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Baroness Finlay of Llandaff
To call attention to measures to improve the quality and quantity of life of people with cancer; and to move for papers.
Baroness Finlay of Llandaff
My Lords, I am delighted to have secured this debate at this time. We are facing a huge upheaval in the way the NHS functions. The good news is that cancer deaths are falling. Cancer control is key as cancer becomes a chronic disease. However, cancer still kills more than 150,000 people a year—a quarter of all deaths in this country. It cuts many off in their prime; 23 per cent of those who die are aged 18 to 64. They often leave behind young children, who carry the details of their parents’ death emblazoned on their memory. Unlike many others in Europe we have excellent registration data that allow us to progress year by year and monitor that, but the EUROCARE study data suggest that we lag behind Scandinavian countries, which are the best in Europe, probably because of delayed diagnosis.
We must improve time survived as well as quality of life for patients, so let us look at the cancer journey, the problems on the way and the issues that the planned NHS reorganisation throws up. Smoking is the biggest single risk factor for cancer. A third of all cancers, and nine out of 10 lung cancers, are attributable to smoking. Cancer prevention through tobacco control strategies is already having an impact; the peer pressure to smoke is less. Tobacco control is cost-effective and a public health success. There is evidence that even once one type of lung cancer has occurred, stopping smoking slightly improves survival time. Can the Government assure me that the planned regulations to ban point-of-sale displays will come into force soon?
I turn to early diagnosis through screening. The breast screening programmes are improving their information to patients to provide a more balanced view on early detection. Bowel screening through faecal occult blood has been rolled out to those aged 60 to 75, but adding flexible sigmoidoscopy at 55 years of age should detect many more early cancers. It is being assessed through pilots already, but in the new NHS how will new screening programmes be advanced, commissioned and progressed? What will happen about the increasing calls for PSA tests for prostate cancer and the problems of interpreting results? How will biopsies be commissioned? As other early diagnostic tests emerge, such as viral testing for cervical cancer, how will they be rolled out nationally?
The biggest challenge we face overall is that of delayed diagnosis. Patients are seeing cancer specialists too late in their disease. The target of diagnostic testing within a week has been abandoned. Patients wait terrified, believing that every day's delay lessens their chance of survival, so if we are to have a patient-focused NHS why has that one-week wait been dropped? In the new NHS, whose responsibility will it be to ensure early diagnosis? Public health should encourage patients to come forward to the GP, who is in turn responsible for diagnostic testing. If the delays worsen, who will be held to account? Currently, GPs act as gatekeepers, sometimes holding the gate too tightly closed. I know only too well that having the right “index of suspicion” is not easy, but who will ensure that GPs examine and investigate, and if in doubt proactively bring patients back in two weeks for review, rather than become overzealous gatekeepers at a time of pressure to limit referrals?
In the GP consortium, what sanctions will there be against primary care if diagnostic delays continue or worsen? Will there be greater powers to counter clinical underperformance? It is not enough to say that a patient can change GP; for the patient subject to delay that is too late. People with suspected or proven cancer want to see a specialist. They will travel to an expert in a centre of excellence with good outcomes, whose team personalises treatment with good information to meet a patient’s individual needs.
Specialist oncology services peer review—the CQuINS report—shows that, despite many recent improvements, 5 per cent of teams are underperforming and some patients are not being referred readily enough to specialist centres. The report shows the impact of national benchmarking, quality assurance and specialist centres. It highlights the adverse patient outcomes when complex surgery is undertaken outside a specialist centre, when there are gaps in the core multidisciplinary team membership, when data use is suboptimal and when communication across organisational boundaries is poor.
The Government have stressed the need for good outcome measures in mortality, morbidity and patients’ reported experience of care. The National Cancer Action Team report illustrates the importance of collaboration, but when each hospital is a foundation trust how will cross-referral be assured? Decision aids are being developed to help patients access information about treatments when various options are available. These are particularly important in conditions such as bowel cancer, where laparoscopic surgery for an early tumour may be the best choice. However, if the hospital does not offer that option, who will be responsible for ensuring that the patient is referred, and what sanctions will be in place if a trust hangs on to patients inappropriately? What will stop competing trusts dabbling in oncological surgery or chemotherapy, especially if the Patient Safety Agency monitoring is cut back? How will the CQC's responsibilities link with Monitor and who will determine whether a local service should continue? What if the GP consortium, the CQC and Monitor's conclusions suggest different decisions?
There is always a balance between locality and centres of excellence, but real choices need to minimise risk. Commissioning along disease pathways will require secondary and tertiary care to be at the table with primary care in planning a whole service to optimise outcomes across the population. Individual needs vary. Cancer management is not an off-the-shelf package. It is complex, involving close collaboration between many experts from different fields to personalise care for patients. Patients cannot possibly know the ins and outs of each option. Choice per se can be a red herring. The choice that is important to patients is the choice of appropriate treatment, with people working together, driven by clinical quality assurance not financial gain. The previous Government instigated quality standards development by the National Institute for Health and Clinical Excellence. Can the Minster assure us that this work will continue to inform the national outcomes framework?
When it comes to non-surgical cancer treatment, radiotherapy and chemotherapy are the mainstays. Where will the levers for building capacity lie? Radiotherapy will have to be centrally commissioned, given the need for major capital investment. Techniques such as intensity-modulated and image-guided radiotherapy reduce toxicity by ensuring accurate targeting of the tumour at every dose. CyberKnife, which was featured in the news yesterday, and results from the prostate radiotherapy trial in my own centre in Cardiff, have shown remarkable results. Other super-targeted techniques are developing apace. We know if radiotherapy is poorly targeted; there is a 20 per cent deficit in two-year survival. How will the commissioning board ensure that the ongoing functioning of a modernised unit is not starved of funds locally by a consortium?
As chemotherapy also becomes more targeted, new genetic tests indicate who is likely to respond. For example, colon cancer patients with the K-ras mutation have a much higher chance of responding to Cetuximab, which costs about £1,000 per dose. The test costs £140. It is really good value for money. In 4 per cent of non-small cell lung cancers, the presence of a specific fusion protein indicates likely drug response, allowing far better patient selection and avoiding inappropriate chemotherapy for those who will get only side effects without a response. Quality control and economies of scale suggest that it is better to invest in a few laboratories to do all such tests nationally. Will these be centrally commissioned or left to the randomisation of market forces?
There is evidence that patients treated in research-active cancer centres have better outcomes overall, whether or not they are in a clinical trial. The National Cancer Research Network has increased patients entering trials from 4 per cent to 18 per cent over the past decade. The investment is reaping rewards for everyone going through these services, so will research-active units be commissioned as accredited centres nationally? Major advances occur, often sporadically, in a research-rich environment. The human genome project revealed that the B-Raf mutation is a key trigger in melanoma, with a B-Raf inhibitor showing a short-lived but dramatic effect in 60 per cent of patients with the mutation.
The cancer drugs fund was welcomed, but now that it has been handed out to local SHA decisions a postcode lottery has emerged. Avastin for bowel cancer is funded in Newcastle for first-line therapy, in London only for second-line therapy, and in Wales and Scotland not at all—in line with NICE’s recommendation. Rather than abandon NICE’s decisions, with its rigorous processes, would it be useful to discuss variable parameters around their QUALYs assessment mathematics, or will litigation eventually set a precedent before NICE’s role is reconsidered and reinstated?
Palliative care has a role during active treatment, not just at the end of life. Recent research published in the New England Journal of Medicine showed that early palliative medicine interventions in patients with lung cancer improves the quality of life and mood of patients, including lower depression scores. This was a proper randomised controlled trial, analysed on an intention-to-treat basis, so the data are very robust. The surprising finding was that those who had prospective palliative care lived longer, with an average of three months’ extra life of better quality, than those in oncology who were referred only as the clinician saw fit. Given the impact that my discipline—I declare an interest—of specialist palliative care services has across the UK, will the Government ensure that such services are commissioned at a local level in line with national guidance, with stated minimum levels of specialist palliative care staff everywhere, recognising the enormous contribution of charitably funded hospice inpatient, daycare and home services?
For the 150,000 people who will die of cancer this year, whose preferred place of care is often home, seven-day services are essential. However good the cancer care, it is a disaster if it falls apart over a weekend. All the good is undone. I suggest that England should follow Wales's example of seven-day working by dedicated palliative care teams, with consultant advice available 24/7 everywhere. I declare my interest here, too. It is proving very effective at low cost. If the local supermarket is open seven days a week, why is our NHS fully operational for only 30 per cent of the time? Seven-day working would be a more efficient use of valuable resources in primary, secondary and tertiary care.
We face a huge upheaval in GP commissioning that raises more questions than it answers. I was privileged to be part of the original Calman-Hine committee that recommended cancer centres and units, with national standards. Cancer services have come a long way since then. Multidisciplinary teams and tumour site-specific groups are firmly embedded across the UK's NHS services. There is real anxiety that market forces may fragment this progress. Services from screening through primary care to secondary and tertiary care must be planned and integrated. The cancer journey will be a far better pathway if there is integrated planning. Patients will live longer and better. Independent living allows them to return to economic activity. If young patients die early, it is their children who carry the scars and burden of bereavement for the rest of their lives.
Delivering high-quality care depends on co-operation between professionals. The idea of any willing provider, and competing hospitals, is anathema to the collaborative model of delivering stable, high-quality healthcare. We cannot promote fragmentation if patient outcomes in cancer are to continue to improve, as they have done so dramatically over the past 10 years. I beg to move.
Viscount Bridgeman
My Lords, the whole House will be grateful to the noble Baroness, Lady Finlay of Llandaff, for securing this important debate. In her speech she once again reminded us of the leadership that she continues to give in this field, which is of continuing urgency. I declare an interest as a former chairman of St John’s Hospice in St John’s Wood, central London.
