of this, I was dealing with the media on rail fare
increases, which they find more interesting than breast cancer, unfortunately.

Are there any real steps that we could take in London in the short term to boost
productivity or are you recommending a longer-term strategy, so all of the blockages are
synchronised in an improved, systematic way?

Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): Well, I think it is a long term issue. You can deal with a waiting
list as a short term fix by extending the working day, but it takes a big toll on the staff, who
find it very difficult. And it is the same staff, so you are asking them to work overtime. It is
a job that is very demanding, so I think you can do that if, say, the machine has broken down
and everyone will help to deal with the problem for the patient’s sake. I think you can have
fixes like that, but really it is a long term challenge and I would encourage you to persuade
NHS London to make it a priority to look at it with its providers and I am very pleased to
hear that you are going to look at cancer networks working together and I think looking
across the whole service, and I would think there are also issues about where the service is
provided and so forth, how much travelling there is, about which I know nothing, apart from
it is very difficult in London. One of the things we wrote a report on about three years ago
is devolved radiotherapy units, where you have a centre where you have all the physics and
so forth and you can have a sub-centre where you deliver treatment, preferably with two
machines, so that if one breaks down the other can run longer hours and patients are not
disrupted and I do not know if that is going to be considered for London, because although
the distances are not great, the travelling times are very large.

Geoff Pope (AM): You have got lots of priorities, is this one of the highest priorities to
tackle this waiting list?

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): It is certainly is the priority and I am sure it is going to be made even more
of a priority with the cancer reform strategy that we are expecting to come out next week.
Michael [Williams] is quite clear, this is a long-term problem, but we will be talking to all
the radiotherapy departments just to check that they are making the optimum use of the
resources that they do have available to them, and again helping to share best practice across
London, to make sure that if there is anything to learn from one unit to another that those
lessons are learnt.

Geoff Pope (AM): The longer term approach, who will be driving that forward and how
will that be carried out?



                                              23
Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): I think that is going to have to be in partnership, as we have already heard.
There are issues about training, there may be issues about capital equipment as well as
actually the organisation and delivery of the service, both within a radiotherapy department
and indeed, as treatments become more complex, between radiotherapy and chemotherapy in
order to make sure any care is co-ordinated as well as between hospital trusts, one of whom
may be providing diagnosis and surgery and another providing the radiotherapy.

Geoff Pope (AM): Are you confident that we have got the right networks and partnerships
in place to do this work where we can?

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): It is difficult to know what we have not got at the moment, but many of the
linkages and partnerships are in place to start this work and then we will have to forge any
new ones that it becomes apparent that are needed.

Maggie Alexander (Director of Policy and Campaigns, Breakthrough Breast Cancer):
I think one of the things we do not know yet is what the impact of the move away from
national targets to much more local commissioning is going to be. I hope that there are
going to be ways of monitoring that, so that if it does lead to either improvement or a
deterioration in service, that can be looked at and fixed very quickly. We have some
concerns about the move away from national targets and we hope that the cancer reform
strategy will retain some of those because we think some of them have been very helpful in
driving up standards. Clearly that, linked with what is going to be in the cancer
commissioning toolkit and any changes in the Healthcare Commission in terms of the
emphasis on fully implementing NICE (National Institute for Clinical Excellence) guidelines
and so on, is all going to be very important in this area, but I think that where we stand
today there are a number of uncertainties and considerable concerns, certainly in our
members, about this whole area. We really look forward to working with the colleges to do
whatever we can - whatever the charities and their networks can do to help.

Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): Yes. As far as pull-up is concerned. One of the work streams of
the NRAG was something called RES (Radiotherapy Episode Statistics), which is a horrible
name but it is like Hospital Episode Statistics, which has been going for a long time, where
you have data on who is admitted with what, had what operation and how long did they
stay, and so forth. So for radiotherapy, those data are now going to be extracted nationally
from all the machines. Because they are controlled electronically, everything that happens
to patients is on the database and a data extraction tool has been designed and we already
have, I think it is about two-thirds of people, contributing data. It is going to become a
mandatory data set from, I think, January 2009 and it is going to be collected by most
centres over next year. So that will have who the patient was, where they lived, what the
diagnosis was, how many treatments did they get given, what was the waiting time, was the
treatment plan changed during treatment and was what was delivered the same as the
prescription if for some clinical reason that the patient got unwell and ultimately you can
then link it to the NHS database and get outcomes, is the patient alive or dead in five years.

