Professor Pat Price: ‘The NHS can’t run at full capacity – bureaucracy is clogging the system’
Professor Pat Price is interested in my microphone. I’ve asked the renowned cancer specialist to attach a little wireless mic to her lapel, the better to record our conversation. “The better the quality of the audio,” I explain, as we settle down to chat in her flat in London’s Holland Park, “the better the transcription.” For I am also using software on my phone which will automatically transcribe what we say. It’s the kind of technology that when I started my career 25 years ago would have been unimaginably futuristic but today is cheap, simple and eliminates a time-consuming chore.
Price considers such progress with wistful envy. In the NHS, where she has spent her career trying to do far more important things than record interviews, doctors like her are routinely prohibited from using their initiative and on-the-ground experience to make such small improvements. Improvements that, when applied to very sick patients, can make all the difference – bettering care, freeing up precious staff time and equipment availability. Incrementally making, through countless such changes, the whole system run more smoothly. But no. Instead, Price says, the cold, dead hand of bureaucracy crushes attempts to deliver any kind of change. “The rules!” she whispers, like some Soviet dissident in the 1970s muttering about the latest politburo diktats. The tragedy is that in her account those rules are costing lives here, today, in modern Britain.
Her stories quickly escalate. At first, thinking about my microphone, she laments how doctors, unlike me, are prevented from getting their hands on “readily available technology and software to speed up and manage their work”.
“It’s bureaucracy that stops us doing all these things – it’s taking up staff time dealing with it. One doctor was telling me he’s fought for three years with business cases up to his eyeballs for a bit of software that only cost about £3,000 that saved [the need for] one member of staff. Three years’ madness. It should be a case of [NHS bureaucrats] saying: ‘Look, we’ve got these precious staff. How can we help you do your job better?’ Whereas we’ve got it the other way around.
“It's stopping us getting on with what we do and do well. Some of the consultants I know are 30 per cent less productive [than they were]. Why is that? Because somebody got rid of the secretaries; they’re typing their own letters.”
These might sound like the minor inconveniences of a top-heavy system. But in the NHS, careless, petty measures, imposed from on high, cost lives. Inefficiency, as Price describes it, is baked into the system, mandated and enforced from above.
“Treatment… isn’t at capacity now,” she says, causing me to blink in astonishment. This, after all, is a time when barely a day goes by without another story of growing waiting lists, of backlogs in screenings and consultations condemning Britain to slip ever further down international cancer-care league tables, where we have shamefully languished in the relegation zone for far too long already. “Two years ago [the cancer charity] Macmillan was saying we’d need to go around 110 per cent capacity to catch up in five years. We’re going at about 80 per cent capacity. We’re not giving all the treatments we could do if things weren’t getting in the way. There are so many blocks in the system now. The whole thing’s clogged up. Give us the tools and we can be more productive.”
The effect of what she calls “processes and bits of paper” cascades through the NHS, creating a log-jam which prevents the newly-diagnosed getting vital treatment. “Particularly [cancer] surgery,” she says. “Because obviously if they can’t operate [because of diagnostic delays, or because there’s no recovery bed] then that patient with head and neck cancer doesn’t get the operation.”
It conjures the awful image of specialist cancer surgeons desperate to conduct life-saving operations but instead twiddling their thumbs. They must be in despair, I say. “Correct,” she replies.
She moves on to describe other pernicious impacts of red tape – processes that would be almost comic in their self-defeating logic, were they not so obviously awful for both patients, doctors and the taxpayer.
“For instance we’ve got this tariff system in radiotherapy whereby the [hospital] trust actually gets more money for treating patients longer.” It takes me a second or two to work out the implications of this. Then I understand. Efficient care is penalised. Spinning out care is rewarded. “Brilliant! It’s brilliant,” she laughs in what I come to discover is her habitually good-natured disbelief, before returning to seriousness with her understated but categoric judgement. “No, that's not a good idea.”
But the bureaucratic meddling doesn’t just cost money. “Over the last 10 years everything we tried to do has been blocked and stopped,” says Price. “All these advances. We don't understand it.” This time she’s not talking about new computers to replace pen and paper; she’s talking about doctors being prevented from taking advantage of new treatments that can save lives. “For example, we’ve only been recently allowed to give stereotactic radiosurgery [which uses precisely focused radiation to treat tumours] for lung cancer, after we made a fuss and wrote to the Government in August and said: ‘We've got to all be allowed to do it.’ This has been around for 10 years. The NHS had the kit. But this is bureaucracy, bureaucrats [making clinical decisions], saying you’re allowed to do that, you’re not allowed to do that.”