I will speak briefly on care at home in the context of cancer sufferers. A joint report by Healthcare at Home and Dr Foster estimates that delivering end-of-life care services at home could save the NHS £160 million, yet only a quarter of patients are able to die at home. It is worth talking through what a well organised hospice—and I am happy to say that there is a gratifyingly large number of them—is able to achieve with Hospice at Home.
The totem words are “hospital avoidance”. The core of the home service is a close relationship with community nurses and GPs. However, the important point is that there is also a team of carers without formal qualifications who are given basic training at the hospice. They will look after the patient's basic needs such as washing, bed-making and shopping. Often, they become effective counsellors, which is particularly important to long-term cancer survivors as it can restore their confidence to get back into the world around them. These carers not only provide a valuable human resources augmentation, but they can at any time call on the community support team of trained professionals and on the resources of the hospice. It has been said to me that the fact that the patient can be cared for at home is in itself one of the most valuable and effective palliative treatments. So it is, if one can use the term respectably in this context, a win-win situation. The patient, often very confused and terrified of any form of hospitalisation, has all the familiarity of home surroundings; at the same time, hospice and hospital beds are freed up and, significantly, Hospice at Home is a cost saving for the health service.
I have referred to long-term cancer sufferers, for an increasing number of whom life expectancy has been prolonged thanks to new and effective drugs. The noble Baroness referred to clinical developments in palliative care which are assisting this extension of life, which is of course pertinent to the subject of this debate. This extended life expectancy will provide additional demands on community and palliative care nurses.
The Government’s commitment to 24/7 community nursing is to be welcomed. More of concern, however, was the announcement in the comprehensive spending review that the Department of Health will no longer financially support the previous Government’s commitment, given by the then Prime Minister personally in a speech to the King’s Fund on 8 February, to provide one-to-one nursing services for every cancer patient. That said, however, I was encouraged by the remarks of my honourable friend Paul Burstow, the Minister for care services, in another place on the debate on rarer cancers on 27 October. He said that the Government are re-examining the question of one-to-one support. I shall very much welcome any further reassurance that the Minister can give on the current position and on one other small point. Can any initiative provide for the requirement that, wherever possible, a terminally ill patient’s preferred place of death is recorded? I do not need to point out how useful this information is in planning the care of cancer patients.
Lord Kinnock
My Lords, I naturally join the noble Viscount, Lord Bridgeman, in thanking the ever-vigilant, ceaselessly campaigning and profoundly knowledgeable noble Baroness, Lady Finlay of Llandaff, for initiating this debate. In my contribution, I want to focus on the need for improved measures of information, advocacy and treatment relating specifically to prostate cancer.
In the UK, around 36,000 men are diagnosed with prostate cancer every year, making it the most common cancer in men. More than 10,000 men die each year from the disease—about 12 per cent of the total number of men killed by cancer. Only the rates of lung cancer exceed those figures among men. Prostate cancer mortality rates have remained almost constant for the past 20 years in the United Kingdom.
Against that background, I offer the argument that this major killer, which on average takes the life of more than one man every hour, should be a high-priority target of policy-makers and medical practitioners, as it is a disease which, if diagnosed early, can be very effectively treated and even cured in many cases. The requirement of early diagnosis is therefore vital. To fulfil it properly, however, several barriers of ignorance and cultural diffidence have to be dismantled, advances have to be made in the knowledge and practices of general practitioners, as my noble friend Lady Royall has emphasised on previous occasions, and far stronger efforts must be made to implement policies which have been approved by successive Governments but have not been applied with the necessary vigour.
The need for the first development—combating public ignorance—is graphically illustrated by the fact that, while at least 10,000 families, neighbours and workforces every year suffer the loss of a male relative or friend, seven out of 10 adults do not know what the prostate gland is or what it does. Forty-six per cent of respondents to a reputable survey earlier this year were unaware of the prevalence of prostate cancer. The same survey also showed that 70 per cent of the men questioned were not aware of the existence of the prostate specific antigen blood test, which so far is the only easily administered test that can identify a prostate abnormality and, helpfully and indicatively but not unerringly and conclusively, show the presence of cancer.
As a result of these factors, the simplest of measures to improve the quantity of life of men with prostate cancer would be hugely to increase printed and broadcast publicity about the nature and incidence of the disease, the need for the earliest possible diagnosis and treatment, the existence and the limitations of the PSA test and the right of men—recognised and accepted by the current and previous Governments—to make an informed choice about whether to have a PSA test, and to get the test on the National Health Service if they want it.
That established entitlement to make an informed choice is crucial. Indeed, I would make the argument that the full and effective exercise of that right requires the introduction of a national programme of screening that is comparable with the programmes for detecting breast, cervical and bowel cancer. The National Screening Committee has, I know, been consulting on this matter, and I would be grateful if the Minister could now say what, if any, conclusion has been reached on those consultations. I would also like the Minister to respond to the following questions.
First, it is now three years since the Department of Health’s cancer reform strategy recognised the need to explore new approaches to improving the information about prostate cancer and the PSA test. No new approaches have been introduced or even piloted. I would like to know whether action is going to be taken.
Secondly, the Government’s worthy and continuing policy—explicitly expressed by the Chief Medical Officer in July 2009—of recognising men’s right to make a universally informed choice about having a PSA test, and to be tested on the NHS if they want it, is commendable. However, that policy must be embraced by the cancer reform strategy, supported by much more resonant and widespread publicity, and communicated more directly and rigorously to general practitioners.
Finally, I emphasise the irreplaceable role of GPs in achieving improved knowledge about the diagnosis and treatment of prostate cancer. But I also underline the need to deepen and widen the awareness of GPs—a need which is made emphatic by the following survey results. 75 per cent of the 250 GPs surveyed by the Prostate Cancer Charity this year were not aware of government guidelines for delivering information to men about the PSA test. 75 per cent of those surveyed said they never or only occasionally had unprompted discussion about the PSA test with asymptomatic men aged 50 to 70. 15 per cent of the surveyed GPs said that they do not support the right of asymptomatic men to have access to the PSA, even if requested by the patient on the basis of an informed decision. These findings are cause for concern. I do ask the Government, forcefully, to take their responsibilities seriously, to implement their policies and to secure a new level of awareness and action, particularly among GPs.
Lord Clement-Jones
My Lords, I, too, congratulate the noble Baroness, Lady Finlay, and pay tribute to her for her tireless campaigning on cancer services. At the outset, I want to recognise the great progress made in cancer treatment and survival rates under the previous Government. I welcome the coalition Government’s commitment to refresh the cancer reform strategy. I also welcome the other actions that they are taking and the additional resources being made available to cancer services, such as the cancer drugs fund announced in the comprehensive spending review and committing the funding needed to deliver 1,200 additional specialists involved in cancer services by 2012. I welcome other measures to expand access to certain therapies and the raising of cancer awareness, but as the noble Baroness, Lady Finlay, so ably put it, more needs to be done.
Given the time available, as vice-chairman of the All-Party Ovarian Cancer Group and a former trustee of Cancerbackup, whose cancer information service is now part of Macmillan Cancer Support, I want today to concentrate essentially on the implementation of information prescriptions on issues relevant to ovarian cancer diagnosis and treatment. Research by Macmillan Cancer Support shows that 93 per cent of cancer patients want to be “very or fairly involved” in decisions about their treatment and care. My late wife, Dr Vicky Clement-Jones, who founded Cancerbackup, rightly described,
“knowledge as the antidote to fear”.
Information is the key to realising the vision of a patient-centred NHS. To make informed choices, a patient must be enabled and empowered with the right information at the right time. The creation of information prescriptions was announced in 2006. These would be designed to offer cancer patients high-quality personalised information and support at key points through their treatment. The pilot schemes for information prescriptions have shown the significant improvements they can make to the delivery of information. If every cancer patient received an information prescription as standard and was supported in understanding the information given, it would also help to tackle health inequalities. So it is extremely heartening that the coalition Government have made,
“no decision about me without me”,
the central theme of their health reforms.
But despite progress on information prescriptions in general, we are still awaiting the publication of the Department of Health implementation plan for cancer information prescriptions. The implementation plan needs to be launched as quickly as possible to guarantee that every cancer patient in England has an information prescription by 2012. Information prescriptions should be routinely offered to all cancer patients so that everyone can receive high-quality personalised information at key points in their cancer treatment.
I now come to issues relating to the less common cancers such as ovarian cancer. I pay tribute to Target Ovarian Cancer, the Eve Appeal, Ovacome and Ovarian Cancer Action variously for their work, information and advocacy in this field. After breast, lung and bowel cancer, ovarian cancer is the fourth most common cause of cancer death in women. It is estimated that at least 400 women’s lives could be saved each year if the UK matched the average European survival rates for ovarian cancer. England has the lowest ovarian cancer survival rates in Europe, and the UK as a whole is very close to the bottom of the table.
I have welcomed the Government’s commitment on spending on cancer drugs, but before treatment it is important to ensure early detection. Currently, 75 per cent of women with ovarian cancer are diagnosed once the cancer has already spread and successful treatment is much more challenging to achieve. Improving early diagnosis for women with ovarian cancer is essential in order to give them the best chance of survival. It is imperative that action on symptoms awareness and access to diagnostics is taken as a matter of urgency. To do that, women in the general population must be made aware of the symptoms of ovarian cancer, and of the importance of acting on frequent and persistent symptoms. Awareness of ovarian cancer is much lower than it is for symptoms of breast, lung and bowel cancer. In 2008-09 the Department of Health accepted that there is now robust evidence on symptom patterns for ovarian cancer that distinguish it from other conditions. I understand that NICE guidance on recognition and initial management of ovarian cancer will be published in April 2011.
I welcome the signs and symptoms campaign recently announced by the Department of Health, but it will focus essentially on breast, lung and bowel cancers. There do not appear to be plans to invest in ovarian cancer. GPs must also have prompt access to the diagnostic tests that help them to decide who should be referred urgently, and they should be updated on new developments in symptoms research. In autumn 2009, it was announced that all GPs would have access to urgent diagnostic tests for bowel and ovarian cancer within a week. That commitment to one week was removed in the CSR, but it is not clear whether there is still a commitment to make sure that all GPs have access to these tests. I would very much like to hear the Minister’s response on that matter.