What that will particularly give you is waiting times from referral by the GP to treatment
and from the decision to treatment. Those will then be available in the public domain, for
everyone to see. That, I think, will become a great driver to improve quality because you
will be able to see that your hospital is good or bad and that the hospital down the road is
better. So that, certainly next year, will be available under freedom of information enquiries


                                              24
because there is no reason to retain it and you could probably ask now and get some data
from London. So my sitting here saying that I have got confidential data, I am not free to
share with you, is going to completely go, because it will be data for us all to see.

So waits is one big thing which will be looked at and the other thing is access which is, “Are
patients who should get radiotherapy actually getting it?” Across the board, probably not.
Probably in some cases, breast cancer patients do not get the radiotherapy that they should
do. So the access rate in the whole of England is 38% of patients with cancer and it should
be just over 50%. So there are 36,000 patients in England not getting radiotherapy for some
reason or another. One particular choice would be distance, so that if you are a woman who
has got breast cancer and you are told, “You can have a mastectomy now and get it all over
with or you can have a lumpectomy and then you have to travel 50 miles every day for five
weeks” and so on and so forth, a proportion of women, because of the inconvenience, will
choose to have a mastectomy. So all those data will be available through the RES project. If
the right questions were asked, then the answers are available.

Geoff Pope (AM): That is really interesting, but it does not take away -- it seems to me as
though the real problem is the fact that there are not enough staff and the training
programme is losing potential staff. That is really the big issue for making a step change in
waiting times, is it?

Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): Yes. Well that has already started to be addressed, but I think
one of the things is going to be getting the service prioritised and funded to have capital
investment and to pay for the salaries of people who have been trained. What we do not
want to go down the road of, as began to happen last year in diagnostic radiography, was
that radiographers who were trained could not get a job. So you have got to produce them
and you have also got to employ them.

Joanne McCartney (Chair): What is the training? How long is the training?

Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): For radiographers it is three years. It is a basic degree and then
there is further training during their career.

Joanne McCartney (Chair): So it is a minimum of three years from start to finish?

Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): Yes.

Geoff Pope (AM): I think you mentioned best practices. Is this linked in with the fact that
we have had a number of submissions highlighting the need to maintain radiotherapy
machinery much more effectively to allow sufficient time for regular maintenance? It sounds
a fairly basic issue, is that something which is an issue that needs to be tackled?

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): All machinery needs to be regularly maintained in order to keep it working
correctly. I think there is a question about when that maintenance takes place; whether it
takes place during hours when patients would be willing to be treated, during office hours, if
you like, or extended days and whether it is done overnight or at weekends.




                                              25
Geoff Pope (AM): So I mean you were talking about best practices, that is why I thought if
we could find some good practices where the down time is at an inconvenient time for
patients, if that could be spread as good practice that would surely help.

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): Yes, I am sure that would. I think there are other good practices in the way
that staff are deployed within particular units and which groups of staff are being asked or
allowed to undertake what types of procedures and making decisions. For example, within
London, some units experience difficulties and delays in getting decisions made about
treatments for patients because the doctors go out to other hospitals and may not be
available within the radiotherapy centre to actually sign off the prescription for that
particular patient and looking at ways in which that can be done, either by the use of
technology or else by enabling other staff, or allowing training other staff to enable them to
undertake some of those tasks.

Geoff Pope (AM): Well it is good to hear that there are some potential quick wins as well
the long terms improvements.

Joanne McCartney (Chair): That is right.

Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): The servicing issue involves about 20 days a year and I agree
with you that it is first of all servicing the machine to make sure that it is working properly
and then quality assuring it and measuring its output to make sure it has not changed. So
there is a lot of work checking what is delivered. It would be better if it is outside the
working day, the problem with that is you are then targeting another staff group for an
unattractive working life, who are also in short supply. The other solution which we have
adopted in Cambridge, where we have eight machines, we in fact have seven teams of
treatment people and they move round so that they move according to which machine is
being serviced. It also allows you to have very rapid response to a breakdown, you just
move to another machine, unless of course the machine is already in pieces. So that way of
working has been recommended in the NRAG report, called A Service Continuity Machine.
In fact you use your machine, overall, I think it is 96% of the time. So it sounds terribly
wasteful, but in fact it is a very efficient way of working.

Geoff Pope (AM): It is a bit like an IT network, that this back-up is built in. We do it with
data, so maybe we should do it with people as well.

Elizabeth Howlett (Deputy Chair): Can I just ask one question? I read somewhere,
probably in the Times Health Supplement, whichever it was, that there is a new way of
treating breast cancer, that you zap the patient during surgery. Is that so? Did I misread
this, or is …?

Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): No. Well there are two approaches; one is putting a device in
with a ball on the end, closing the wound and then irradiating it and the other is doing a
similar thing shortly after the treatment. It is being promoted by Michael Baum [former
Professor of Surgery, King’s College Hospital and later Professor of Surgery at the Royal
Marsden and University College Hospital], which is tremendous. The problem is he has not
got long-term outcomes. If it is proven to work then it will be fantastic, that you have an
operation, you have the radiotherapy and that is the end of it. But we do not yet know that
it is as effective as radiotherapy given conventionally. It also does not allow you to assess


                                              26
the histology, look at the margins and so forth. So when a breast lump is removed, there is a
lot of analysis of it has it all been removed and if it has not then they go back and re-operate
on some occasions. So I think it is a very interesting technique but at the moment it is not
proven.

Peter Hulme Cross (AM): Is there a need for a more strategic approach for radiotherapy?
At the moment, all over the country it is a sort of pan. Is there a need for a pan-London
approach, taking London itself and providing radiotherapy services?

Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): Yes. I think that we would hope to see strategic health
authorities taking a lead role, working with the radiotherapy centres and cancer networks
and I think it has been run on too small a basis. It is true that a radiotherapy centre needs a
population of about a million to be viable.

Peter Hulme Cross (AM): About a million?

Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): About a million, so that would give you about six or eight linacs
(Linear Particle Accelerators) or something, but to co-ordinate the service properly, it is
much better to work over a bigger area and that is what we would look to the strategic
health authorities for and I think you should look to NHS London for that. I think that
would provide a much better service and have much more long term planning because you
need to link, as has come out in this discussion, into education and long term investment,
you need to have a plan to continually replace the machines. Once they have got beyond ten
years old they may still function but they will be out of date in what they can deliver. You
need to upgrade the software that controls them, every three years. So you need a planned
programme of investment and a planned programme of education over a large area.

Peter Hulme Cross (AM): That is not unusual. With IT equipment, you plan to replace it
on a cycle, software upgrades come along quite regularly and so on.

Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): That you do not work in NHS is quite clear, because it is an
enormous battle …….

Peter Hulme Cross (AM): Yes, you are quite right there.

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): I was going to say that within London we are divided into the five sectors,
or the five cancer networks, each covering a population of about 1.5-1.8 million,
approximately. So that gives you approximately one radiotherapy centre per sector each,
type of thing. Then we are proposing that those five cancer networks will work together to
look at the radiotherapy service, pan-London. Of course there are some bits of the
population sitting just outside London who will come to London and us. So more flow is
coming in that way, rather than going out the other way. So we will get the cancer
networks to work together on a pan-London basis and look at what it is best to do, pan-
London. Then for the individual cancer networks to work with their individual radiotherapy
services to look at how it is best provided within that particular sector.

Peter Hulme Cross (AM): Because London has an increasing population now. There were
years when London’s population was decreasing, but we are now increasing.


                                              27
Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): That is always a challenge to work out which way it is going and how long.

Peter Hulme Cross (AM): Now it is increasing.

Geoff Pope (AM): Increasing. Oh, yes.

Peter Hulme Cross (AM): There are lots of indications that we have had from other
sources that it is actually increasing and it is quite a sizeable population.