“One of my colleagues from the [Royal] Marsden, he had a lady with a bone metastasis. He knew the stereotactic blast high dose would control that for the rest of her life. He wasn’t allowed to do that. He had to give a lower dose, knowing it would come back. It is madness. Too micromanaged in terms of clinical decisions.”
It is also an oppressive system that makes retention harder at a time when the NHS is critically understaffed. Both in terms of manpower and equipment, she says, inefficiency means “you’ve got all that pent-up resource. We just have to turn this upside down here. And we can be absolutely amazing.” So it’s not like the NHS budget needs to double? “No, no no no. And in fact, the worry is it would then just go on more bureaucracy atop. It could do more with the same amount.” Not that she’s advocating a total cash freeze. Of course not. But small, well-targeted investments – the equivalent of my microphone – and above all the empowerment of frontline staff otherwise staggering under the directives of pen pushers, would in Price’s opinion have an almost magical effect. “The bureaucracy needs to be cast away and just let people get on,” she says. “We don’t need massive breakthroughs in research. How about just treating all the people on time with the standard treatment? It would transform survival in the UK.” Again, she intones, against “the rules”.
But then Price has perhaps always been, in her way, a pusher back against the rules. Not one of those vainglorious rebels, elbowing their way to the front of the barricades to ensure theirs is the face of the revolution, but with the quiet steeliness born of principle. She is retiring (“I don’t like doing media”), and is most excited when talking about the prospects for the kind of technical but vital research with which she made her name. Still, here she is, banging the drum amid post-Covid backlogs for cancer treatment generally and radiotherapists specifically. She may be co-editor of the standard UK oncology textbook and academic clinical oncologist at Imperial College, but she also finds herself the leading figure behind the Catch up with Cancer Campaign. “I’m an accidental campaigner,” she insists.
Many thanks to all parliamentarians and cancer campaigners who attended the #CatchUpWithCancer event ahead of World Cancer Day, to highlight cancer treatment waiting times across the UK, and to discuss the solutions that radiotherapy can offer in tackling the backlog! pic.twitter.com/e2Duf8lg6b
— CatchUpWithCancer (@RTherapy4Life) February 3, 2023
Maybe. But when she describes her upbringing it doesn’t seem so accidental. “It’s not that I’m anti-establishment,” she says, “but I’ve found that I can do more pushing what I think is right. Because a lot of people go very establishment. And in cancer and in medicine, there’s a lot to do for patients and research and if the establishment is doing the opposite, I’d rather do what’s right for the patient. My parents always brought us up [insisting that] whatever talents you've got, use them and use them for the good of others. And that was completely focused on.”
She was brought up in Coventry, where her father had moved during the war to help with the production of aircraft engines as an electrical engineer. Her mother, a teacher, was “very bright”, and Price and her two brothers and one sister were encouraged to strive. Price passed the 11+ and went to grammar school and from there in 1975 to study medicine at Newnham College, Cambridge, completing a single-generation vault into elite academia: her father had left school at 14. “I wanted to be a doctor from the age of seven.”
Rotating through NHS specialisms after graduating, she found that oncology offered the potential for an alluring combination of on-the-wards, face-to-face patient care and academic research. So she twinned a spell at the Royal Marsden cancer centre in London with work at the Institute of Cancer Research before, in 1989, securing a consultant’s role at Hammersmith, south-west London, where she fitted right in. It was, after all, “an academic hospital… full of non-conformists, which made it quite comfortable.”
At Hammersmith her life changed, both professionally and personally. Her first marriage, during which she had two boys, had wound down (“all very amicable,” she says). But on the wards she began looking after the wife, Sigrid, of one of her colleagues, Terry Jones, a physicist working on revolutionary techniques to improve medical imaging. Sigrid, a psychiatrist, eventually died aged just 39, leaving a two-and-a-half year old daughter with Jones, who had two other children from a previous marriage. Eventually, when her two boys were seven and five, Price married the widower, 17 years her elder, creating what Price happily calls “our complex family arrangements”. Now 82, Jones remains a celebrated researcher and is still hard at work.
Pursuing a full-time career while raising young children was not easy. “It keeps you grounded, makes you very efficient and productive, and ensures you don’t take yourself too seriously,” Price says. Her magic lessons for work-life success as a parent: “Don’t try and be the perfect parent – good enough will do; stay very professional at work – people don’t want to hear your childcare problems, just get them sorted; however short the time, make sure your kids know they are the most important things in your life; the evenings and nights are very good times to catch up when they are in bed; and when in doubt hire more help, even if you are spending all your salary on help.”