I turn briefly to another site-specific cancer, lung cancer. Despite improvements in service provision, the UK still has one of the worst lung cancer survival rates in Europe. The recently announced awareness campaign will cover lung cancer, and I welcome that, but there is still a need to develop screening programmes because it is the only cancer among the main common cancers which does not have such a programme. The National Lung Cancer Audit shows that only 51 per cent of lung cancer patients receive any form of active treatment. I join with the British Lung Foundation, which states that more lung cancer patients should be considered for active treatment, with all centres learning from best practice, in order to bring about better patient outcomes.
Finally, I wish to express concern about the impact on world-leading cancer research of a cap on immigration for tier 2 migrants. My noble friend Lord Ryder, as president of the Institute of Cancer Research, expressed this extremely well in the debate in October on immigration controls. His fears are well founded and I hope the Minister will reassure us that exemptions can be put in place, along with answers to the other issues I have raised. I look forward to his reply.
Baroness Pitkeathley
My Lords, I thank the noble Baroness, Lady Finlay, for securing the debate. No one is more fitted to lead such a debate, and it is a privilege to take part. It is a privilege, too, to speak in your Lordships’ House from personal experience. It is even more of a privilege that, thanks to the expertise and dedication of NHS staff at many levels, I am alive to participate, as I have twice recovered from cancer—although on the second occasion it was a very close run thing.
As well as to that expertise and dedication, my recoveries—in the plural—can be put down to two things: early diagnosis and proper follow-up care. On early diagnosis, I am delighted that I share the view of the noble Baroness and of Professor Mike Richards, the cancer tsar. He was recently quoted as saying:
“if you wanted to sufficiently change outcomes from cancer I would not spend £200 million on expensive cancer drugs; I would spend it on earlier diagnosis and involving GPs”.
That was certainly my experience.
The first time that I was found to have cancer was due to the vigilance of my GP, as I had virtually no presenting symptoms; he just had an uneasy feeling that something was wrong so he sent me to see a consultant. The second diagnosis was made no less than 14 years later as a result of the screening that I was still having, although, admittedly, only occasionally. On that occasion, another primary cancer was detected in another part of my colon. I was considerably more ill the second time and spent a long time in hospital, but the important thing was that all the cancer was removed. Although I was constantly back and forth between intensive care and the ward, there was excellent liaison among all parts of the system.
In this context, I want particularly to mention the work of patient emergency response teams, which are now often referred to as critical intensive care outreach. My team was based at the Middlesex Hospital—it now operates at UCH—and ensured the liaison between teams that is so important to patients. The period of transfer between intensive care and the ward is often difficult for patients. I commend those teams.
I have mentioned the elements that I believe led to my recovery and to the excellent health that I now enjoy because, like the noble Baroness, I fear that they may at this moment be under threat because of the spending programme that is being implemented. We keep hearing that the money for the NHS is ring fenced but, as a 0.1 per cent real-terms increase is nowhere near enough to keep pace with demand, I wonder how these services will continue. As the coalition has abandoned the one-week target for cancer test results, literally more people will die as a result of late diagnosis. That figure is currently estimated at 10,000 per year.
Much late diagnosis is due to patients not seeking treatment until it is too late, so I hope that the Minister can assure the House that the Government have no plans to scrap screening programmes or those promotional activities designed to ensure that people seek consultation. As a result of there being a possible hereditary element to the cancer that I had, my son and daughter also have regular colonoscopies. Will such services fall victim to the “must do more with less” mantra? Sadly, there are still too many people who find a possible diagnosis of cancer so frightening that they put off consulting a doctor until it is too late. I am sure that every one of your Lordships could name a friend who has ignored obvious symptoms such as weight loss, unexplained bleeding, coughs and so on. That is one reason why those of us who are fortunate enough to have recovered have an urgent responsibility to say so and to help remove the fear that gets in the way of seeking help.
I do not see how, in these hard financial times, we can possibly be thinking of spending £3 billion on an NHS reorganisation, which few seem to want, without it further affecting the services that are so vital to early diagnosis. Moreover, I fear that giving the bulk of the resources to GP consortia will run counter to the liaison between hospital and locally based services, which proved so helpful to me. GPs will have to decide whether treatments are necessary, affordable and the cheapest option, but the care will be in the hands of the hospital consultant. How is that likely to benefit the patient? At the very least, it seems to provide much opportunity for delay and little encouragement for the integrated services that cancer patients often need. We must be wary, too, about GP consortia becoming so overloaded with their commissioning functions that they cease to have as much interest as they should in promoting lifestyle changes, such as smoking clinics and exercise clubs, which are so important in the prevention of cancer.
I finish with a plea to remember the families and carers of those with cancer. They, too, need to be involved in the process and fully informed, as they will often provide the bulk of the care. I know that confidentiality of information is an issue, but that can usually be resolved. If families do not know, they cannot help. Cancer affects the whole family and we need to remember that.
Baroness Emerton
I, too, congratulate my noble friend Lady Finlay on raising this debate and on so eruditely setting out the complexity of the integrated care plans for patients suffering from cancer. It is important to ensure a seamless service to patients who, together with their families, as the noble Baroness, Lady Pitkeathley, said, are filled with trepidation by the word cancer.
I shall highlight the importance of specialist cancer nurses. A recent report from the Royal College of Nursing entitled Changing lives, saving money states that evidence to date demonstrates that specialist nurses play a vital part in a range of ways in assisting patients through a complex pathway by delivering high-quality specialist care. They frequently help avoid unnecessary admission or readmission to hospital. They reduce post-operative hospital stays, thereby freeing up consultant appointments for other patients. They provide treatment at the point of need, so reducing patient drop-out rates. They assist in the education of health and social care professionals, provide direct specialist advice to patients’ families and ensure rapid referral if necessary to other medical treatment, so reducing waiting times.
A survey conducted by health advocacy groups nationally demonstrated that patients consistently rate the specialist nurse higher than any other healthcare professional in understanding patients’ needs. Specialist nurses provide a lifeline to many patients and families, the patient having gone through incredible physical and mental upheaval. While the good news is that survival rates have increased, patients will continue to need to access expert care and support. It is also proven that specialist nurses’ expertise keeps patients safe and exposes them to less risk.
The noble Viscount, Lord Bridgeman, mentioned the recent announcement in the comprehensive spending review that the right to one-to-one nursing care for patients, having been promised, is to be rescinded. I have heard that further consideration is being given to this decision. Will the Minister confirm that? Evidence points to unequal access to cancer specialist nurses across the country, and it is also reported that one-third of them are supported by the Macmillan Cancer Support.
Commissioners need to address as a priority whether there are enough specialist nurses to meet patients’ needs. Local management needs to ensure that the skills and expertise of specialist nurses are not deployed to fill gaps in ward or department staffing, as this is a waste not only for patients but also in economic terms. Another study shows that if provision could be made for administrative support for specialist nurses it would save 6.6 hours per week per specialist nurse. Specialist nurses are highly qualified and educated mostly to masters level and are too precious to be deviated from their dedicated programmes which would result in a loss of care to patients.
It is a known fact that patients prefer to be cared for at home where at all possible. Obviously early diagnosis is vital in order that treatment starts immediately; the majority of patients starting with surgery. With the least invasive approach, the length of stay in hospital is reduced and then the requirement is for expertise in the home by specialist nurses and experienced nurses in post-operative care. The Marie Curie and Macmillan nurses provide a very good service.
The noble Viscount, Lord Bridgeman, also spoke about the Healthcare at Home service as a leading provider of home care to cancer patients. The service has developed over the past 15 years and continues to grow, and now includes the administration of highly cytotoxic chemotherapy regimes to patients at home by highly skilled experienced nurses. The service delivers 24/7, 365 days a year and has improved efficiency and safety by investing in bespoke industrial leading infrastructure and new technology. It continues to develop outcome measures.
The service works in partnership with the Department of Health. The important thing is that the patients who have received Healthcare at Home are still maintained by their clinical teams, who retain ultimate responsibility for patients and with whom Healthcare at Home maintains close contact. Evidence so far shows improved outcomes, as has already been mentioned by Dr Foster Intelligence, and that a considerable amount of money has been saved.
Innovations as described by Healthcare at Home certainly cannot be ignored in taking forward the ways to increase the quality and quantity of life for cancer sufferers. I mentioned the good news of improved survival rates and much work is being developed in Living with Cancer. Emphasis on this work needs to continue with education to patients and the public as mentioned by the noble Lord, Lord Clement-Jones. This is an important point for all patients, their families and their friends. Healthcare professionals are taken up with the actual delivery of care, but there needs to be healthcare provision by experts in setting out the information that is so necessary for the understanding of the general public as well as patients and their friends.
Lord Howard of Lympne
My Lords, I rise with some trepidation to make my maiden speech in your Lordships' House. It is, after all, more than 27 years since I last made a maiden speech, so I am certainly out of practice. I am also cognisant of the many warnings I have been given about the differences between your Lordships' House and the House in which I was privileged to serve for those 27 years. It may take me a little time to adjust, but I assure your Lordships that I shall do my best.
I am most grateful for the welcome I have received in your Lordships' House, to the staff for their unfailing helpfulness and, particularly, to those in the information technology department who laboured so long to ensure that I was properly connected.
Before I turn to the subject of this debate, perhaps I could be forgiven for saying a word or two about the place from which I take my title. The spelling of the name, of course, bears only a passing relationship to its pronunciation, which is a frequent cause of confusion, but I suspect that it shares that distinction with many other places from which your Lordships’ titles are taken.