Geoff Pope (AM): It is higher than the census.

Peter Hulme Cross (AM): Yes. Definitely. Yes.

Joanne McCartney (Chair): There is obviously the consultation at the moment on the
Healthcare for London framework, about having the better resourced centres of excellence.
I am wondering whether what we have been talking about today fits into that and we are
looking forward and seeing how many changes in London would fit into a possible new
scenario of how we would deliver in those specialist centres.

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): Radiotherapy centres are examples of that because they are so very
concentrated at the moment and indeed, what Michael [Williams] has been talking about is
possibly dispersing some to make them more accessible. So it is the balance between the
very concentrated radiotherapy centres and yet that works against the accessibility and we
need to look at how we strike that balance but certainly cancer care is being developed so
that the most appropriate care is given in the best skilled places, with the staff with the right
skills. So it really does fit into that sort of model.


Joanne McCartney (Chair): Well, we have come to the end of our questions, but I am just
going to go through the panel and ask if there is anything that you think we have missed or
we should be looking at? Or, if there is not, if you could just tell us what you think is the
most important thing to improve take up and treatment. We will be looking to make some
recommendations out of this and perhaps you could us what you think your number one
recommendation would be. That would be helpful.

Maggie Alexander (Director of Policy and Campaigns, Breakthrough Breast Cancer):
I think we need a very sound evidence base and when we find it, about what really works,
then a plan for implementing it. This road is littered with pilots and there have been some
very promising pilots and very few of them -- the ones that have been promising - have not
been taken forward. So I would urge the continuing support, but clearly the project that we
are planning to do, the section 64 project, should provide some very useful data and I think
it is going to be vital to share that and the others and then where there are examples of good
and effective practice, to ensure that they are delivered.

Nikki Cannon (Screening Co-ordinator, Westminster and Kensington and Chelsea
Primary Care Trusts): Repeating what I said earlier, as I think there is huge amounts of
work going on across London which do need to be co-ordinated, but first of all we have got
to tackle the GP side of things and engage them.



                                               28
Michael Williams (Vice President and Dean of Faculty of Clinical Oncology, Royal
College of Radiologists): I think you need to hold the service to account for investing in
all these things we have said, equipment, training and so forth and you need to understand
how big the current gap is. So the NRAG report which was produced with us, with the
Department of Health, for Ministers states that overall, in radiotherapy, there is a 60%
shortfall in radiotherapy capacity. In other words, the NHS in England delivers 1.5 million
fractions of treatment but should be delivering 2.5 million and the shortage is in how many
fractions patients get given and some patients, as I have said, not getting any treatment at
all. So there is a huge deficit and what we do not want is a sticking plaster. We want a
major change in the way in which radiotherapy is funded, if we are going to see it get better.

Michael Michell (Clinical Director, South East London Screening Service &
radiologist lead for the London Quality Assurance Reference Centre): I would like to
echo some of the previous comments. I think that there needs to be the continuing co-
ordinated approach to basic research to understand more about how to improve uptake and
then to adopt the appropriate intervention. I think that in the meantime, that we should be
actively promoting the message that this is a very high quality, proven and effective
programme, and if there is any way of controlling the message that the media give out about
breast cancer, they could perhaps change their emphasis from young women with breast
cancer, which makes headlines, to actually emphasising the risk which is more in the older
age group.

Kathie Binysh (Medical Director, West London Cancer Network, also representing
NHS London): I think on the breast screening side, it is about getting the information out
to women, the correct information, that it is worthwhile coming forward for a screening and
participating in the programme within London, which a very high quality programme and it
is a worthwhile thing for women to do. I think that I would like to make the service more
accessible to women by looking at a pan-London call and recall service and being able to
provide them with a single number that they can ring up if they want to change their
appointments.

Joanne McCartney (Chair): May I thank you for coming. You have alerted us to the fact
that the cancer reform strategy may well be published next week. If that is so, can we write
to you and contact you again as to whether you think that strategy actually addresses some
of the points you have made or if it does not, what is still missing, because I think that would
be quite useful for us looking to the future. But thank you very much for attending. It has
been very useful for us.




                                              29

								
To top