It was also at Hammersmith that she made her name, pioneering the use of PET scans, which tag molecules with radioactivity to see what they are doing inside the body. This allowed the effectiveness of cancer drugs to be checked without invasive sample gathering or simply experimenting, as was then the norm, by upping dosage. One drug identified this way, temozolomide, went on to become a billion-dollar blockbuster, with royalties flowing back to Cancer Research UK.
It is her contribution to a host of advances in cancer care that have marked her working life: diagnostics and imaging have infinitely improved, the three principal treatments –surgery, radiotherapy and chemotherapy – have become more precise and less toxic. Above all, we have understood that tumours are as unique as the patients they ail, and that treatments need to be tailored to match. What Price calls “transformative” immunotherapies, which harness the patient’s own immune system to kill off the cancer, have emerged to be just that.
But if she talks with ebullience about such breakthroughs of the past, she talks with gloom about care in the present. “This is the biggest cancer crisis in my lifetime or ever,” she says. “The NHS is in a big mess, but cancer needs to be back at the top of the priority list. It’s a real watershed moment. Will somebody listen and help?”
Anyone can understand her urgency. Cancer, as she points out, is one of three key NHS services where time is critical. But while the other two – A&E and maternity – “were really well protected and pushed on in Covid,” her area was not. “I think cancer should have been [protected too]. But there was a lot of redeployment of staff.” Now, she says, new analysis suggests 17 per cent of cases are being diagnosed late. “That’s a lot because then you go from curable to not curable.” She notes that “for every four weeks’ delay in treatment that can mean up to 10 per cent reduction in survival”. In contrast to the well-publicised images of Covid sufferers labouring for breath in hospitals, she worries that cancer victims, collateral victims of the pandemic, will die silently, unnoticed. “If you’ve missed the boat and present late [with cancer] then you may not be dying until you’re at home somewhere in three or four years’ time. We’re only just starting to see that come through. You can’t cancel cancer.”
During the first months of the pandemic, diagnoses of early stage cancer in England fell by a third. By autumn 2020 Macmillan estimated that 50,000 fewer people than expected had been diagnosed with cancer, with 30,000 fewer beginning treatment. “There’ll be tens of thousands of cancer patients who will lose their lives prematurely because of this,” Price said earlier this year. Yet Covid only exacerbated a cancer care system that, compared with peers abroad, was already dramatically failing patients.
The result today is near collapse. Only 72 per cent of patients with suspected cancer are seen by a specialist in two weeks (the target is 93 per cent) and 36 per cent do not begin treatment within the two-month target. In a field where every moment counts, 70,000 people are being made to wait more than 62 days, twice as many as five years ago. And 62 days is itself, says Price, a standard set pathetically low. It is a bar we fail to hurdle nonetheless. “We now actually have a category for 104-day waits, three months late. It’s just totally unacceptable.”
What’s the solution? There are, she insists, quick fixes. The first would be for the government to “accept the problem and accept the scale of it” instead of trying to reassure with “a confusing array of unbelievable targets”.
Rather, she says, out-of-date radiotherapy equipment needs to be replaced, and some of those new machines need to be embedded in communities – 3.5 million people live too far from therapy to make getting treatment easy. Then there’s the better software and tech and the bureaucracy. “Immediately strip out red tape,” she writes to me later to ensure I’ve got the message.
To drive that agenda through, she thinks, a figurehead is required. A do-er. “Get somebody who is in charge of making sure cancer targets are hit and who is completely accountable for delivery – just like the vaccine programme.” The new Kate Bingham? How about Price herself? “I don’t think I’m good enough to do that job.” Well that at least is patently cobblers. Perhaps she just needs to be asked.
If anyone did ask, they would need to convince this woman, who has always been tugged towards the anonymity of the research lab, once again to take on the established order and, as her parents taught her, “[use the] talents you've got… for the good of others”. Maybe she’d have to park for a while her next research aims, looking at the way white blood cells act on disease “in real time” (her eyes light up just mentioning it); there might be fewer trips to the rugby with her family (her husband is Welsh, one of her sons works at the RFU); she might even have to cut back on the running which she says keeps her sane (she has completed the last six London marathons). But even this accidental campaigner acknowledges that she has developed a knack of “speaking truth to power, just calling it out as it is”. And perhaps that is just what cancer care, and the NHS more broadly, needs right now.