Lympne is a village in my former constituency where my wife and I have the pleasure and privilege of living. It dates back to Roman times when Portus Lemanis was built to protect the Roman ships in the harbour, which then existed below where the current village is situated. It also features frequently in books by HG Wells, who lived nearby. It is mentioned in both “The First Men in the Moon” and “War of the Worlds”, which may have something to do with the fact that, more recently, several observers have claimed to see unidentified flying objects in the vicinity of my house. I am afraid that I have never seen them or been in any way aware of their existence, so I cannot confirm, but nor of course can I deny, the veracity of those accounts.
It is a privilege to be able to take part in today's debate. I do so for two reasons. The first is the kind of personal reason that I know touches so many of your Lordships. My father died of breast cancer 44 years ago at the young age of 49. This coming Saturday would have been his birthday. He died at home and was wonderfully cared for in his last days by a dedicated group of nuns whose selflessness far exceeded any praise I could bestow on them.
The second reason is that, in a few days’ time, I shall have the honour of succeeding my noble friend Lord Newton of Braintree, who I am delighted to see sitting beside me this afternoon, as chairman of Help the Hospices. I am conscious that my noble friend’s shoes will be very difficult to fill, but the opportunity of helping this great movement in however small a way was one that I could not turn down.
For the hospice movement, to which tribute has already been paid in this debate by, among others, the noble Baroness, Lady Finlay, and the noble Viscount, Lord Bridgeman, is surely one of the finest jewels in our healthcare crown.
“We lead the world in quality of death; many developed nations must work to catch up”.
These are not my words; they are the words of an independent report commissioned recently by the Economist Intelligence Unit, which went on to say:
“The UK has led the way in terms of its hospice care network and statutory involvement in end-of-life care and ranks top of 40 countries measured in the index”,
which that report drew up. It quotes Sheila Payne, Director of the Institute of End of Life Care at Lancaster University as saying:
“The UK has perhaps had the longest period of sustained charitable development of hospices and, more recently, limited statutory involvement and investment”.
I am of course conscious of the fact that today's debate is about cancer patients and about the quality and quantity of the life of those patients. Although hospices increasingly care for patients suffering from conditions other than cancer, it remains the case that a large majority of the people they look after do have cancer. Indeed, local hospices support almost 28 per cent of all people diagnosed with terminal cancer. What is perhaps less well known is that access to high-quality hospices and palliative care is important not only at the very end of life but often from the point of diagnosis. Many hospice patients are supported by their local hospice for many months or even years, benefiting from a suite of flexible services that are tailored to meet their own individual needs.
Something else that is not very well known is that 70 per cent of hospice care is provided in people's own homes through a range of community and home care services, including hospice at home, day care and out-patient care. In recent years there has been a dramatic increase in the number of hospice patients supported in their own home. In fact, between 2004 and 2008 it increased by 58 per cent, and this trend is continuing.
What is most remarkable about all this is the extent to which it has been achieved with a minimum of financial help from the Government. Health services are funded separately by the devolved Governments in each nation of the United Kingdom. In England, the Government contribute an average of 32 per cent of running costs for adult hospices, predominantly through primary care trusts, and about 15 per cent for children's hospices. The rest has to be found by charitable fundraising. Together hospices raise £1 million pounds a day to pay for the services that they provide. Almost 100,000 volunteers work in hospices throughout the United Kingdom, and the hospices could not do the work they do without them. It is hardly surprising therefore that my right honourable friend the Prime Minister, answering a question in another place from the honourable Member for Worcester, said on 30 June that,
“the hospice movement ... has been one of the great successes of the big society that we have in this country. I think we all cherish what the hospice movement does”.—[Official Report, Commons, 30/6/10; col. 859.]
Of course, challenges lie ahead, and we look forward to the Demos report on those challenges which is to be published next week. I hope to have something to say about those challenges on future occasions. For the moment, conscious of the need in this speech to eschew any hint of controversy, I content myself with commending to your Lordships the enormous contributions made by the hospice movement to the quality and quantity of life of people with cancer.
Lord Hameed
My Lords, it is a matter of great honour for me to follow the maiden speech from the noble Lord, Lord Howard. It stands out as a unique piece of thought and vision, for which I am sure we would all want to congratulate him and to wish him many great and productive years in this House, in the ongoing contribution to this country, its Parliament, leadership and democracy which he has made over the years from the other place.
Turning to the debate, I was given some statistics by Cancer Research UK which I would like to share with your Lordships. More than one in three people will get cancer at some stage in their lives. Nearly 300,000 people are diagnosed with cancer each year in the UK and one in four people will die from the disease. However, cancer survival rates have doubled in the past 40 years, and now half of people diagnosed with cancer survive for more than five years. Yet outcomes from cancer diagnosis in the UK remain behind the best performing countries in Europe. The diagnosis of cancer in the UK is often late. This is one of the primary factors in the UK’s survival rates being behind those of other countries. This tendency for late diagnosis has a negative impact on both the quality and quantity of life of people with cancer because if cancer is diagnosed early, treatment is nearly always more likely to be effective. Estimates suggest that up to 10,000 deaths could be avoided each year if we diagnosed cancer earlier and ensured access to appropriate treatment.
Cancer prevention is the most cost-effective approach to saving lives. Extensive research indicates that alcohol is definitely a cause of cancer. In particular, alcohol consumption increases the risk of oral cancer and cancer of the oesophagus, or food pipe, the oral cavity, pharynx and larynx, as well as increasing the incidence of bowel and liver cancer. Vegetables and fruits contain antioxidant nutrients such as vitamin C and carotenoids, folate and a range of phytochemicals. Studies indicate that each daily portion of 80 to 100 grams of fruit or vegetables halves the risk of oral cancer, reduces the risk of squamous cell carcinoma of the oesophagus by approximately 20 per cent and of stomach cancer by about 30 per cent.
Surgery cures more patients than any other type of treatment. It is another strong argument why early diagnosis is so imperative. With late diagnosis, surgery becomes less feasible and effective. Further progress should be made in rolling out new surgical techniques, such as laparoscopic surgery, robotic surgery and radio surgery across the United Kingdom. Radiotherapy services in the UK lag some years behind those in other, comparable countries. Planning should incorporate the need to replace radiotherapy machines once they have reached the end of their working life.
Improvements in research mean that the treatment of cancer with the use of chemotherapy and other systemic agents is rapidly changing. The rate of introduction of new drugs is accelerating and the number of patients benefiting from such treatments is rising. Patients are increasingly being treated closer to home, while chemotherapy is becoming much more targeted and tailored to individual cancers.
Providing patients with access to high quality information is a prerequisite for them to be able to participate in decision-making about their care and reduce their fear of cancer. Individual patients will want to acquire information in different ways. For many, face-to-face communication with a health professional they trust is of paramount importance. Many people wish to be cared for and to die in their home, but the number of people able to do so varies significantly with age, geographical area and by condition. The key challenge facing all of us who are committed to caring for people at the end of their lives, and their families and carers, is making sure that even in times of economic uncertainty, high quality palliative and end-of-life care is available to those in need.
An independent evaluation of Marie Curie Cancer Care by the King’s Fund found that there was an increase in the proportion of deaths at home and a corresponding decrease in deaths in hospital. It was shown that the proportion of those able to die at home could be doubled. Evidence therefore shows that this can be done through providing good quality services in people’s homes, at no extra cost to the NHS. These changes can only be brought about through partnership between health and social care agencies and professionals, local authorities, voluntary organisations, community groups and individuals working together to mobilise a community to meet the need of their local population. This allows more people at the end of life, with their families and carers, to choose what is best for them.
Lord Beecham
My Lords, I come to this debate two years after my wife was diagnosed with inoperable bowel cancer and with secondaries in her liver and lungs. I therefore hope that your Lordships will bear with me if I speak in a more personal vein than is perhaps usual in debates in your Lordships’ House. My wife was diagnosed after some months of suffering from constipation. Her GP did not refer her to a cancer department—despite there being something of a family history—although in all fairness, as it turns out, it was probably too late in any event. But it is quite significant that constipation is not always recognised, even by some bowel cancer charities, as a significant symptom. It is to be hoped that that matter can be addressed in alerting the public in future to the need to seek advice.
I join most of the speakers who preceded me in paying tribute to the noble Baroness, Lady Finlay, for securing this debate and in particular for her emphasis on the quality of life. My wife was very realistic about her prospects. She did not chase after alternative treatments. She did not seek second opinions. She was determined to make the most of what time was left to her. Within a couple of months of being diagnosed, she made an acclaimed documentary for BBC North East and Cumbria about her condition and about the need for people to seek advice. She even wheeled on a footballer who had previously captained Newcastle United and Scotland to participate in that programme. Indeed, only last week I was approached by somebody quite unknown to me while shopping who had seen that programme and who had, as a result, sought advice and undergone a colonoscopy.
Not only that, my wife subsequently underwent a caecostomy in 2009, which made her a stoma patient. Of course, stoma patients have suffered from a variety of conditions, not just cancer, but together with other stoma patients she went on to make a DVD called “Have Bag, Will Travel”. It was trying to explain to both patients and their friends and, indeed, to practitioners about how to cope with stoma. That is also now being much used. It is available on YouTube and is being used and disseminated in hospitals, universities, medical schools and the like. She had undergone chemotherapy; at first, it seemed to be successful but the tumours began to grow again. She then had a second course of chemotherapy, which did not work; finally, she was treated with cetuximab. She passed the gene test, probably marginally, but alas the treatment did not work. However, NICE did its job. It was an approved treatment and, with some more luck, she might have been able to benefit from that.
However, she went on in her efforts to promote information. As a life coach and counsellor, she then organised a group counselling course for a number of other women who were cancer patients. That has been written up in a booklet called Moving Forward, published by Coping With Cancer. The aim of the booklet is,
“to provide tools to help people who have experienced cancer to reassess their present situation and move forward with their lives”.
That also is now being quite widely disseminated.
In the mean time, she received excellent treatment and support from the new cancer unit at the Freeman Hospital in Newcastle, from her district nurses and from Macmillan nurses. These were all very helpful. In her last weeks, a series of aids and adaptations were installed extremely rapidly. She did not in fact live long enough to gain the benefit from them, but close collaboration between the adult services department of the local authority and the PCT led to those being installed. There are considerable advantages to the close collaboration of those two organisations. Finally, she went to a hospice and received excellent treatment there. As she wished, she was sedated so that her last two or three days were spent without pain.
A number of policy issues arise from this and, of course, from many other similar histories. The first is to promote a better understanding of symptoms, not only among patients but among practitioners. The second is to welcome the improved screening; I am now speaking particularly about bowel cancer. The previous Government instituted tests by faecal smears. The present Government have promoted flexible sigmoidoscopies, although it should be pointed out that my wife had a sigmoidoscopy but it was not able to detect the tumours; the process does not go far enough, as it were, whereas colonoscopies do. I understand it to be the case, certainly in America and maybe in other places too, that more regular colonoscopies are available and are almost treated as routine. That could have a significant effect on detecting cancer early. Although I would not of course expect the Minister to make any kind of commitment, perhaps he would like to comment on the possibility of going beyond the further use of sigmoidoscopies. I would also like the Minister to comment on the provision of stoma nurses because it was apparent, certainly in our area, that there was a limited number of stoma nurses in the community. It would be helpful to have more of them.
A further issue is psychological support, which is the subject of the booklet that I have just mentioned and which again perhaps needs further emphasis. There again, GPs really must be encouraged to have closer contact with cancer patients.
There is also the question of support for the charities that the noble Lord, Lord Howard, so eloquently referred to: Macmillan, Marie Curie and the hospice movement. It is of course wonderful that so many people devote time to, and raise funds for, those hospices, but surely it is time to recognise that perhaps a greater degree of government funding and support is necessary.
Many patients, and my wife was one of them, would like to die at home. It was not possible in her case and perhaps not appropriate, but for many others it would be. I endorse the views of noble Lords who have called for further efforts to ensure that that is available to more patients.
Baroness Hussein-Ece
My Lords, I, too, congratulate the noble Lord, Lord Howard, on his excellent maiden speech and on his new important role in leading the hospice movement. I also thank the noble Baroness, Lady Finlay, for securing this debate and for the leadership that she shows in this subject.
All people who have cancer want high quality services and want to be involved as equal and active partners in decisions about their treatment and care. I welcome measures to improve cancer services in the UK over the years. Attitudes towards cancer care and quality of life have changed, and many want to ensure, as has been mentioned, that cancer care and early diagnosis are given the same priority as research into treatments and cures. Improving quality of life matters as much as improving quantity of life.
Dealing with a cancer diagnosis is difficult for both the patient and their family and friends. Being given the right information and support, whether that is someone to talk to, information about specific cancers or advice on benefits, can make a difference and make living with cancer a little easier.
More than 109,000 people of working age are diagnosed with cancer each year. The impact of this usually means people making changes to their working lives or leaving work. The effects of cancer and treatment can impact on people’s lives in many different ways and can affect them for weeks, months or even years after treatment has ended. Fatigue—extreme tiredness—is a very common and frustrating problem, with 65 per cent of cancer survivors saying that they have to deal with fatigue following treatment. Then there are the practical problems when people who are diagnosed with cancer need to take time off from work for treatments or check-ups. Practical problems such as these can make a person’s working life difficult, especially if employers are not supportive or understanding of their needs.
I was interested in what support is currently given to people with cancer to help them remain in work or return to work. The truth seems to be that too many people do not receive enough help or support. There is a lack of information available for people who want to remain in work, and there seems to be a lack of knowledge of legal responsibilities. A supportive employer can be vital in helping someone with cancer return to work. However, new research shows that the majority of employers do not know about their legal responsibilities towards people with cancer—for example, fewer than half of employers know that cancer is covered under the Disability Discrimination Act. Equally, employees also lack knowledge of their employers’ legal obligations to them, and so will often not request the support they are entitled to.
Fewer than 40 per cent of people with cancer know that cancer is covered by the DDA. From 1 October this year, all disability discrimination legislation falls under the Equality Act, as we know. Under the Equality Act, employers must consider requests such as flexible working hours or physical adjustments to the workplace from someone who has cancer. If they meet these obligations, they can avoid potential discrimination charges along with damage to their reputation, legal fees and lost time. Employers who support an employee with cancer will generally foster a greater sense of loyalty from them and improve engagement and morale. Seeing a colleague supported in this way can also reinforce other employees’ sense of fairness and trust and fosters a positive image of that particular employer. Sometimes it will take a minor adjustment to help that employee to remain in work. I ask my noble friend the Minister what can be done to address the lack of information to patients on this matter.
I turn to an issue that, sadly, is not consistent across the UK. Overall, England spends 5.6 per cent of its healthcare budget on cancer, compared with 7.7 per cent in France and 9.6 per cent in Germany. Spending on cancer services has increased by an estimated 36 per cent over the past five financial years, but survival rates have not improved at the rate they should have done, given the increased investment. In January this year, research found that patients from deprived areas in England were more likely to have a late cancer diagnosis and be admitted to hospital as an emergency, as a study suggests. Women and older people also fare worse in getting a prompt diagnosis, as a study team from University College London found. Patients from deprived areas were also less likely to undergo key procedures for rectal, breast and lung cancer, despite the good news that there was a downward trend in the proportion of patients with breast cancer admitted as emergencies. In all, though, patients from deprived areas, older people and women are more likely to be admitted as emergencies.
We know, as has been mentioned, that good-quality palliative care, which helps the most seriously ill and terminally ill to make the most of the time they have left, can provide a period of quality of life for terminal cancer patients. A recent study found that patients who started, soon after their diagnosis, on palliative care along with usual cancer care lived nearly three months longer than people given only standard cancer care, even though this second group had more chemotherapy. I touched on my own experience in a recent debate in your Lordships’ House when my own late father had a very late diagnosis followed by an extremely poor standard of care. This seems to vary from hospital to hospital. Older people are also less likely to receive appropriate pain control than their younger counterparts. This is especially so for patients with dementia.
We need to focus not on the question of additional resources but on ensuring consistency across the country. Older people in particular should be given the same treatment as a young person.
Baroness Masham of Ilton
My Lords, I thank my noble friend for raising this important matter today. I am a member of the All-Party Group on Cancer and I know there are many improvements that should be made.
I know two people who went to our local GP’s surgery for help, only to be told to come back later if they did not feel better. For Lucy, had there not been a three-month delay the outcome might have been different. She was diagnosed with bowel cancer eventually. She had a very hard struggle, which she fought bravely until she died. My other friend went three times to the surgery but was not diagnosed. It is often said that men are loath to turn up at doctors’ surgeries but he did. In the end, with no diagnosis, Mike was taken by his son to a clinic here in London and was diagnosed with prostate cancer straight away. Unfortunately, the delay meant the cancer had progressed to his bones. He is now having hormone treatment. If I know of two late diagnoses from the same surgery, how many must there be throughout the UK?
I read in the Times on Monday that hundreds of people could be saved by a new mix of prostate cancer therapies. It is found that the results in Canada, the USA, Australia and Germany in the treatment of prostate cancer are better than those in the UK. We should find out why this is so. Does the noble Earl agree that when the GP consortia are in place, they should have access to the expertise available to cancer networks to help the effective commissioning of cancer services? Cancer is a set of 200-plus different diseases, most of which have highly complex care pathways. Understanding is needed for both the clinical and longer-term needs of people living with and after cancer.
The NICE appraisal system is inappropriate for dealing with ultra-orphan treatments. It seems appropriate for the remit of the National Specialised Commissioning Advisory Group to be extended to include the commissioning of all ultra-orphan cancer treatments. It is essential that any new decision-making process should be transparent, fair and speedy. There is fear that, with a new organisation within the National Health Service, there might be extended postcode lottery prescribing. Can the Minister assure us that this will not happen? Many pharmaceutical companies are not interested in orphan drugs since they are not cost-effective. However, to the individual patient they are vital.
This week it was announced that an NHS hospital has a cyberknife to treat difficult cancer tumours. This is excellent news. However, last year, on a visit with the health group to the London clinic that had installed a cyberknife, we were told that Turkey has seven. At a drop-in session at St Thomas’s Hospital a few weeks ago, it was shown how the incidence and mortality rates for both prostate and breast cancer in different regions of the country have wide variations. There is a pledge which I hope all Members taking part in this debate will sign. It is:
“I support the UK’s fight against cancer and urge the government to continue in its efforts to bring our survival rates in line with our European counterparts”.
I have been told by a man who has an elderly mother living in south-east Kent, who has cancer and is treated at two different hospitals, that the voluntary drivers who give friendly support to the patients have been told they will no longer receive help with the cost of their petrol. They have also been told that they can no longer have the use of a room with a kettle to have their sandwiches and a drink. These budgetary cuts seem to hit the most vulnerable patients with grass-roots needs. In so many ways throughout a patient’s journey with cancer and other long-term conditions, volunteers—who have often gone through treatment themselves—give great support. This can be lost and dismissed in the costs of high-tech treatment by managers who forget the human needs of a patient’s journey.
Lord Wills
My Lords, I, too, congratulate the noble Baroness, Lady Finlay, on enabling the House to discuss a subject of such importance to so many people in this country, and on her most impressive and comprehensive speech. I cannot lay claim to her professional experience and wisdom but, in the short time available, I will make two points about early diagnosis, which is so crucial to outcomes for people with cancer, as the House has heard so often today in so many moving speeches.
First, I ask the Minister about the Government’s plans to scrap the Labour Government’s commitment to reduce waiting times for cancer tests to one week. There is a legitimate debate to be had about the place of targets in the NHS, but it must be rooted in fact. The Government’s July White Paper states:
“Success will be measured, not through bureaucratic process targets, but against results that really matter to patients—such as improving cancer and stroke survival rates”.
This is a caricature of the previous Government’s health policy. It misses the point that these so-called process targets have been focused on outcomes and have played a significant role in the improvements in clinical outcomes in recent years. Moreover, it is not clear exactly how the Government’s theological position on targets has determined them to scrap the one-week waiting time for tests while retaining the two-week target for seeing a specialist. I hope everyone accepts that reducing the time that patients and their families have to wait anxiously for results must, axiomatically, be welcome. I also assume that it is accepted that the prompter the test results, the sooner any necessary treatment can begin.
So I would be grateful if the Minister could explain exactly why the Government have kept the Labour Government’s two-week target to see a specialist but scrapped the one-week target for test results. All I have heard by way of justification are vague words about there not being enough clinical evidence to support it. Can the Minister provide the detailed reasoning for this assertion and for retaining the two-week target?
My second point is about prostate cancer. Here I associate myself with the powerful speech by my noble friend Lord Kinnock. Prostate cancer is the second largest cause of cancer death in men and has seen no significant improvement in mortality rates. As the House will know, there are specific problems with early diagnosis of this cancer. There is poor awareness of it. Many men, for whatever reason, have been squeamish about discussing possible symptoms with their doctors. There has been a particular problem with the reliability of diagnostic procedures. The PSA test is a blunt instrument. In addition to producing false negative results and a relatively high level of false positive results, it cannot accurately distinguish between aggressive and indolent forms of the disease. This has created doubt about its suitability as the basis for a screening programme. As we know, screening has proved very effective in the successful treatment of other cancers.
On the other hand, last year the European Study of Screening for Prostate Cancer, which surveyed 182,000 men aged 50 to 74 in seven European countries, suggested that PSA-based screening can reduce the rate of death from prostate cancer by 20 per cent, although it also suggested that it was associated with a high risk of overdiagnosis. The Minister will be aware that the Prostate Cancer Charity has been working to develop the concept of universal informed choice to overcome these difficulties. With universal informed choice, it would be not for the Government to make the decision on screening but for the individual, on the basis of properly informed choice. The Government’s role would be to create the circumstances and conditions in which everyone was enabled to make such an informed choice by ensuring that every man over 50 and younger men at higher risk would have access to balanced information about the PSA test.
The charity has suggested three models: one that is GP-led, one based on community walk-in clinics and one based on roadshow clinics. The Minister will I am sure be aware that these are not necessarily alternatives but could well be complementary. Whatever model is adopted, it would, as my noble friend Lord Kinnock pointed out so powerfully, have to be supported by regular public awareness campaigns and consciousness raising among healthcare professionals.
I should be grateful if the Minister could say whether he believes that this approach could play an important role in at last reducing mortality rates of this cancer. If he does not agree, I would be grateful if he would explain why. But if he does agree, can he say what steps he will take in the next year to implement this new approach? For example, will the revised cancer reform strategy endorse the need for universal informed choice in relation to prostate cancer screening?
I recognise that this debate has already been wide-ranging, so the Minister may not have the answers to hand or have time to address all these questions fully. In that case, I would be grateful if he could write to me with the answers.
Lord Crisp
My Lords, I, too, congratulate my noble friend on securing this debate, with its focus on patient experience, and on her forensic presentation of the risks of fragmentation. I am sure that we are all looking forward to hearing the Minister’s response.
As many Members of your Lordships’ House will know, I was the chief executive of the NHS for some years. However, I want to use these few moments to talk about the experiences of people with private health insurance who are seeking treatment for cancer. It is clear that the NHS is the priority, and it is important to get it as good as possible for everyone. Where drugs are proven as effective, they should be available to everyone, and I absolutely take the point about early diagnosis. However, this is not the whole story. I understand, too, that private medicine or insurance have their place for some patients, and any debate about cancer care needs to take account of this.
I have learnt about some of the practices of some insurers thanks to the sad experiences of a friend who has cancer. In a nutshell, people who thought they had bought complete cancer care funding find out, sometimes in the worst of all possible circumstances, that they have bought partial cover at best. I was shocked when my friend told me that his insurer was setting limits on his treatment options which were not referred to in his policy documents and, even worse, proposing to change the terms of their agreement after he had started to claim. My friend is a lawyer, who has great determination and a very loving and supportive family. He decided to fight, and got his MP and me involved. We met the insurers and won some concessions which have prolonged his treatment. It should not be like that.
Having made some inquiries, I find that my friend is not alone. I have spoken to a number of consultants who have told me of patients faced with similar problems who are now paying their own way or have given up. I know of one woman who has to make that decision this week.
These would be sad stories but understandable if it had been clear at the outset what their policies covered. It was not. The fundamental problem is a lack of transparency. Insurance policies are all too often vague and confusing. They do not tell people precisely what they have bought or give them the certainty they need at the time they need it most. Patients find themselves in a negotiation where the insurers hold all the cards. The vagueness of the policies allows the insurers to make decisions entirely on their own terms. I have heard some say that this allows them to exercise compassion and to cover treatments that are not really covered. I am sure that they are compassionate people but they also have a financial bottom line, and such vagueness also allows them to be less compassionate.
The Association of British Insurers has a mandatory code of conduct which sets out the information patients should be given. However, even on its publication it was subject to criticism in the industry, with one source saying that it is very difficult to get any clarity over what is and is not covered. It is not just a question of picking up the policy document; we have to consult the medical advisers and heads of claims in each insurer, and even then it is not clear.
Private health insurance is a financial product, and individuals can complain to the Financial Ombudsman Service. By all accounts, this service works well although of course it can be very difficult for patients to pursue lengthy complaints when they are ill. Nobody, however, appears to be looking at complaints or problems which affect groups of patients or the whole industry. The Financial Services Authority has the power to do that, but has not looked into this in any depth, and I believe that the regulatory system is not working.
Cancer research is developing rapidly, with many new diagnostics and therapies. They offer hope but often bring extra costs. I can see that this makes it difficult to provide cover, but it also makes it all the more important that NHS and insurers’ policies develop equally rapidly.
When I was NHS chief executive, I was very familiar with the criticisms that we did not pay for new and expensive cancer drugs and that patients were subject to a postcode lottery, with access to treatment depending on where they lived. We tried to deal with these problems by setting up the clinically led National Institute for Clinical Excellence to assess scientifically how effective the drugs were. Decisions were made in public; NICE is accountable to the public.
More recently, I have campaigned with others for patients to be able to pay for additional drugs which did not meet NICE’s criteria on the understanding that this field is developing very fast and new treatments are being introduced. In 2008 I was delighted and honoured to co-author a piece to this effect in the Lancet, along with the noble Baroness. I am delighted that the previous Government agreed to do this, and I congratulate the current Government on increasing funding for cancer drugs.
The NHS continues to develop its policies and to improve. It could go further, but what about the private insurers? Let me be clear that not all insurers are as bad as those of my friend; when I talk to consultants, they name the same two or three which they believe are very good and the same two or three which they believe are very poor. But the reputation of all of them is damaged. The industry needs to get its act together. The Financial Services Authority needs to act and the Government need to ensure that they review this whole area.
In the mean time, I would advise any patients in this situation to do the same as my friend—to get their MP involved and to fight. I know that this is not the Minister’s responsibility and that he will refer this matter to his colleagues. However, the Department of Health has a responsibility for looking across this whole territory—we have been given wonderful voluntary sector examples of hospices—and at the impact on the NHS of private insurance and private healthcare. My complaints about clarity also apply to the NHS. It is very important that the NHS spells out what treatment people can expect and therefore, by implication, what space may be available for private insurance.
My experience is that people want clarity and certainty. Whether they are NHS or private patients, they do not want to wait around for decisions. The private insurance industry is failing on this, and I believe that the Government and the NHS could do more.
Lord Colwyn
My Lords, despite the fact that successive Governments have generally maintained funding, modern medicine is, I believe, experiencing an economic crisis that has brought changes that have alienated patients and eroded the job satisfaction of physicians. It has become too expensive. The resultant managed care system is making the lives of both patients and doctors difficult. One of the attractions of medicine as a profession was the promise of autonomy. Today, few doctors can succeed in solo practice and most must work in group practices or corporate settings, where they are told how many patients to see in an hour, which treatments are authorised and which are not.
The very success of modern scientific medicine has been partly responsible for this situation. Eliminating infectious disease—the major killer of the early 20th century—has left us to deal with chronic degenerative illness. The success of medicine has also contributed to the ageing of the population. Of course, medical expenses increase the more elderly people that there are.
Another reason for the expense of conventional medicine is its extreme dependence on technology. Medical technology is inherently costly, and unless we change that dependence, there is little hope of cutting costs. Another powerful economic force impacting on medicine is the still-growing consumer movement that is demanding low-tech options for preventing and treating illness. Consumers are very clear about their desire for natural, complementary and alternative therapies. This is not a passing fad but, rather, a sociological trend with deep roots and a great economic significance.
Patients want greater empowerment in medical intervention and they want doctors who share their views about health and healing. They want doctors and specialists who have time to sit down with them and help them understand the nature of their problems rather than just promote drugs and surgery as the only possible treatment. They want doctors who are aware of nutritional influences on health and who can answer questions about the complex array of dietary supplements and natural therapeutic agents in health food stores. They want doctors who are sensitive to mind-body interactions, who are willing to look at patients as mental-emotional beings as well as physical bodies and who will not laugh at them for inquiring about Chinese medicine or therapeutic touch.
Those are all reasonable demands. A problem is that medical schools are not training doctors in the ways that consumers want and many patients are turning elsewhere. At a time when healthcare institutions are economically pressed, medicine cannot afford to ignore where the market is moving.
It is possible to teach both patients and practitioners about the strengths and indications of standard medicine without in any way rejecting its real achievements. Alternative, complementary medicine is a rich mixture of wisdom and folly. A few alternative therapies are dangerous, more are ineffective and still more are unproven, but many conventional practices are also unproven and many are dangerous as well as ineffective and costly. The use of complementary medicine in the treatment of cancer has attracted particular attention because of the fear among oncologists, radiologists and cancer surgeons that patients may be denied effective and potentially life-saving treatment because of a reliance on unproven fringe techniques. This issue arouses strong feelings among orthodox and complementary practitioners and their patients.
A 1984 study by Cassileth et al found that, in their beliefs about illness and treatment, cancer patients using complementary medicine differed substantially from patients using only conventional therapy. Patients using complementary medicine were more likely to believe that their cancer was preventable, primarily through diet, stress reduction and environmental changes. They were also more likely to believe that disease in general is caused mainly by poor nutrition, stress and worry. Almost 100 per cent of the patients interviewed believed that they should take an active role in their own health as compared with 74 per cent of patients having conventional therapy only.
The challenge is to sort through all the evidence about all healing systems to extract those ideas and practices that are useful, safe and cost-effective. Then we must try to merge them into a new comprehensive system of practice that has an evidence base and addresses consumer demands. The most appropriate term for this system is “integrative medicine”. That term is neutral, accurate and acceptable in academic discussion and it avoids the misleading connotations of “alternative medicine”, which suggests a replacement of the standard system, and of “complementary medicine”, which suggests retention of standard therapies as central and primary.
Integrative medicine is not simply concerned with giving physicians new tools such as herbs in addition to, or instead of, pharmaceutical drugs; rather, integrative medicine aims to shift some of the basic orientations of medicine towards healing rather than symptomatic treatment, towards a closer relationship with nature, towards a strengthened doctor-patient relationship and towards an emphasis on mind and spirit in addition to body. These shifts should make for better medicine in addition to greater satisfaction for patients. I should declare that I am president of the All-Party Parliamentary Group for Integrated and Complementary Healthcare.
Integrative medicine offers the promise of restoring values that were prominent in medicine of the recent past, cutting healthcare costs, improving health and renewing consumer confidence and satisfaction. I hope that my noble friend will confirm that the White Paper will enable and promote patient choice, and that cancer patients and those patients who wish to access complementary therapies will have that access and will not be discriminated against in any way.
Baroness Wall of New Barnet
My Lords, I thank the noble Baroness, Lady Finlay of Llandaff, for giving us the opportunity to debate this important subject. It is a subject which, in one way or another, touches the life of every member of our society. My husband was diagnosed four years ago with an aggressive, inoperable tumour on his tonsils but manages to have quite a good life and is looked after very well within the NHS. There can be few, if any, members of our community, rich or poor, young or old, who do not know someone who suffers from one of the many forms of this diverse condition or, sadly, has suffered, or suffers, from it themselves, for cancer in its various forms is no respecter of class or status.
Even among those of us who have not been touched in these ways, the fear of this condition has probably been with us for some time. We hear much about the war on cancer, but in truth the treatment of these conditions is a campaign, one in which the outcome may be determined at many stages, sometimes, sadly, by the disease itself, but increasingly and positively by the exertions of staff at all levels within our health service. I declare an interest in that I am the chair of Barnet and Chase Farm NHS Trust, which delivers the greatest volume of cancer-related healthcare of any trust in north London. It is clear to those who work in the NHS that enormous strides have occurred in the management of cancer, aided by the investment in funding and purpose of the NHS by the previous Administration. There is therefore both a heavy burden and an expectation on the new Government to maintain and, indeed, increase this commitment. When he responds to the debate, I am sure the noble Earl will assure us that this will be the case.
It is of vital importance in the maintenance of services to our patients, particularly in the present economic climate, that these resources are used wisely and are not dispersed on ill-considered schemes of centralisation, which, while appropriate for some areas of management, often provide an expensive service of no greater quality—often the quality is less good—at a place remote from the patient’s community and friends. Noble Lords are aware of these issues, which are mentioned in the White Paper.
As we seek to improve the lot of those who suffer from this disease, it is important to realise that the greatest possible impact that we as a society can make in improving outcomes is by investing in the education not only of our clinical staff but of society as a whole. As many noble Lords have said today, early diagnosis is undoubtedly the key to better prognosis. In this, much may be gained by ever closer integration of primary and secondary care services that fit together “like a jewelled bracelet”, as Winston Churchill said of the services at D-day. Will the noble Earl assure us that this is the Government’s policy and that it will continue to be so?
However, this will be of little avail if we do not continue the previous Administration’s investment in high technology diagnostic techniques and continue to press forward with the new and innovative surgical and oncological methods now available. It is the experience of my trust, which is among the UK leaders in the application of minimal access and robotic technologies, that these can be applied safely, economically and effectively in the setting of a large district general hospital, with improving patient outcomes and reduced length of hospital stay.
It is impossible to overstate the importance that our patients ascribe to maintaining the highest quality of care for these conditions. However, contrary to the views often expressed by those on committees charged with organising services, our patients are clear that for them one of the most important aspects defining quality of service—let us not forget that they constitute both consumer and paymaster—is local provision. It seems to me that too often current agendas display an arrogance which serves to cover for the self-interest and vested interests of some central institutions in that they believe the service they provide is more important to patients than patients themselves believe.
I should be failing if I did not bring to the attention of the House the concerns felt by our clinicians and patients about the lingering effects of postcode prescribing. We have discussed that in the House before. Nothing can be more corrosive to the local community and its health services than the fear that the quality of your treatment is determined not by your clinician but by your postcode. I therefore welcome the recent announcement by the Secretary of State with regard to the setting up of a limited fund to allow the prescription of some of the recently introduced and very expensive pharmaceutical agents. However, in the individual prescribing, I ask that we make sure that the bureaucratic opportunity is removed and that the clinician is the absolute and ultimate person to ensure that the treatment is applied wherever it properly needs to be.
Other noble Lords have referred to the hospice movement and the choices that people are sometimes able to make at the end of their lives. I endorse and encourage whatever our Government and the noble Earl can assure us about the hospice movement being supported in many ways.
Lord Kakkar
My Lords, I thank the noble Baroness, Lady Finlay of Llandaff, for having secured this important debate. I congratulate the noble Lord, Lord Howard of Lympne, on his excellent maiden speech, defined by the strong values that have characterised his contribution to public life over three decades.
I propose to contribute today on the subject of thrombosis blood clotting, which is common in cancer patients, and in so doing refer your Lordships to the entry in the register of interests where I state that I am a practising cancer surgeon; that I am director of the Thrombosis Research Institute in London, where I lead a large programme of research globally on the problem of thrombosis in cancer patients; and that I have a scientific advisory role to a number of pharmaceutical industry organisations involved in thrombosis research.
We have heard about the important advances in clinical outcomes that have attended many cancers over the past two or three decades; that is welcome. That has been achieved through a better understanding of the biology of many cancers, which allows us to characterise them in more detail and to ensure that targeted therapies can be provided to patients, so improving both survival and quality of life. As we have heard, improvements in the outcomes for patients with malignant disease have also been achieved through earlier diagnosis. That is critical, because many of the advances in surgical practice can be applied only to those patients who present with earlier-stage disease, where radical interventions can in some cases cure, and in other cases ensure long-term palliation.
Advances are available beyond intervention in surgery, through new therapies. One of the exciting developments over the past five to 10 years is targeted biological therapies, which definitely improve outcome and survival but are frequently associated with a high frequency of unintended complications. The agents will improve outcome but can be associated with problems such as infection/febrile neutropenia and, of course, thrombosis blood clotting. Blood clots in any patient population develop in the deep veins of the legs and can often grow up the venous system of the leg, break off and pass to the lung, where they occlude the circulation from heart to lungs and can frequently be fatal. In the United Kingdom, the Health Select Committee of the other place in 2005 undertook a report into thrombosis and blood clots in hospitalised patients—a world first for a parliament—and identified it as a problem, with 30,000 deaths a year associated with thrombosis unnecessarily after hospital discharge.
As a result, we now have a system available throughout the NHS of risk assessment for patients coming into hospital, so that those at the highest risk of developing a blood clot can be provided with appropriate interventions to prevent them. One of the most important risk factors for developing a blood clot is the presence of malignant disease. Some 20 per cent of the total burden of thrombosis is seen in patients with cancer and, regrettably, cancer patients who develop a thrombosis are three times as likely to develop recurrent blood clots during the course of their natural history. Even though they are provided with anti-clotting drugs, they are twice as likely to develop major bleeding complications as a result of their use, so it is a problem.
While cancer patients are in hospital, they will be subjected to risk assessment in the perioperative environment or if they are admitted to a hospital bed for other management of their malignant disease. However, the management of cancer patients extends well beyond a short period in hospital. There are important opportunities to improve clinical outcomes through extending risk assessment into the other care environments where patients with malignant disease are managed. As we have heard, that is at home, potentially in hospice, or in other care environments such as ambulatory care for receipt of chemotherapy in the community. The National Institute for Health and Clinical Excellence has excellent guidelines at the moment on the prevention of venous thromboembolism in all patient populations. When it reviews that guidance, will it take the opportunity to look specifically at the problem of thrombosis in patients with malignant disease outside the hospital setting, and undertake some review of the available evidence with regard to risk assessment in the out-of-hospital environment and the potential use of anti-clotting drugs to prevent thrombosis and potentially improve clinical outcomes?
I ask that of the Minister because cancer patients who develop a thrombosis regrettably have a much poorer prognosis than those patients who never develop one during the natural history of their cancer. With so much emphasis directed rightly on early diagnosis and the provision of surgical intervention or chemotherapy and biological interventions to improve clinical outcomes, we also need to pay attention to avoiding unnecessary complications and to ensuring that the whole spectrum of supportive care for those with malignant disease means that they can benefit from increased quantity and quality of life.
Baroness Morgan of Drefelin
My Lords, I ask the leave of the House to take a couple of minutes to speak in the gap. In doing so, I declare an interest as the patron of the Breast Cancer Campaign and a founding fellow of Breakthrough Breast Cancer. Perhaps more relevantly, given today’s debate, I also declare an interest as someone supporting both my sister and my niece through their own cancer treatments at the moment.
This has been a truly fabulous debate in which noble Lords have touched on almost every aspect of concern around cancer. It has thrown up some significant and challenging questions for the Minister to address, so I do not want to impinge on his time. However, I am particularly concerned about the whole question of the reorganisation of the NHS. Why are focusing our resources—£3 billion in estimate—on that? As the noble Lord, Lord Colwyn, pointed out, it is a time when there are challenges for the cost of care going forward.
Many speakers talked about breast cancer and the improvements that we have seen in outcomes for the 45,000 patients diagnosed with it every year. The noble Lord, Lord Howard, spoke eloquently about his father’s breast cancer. He has personally raised awareness of breast cancer among men; 300 men are diagnosed with it every year. Those improvements have come about because of early diagnosis and awareness-raising by thousands of charity activists. However, also important have been screening and improvements in treatment, most notably because of progress in research but also because of a greater focus on improving service delivery.
I have two questions for the Minister. The first is very much about screening. In the 2007 Cancer Reform Strategy, there was a commitment to ensure that all breast screening units in England had at least one digital mammography set by 2010. I hope that he can update me on progress with delivery of that new technology, which is much more flexible. Secondly, how will the Government continue to work in partnership with charities and voluntary sector organisations to continue to improve the development of infrastructure research projects such as the Breast Cancer Campaign’s national tissue bank—a proposal made following a gap analysis which looked at the barriers to research and how to improve outcomes for people with breast cancer?
Baroness Thornton
My Lords, I join other noble Lords in congratulating the noble Baroness, Lady Finlay, on initiating this important debate. We have had a debate of exceptional quality, but that is only to be expected in your Lordships’ House on this subject. I also join others in congratulating the noble Lord, Lord Howard, on his maiden speech. I am sure that it is the first of many sparkling contributions to your Lordships' House.
I shall start by echoing the remarks of the noble Baroness, Lady Finlay, on tobacco regulation. This seems to be a question that I ask every week. What exactly is happening to the implementation of vending machine bans and point-of-sale tobacco regulation?
The timing of this debate is most appropriate. It is a snapshot of where we are after the previous Government’s work and investment, which have so improved the prospects for cancer patients, and of what still needs to be done. It is also an acknowledgement that change is coming, and poses questions to the Government about what that will mean for cancer patients and their families. It has also provided some suggestions for inclusion in the refreshed, new Cancer Plan.
I was moved by many of the speeches, not least that of my noble friend Lord Beecham, who I am delighted to have as a member of our small but perfectly formed opposition health team. My noble friends Lady Pitkeathley, Lord Kinnock and Lady Morgan made contributions that were enhanced by personal experiences, and my noble friend Lord Wills brought to the House’s attention his forensic ability, which I am sure we shall benefit from as we move forward.
We know that the most effective way of improving cancer survival rates is through prevention and early detection. That is why as a Government we invested in improved cancer prevention and diagnostic services. Breast screening for women, for example, means that 14,166 cases were diagnosed in women aged 45 and over—a figure which is similar to the one the previous year and nearly double that of 10 years previously. The Labour Government also rolled out the NHS bowel screening programme, the first screening programme targeted at both men and women. As a result of cancer screening and the two-week requirement for a specialist to see the patient, survival rates for breast cancer, as for bowel cancer, are improving for those getting this early screening and diagnostic.
The premature mortality rate for cancer is the lowest ever recorded, saving nearly 9,000 lives in 2006 compared with 10 years previously. A recent study by the International Agency for Research on Cancer found that breast cancer mortality rates in the UK were reduced by 30 per cent during the period 1989 to 2006, more than in any other European country. We are on the right trajectory, and it is important to keep moving in the direction in which we have started.
I should like to make a related point to the Minister. It is important to stop allowing this issue to be used as a political football. Andrew Lansley’s continued suggestions that the previous Government somehow failed cancer sufferers is not appropriate. I would be the first to admit that this was work in progress and that there was much more to do, but Mr Lansley does not need to attack the previous Labour Government to justify keeping cancer high on the healthcare agenda.
The Government have, for example, recently used data from EUROCARE that compare UK survival rates of patients diagnosed between 1995 and 1999 and between 2000 and 2002. The data show that the UK has lower survival rates for the most common cancers—lung, breast, prostate and bowel—than other countries with a similar health experience. However, there are two problems with this comparison. Few other European countries have the fully comprehensive cancer registry—referred to by the noble Baroness, Lady Finlay—that England has. Cancer data in Germany, for example, relate to only 1 per cent of the population. This information comes from the King’s Fund. It is also worth keeping in mind that there is a five-year time lag associated with five-year survival rates and that, at the end of this Government, EUROCARE will be measuring the experience of patients diagnosed during the early part of Labour’s Cancer Plan 2000. We know that five-year survival rates for the 21 most common cancers improved for both sexes between 2003 and 2007, compared with the period between 2001 and 2006.
The noble Baroness, Lady Finlay, raised some important questions about the cancer fund. I am still unclear about how the decisions to use this fund will be made and about what will happen if it runs out of money, as it surely will. There are various estimates about the inadequacy of the fund to meet the need. The British Oncology Pharmacy Association has estimated that the real cost of funding treatments will be £85 million this year and £120 million in a full year. We have to ask questions about the fund, which are linked to questions about NICE.
Can the Minister tell us which is likely to save more lives—investing in early diagnosis, or in cancer drugs not approved by NICE? Linked to this is the Government’s intention to downgrade NICE’s work in this area. It is extraordinary that the Government are removing NICE’s authority. It is the one outfit designed to prevent the Secretary of State having to take responsibility for unbearable rationing decisions. As the Guardian reported recently, and as the Minister said, NICE will become “somewhat redundant”. That week we saw the Daily Mail crowing about victory for its campaign. Under the headline “‘Penny-pinching’ NICE stripped of power”, the article stated:
“The scandal of patients being denied drugs just because the NHS rationing body decides they are too expensive will end”.
There is a serious problem here because, regardless of whether the NHS budget is increasing, it is vital to preserve NICE’s integrity and to ensure that the use of all drugs and treatments on the NHS is approved on an equal and fair basis while ensuring that they are cost-effective to the taxpayer. I do not understand why NICE cannot be the body that undertakes the new value-based system which the Government have been outlining. At the end of the day, if the changes go through, how will the Government help those GP commissioners who will be targeted in local campaigns by newspapers and patient groups to prescribe expensive drugs for rare conditions?
I shall return to the issue of waiting lists which I raised in an Oral Question to the noble Earl in the past couple of weeks. I asked about the lengthening of waiting lists for diagnostic tests and its impact on the diagnosis of cancer. Waiting lists for diagnostic tests have almost doubled since Andrew Lansley got rid of the 18-week target. Those are the Government’s statistics, not mine. I clearly did not put my supplementary question to the noble Earl correctly because he told me that I was completely misinformed and wrong. I was pointing out that if diagnostic tests are being delayed, it seems likely that cancer patients will be in that cohort, and that the two-week target—which I am not disputing; I am glad that the Government are keeping it in place—therefore begs the question: how will the Government monitor the consequences of increasing waiting lists for cancer patients and other conditions? Is it acceptable for waiting lists to be lengthening in this manner? How will GP commissioning deal with this issue, and how will the two-week target be maintained under the new regime?
I shall conclude with two questions, one of which picks up on the remarks of the noble Baroness, Lady Hussein-Ece, about people with cancer in the workplace. I am also grateful to Macmillan Cancer Care for sending me a briefing which calls for a set of initiatives to deal with people who want to work and who have, or are recovering from, cancer. Will such initiatives be included in the new Cancer Plan? Macmillan is calling for every patient who wants to work after cancer to be given back-to-work information; explicit outcomes on cancer patients remaining in and returning to work to be included in domain 3 of the NHS outcomes framework; vocational rehabilitation services to be included in cancer quality standards and the NHS Commissioning Board's guidance; and the Department for Work and Pensions to promote employers' awareness of the employment provisions of the Equality Act and their impact on disabled people, in particular those affected by cancer.
Finally, I return to an issue that I have raised before with the noble Lord, namely, the impact of excessive hospital parking charges for those with cancer and other conditions. The average cancer patient pays £325 in travel costs and hospital car parking charges while travelling 53 times to hospital in the course of their treatment. We know that the department's guidance is not working because it is not enforced. Around 60 per cent of cancer patients still have to pay the full price for parking during their treatment, even though DH guidance recommends that hospitals offer free or concessionary rates. Excessive car parking charges are too often the final straw that breaks the camel's back during a highly stressful, emotional and financially challenging time for the patient and their loved ones. We have had a full and fascinating debate and I look forward to the Minister's response.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I begin by expressing my gratitude to the noble Baroness, Lady Finlay, for securing today’s debate and I pay tribute to her for the expertise and leadership that she has shown as chair of the All-Party Parliamentary Group on Dying Well. It is also a particular delight to welcome my noble friend Lord Howard of Lympne and to congratulate him on the not unexpected excellence of his maiden speech.
Cancer, regrettably, touches many people’s lives. In England, more than 250,000 people are diagnosed with it every year. One in three of us will develop cancer in our lifetime. One in four of us will die from it. Today’s debate comes at a timely point, as the Department of Health prepares a new strategy to improve cancer care in this country. While survival rates have improved over the past 25 years, we still compare unfavourably with other leading European countries. We believe that up to 10,000 lives a year could be saved if we could bring cancer survival up to the standards of the best.
One of the main reasons why we languish behind is that we diagnose cancer at a later stage, partly because British people typically present later with symptoms. Cancer Research UK’s cancer awareness measure suggests that only one in three people can recall common cancer symptoms. I agreed with everything that the noble Baroness, Lady Wall, said on that issue. We need to do better, which is why the Government are investing nearly £11 million in new campaigns to alert people to the symptoms of bowel, breast and lung cancer—three of the biggest killers. These will not be the conventional, one-size-fits-all campaigns that we have seen in the past. Most of the funding will go into tailored, local approaches—genuine grass-roots campaigns—firmly evidence-based and using the best marketing techniques to raise awareness.
Once a person presents with suspect symptoms, fast access to diagnostic tests is crucial. The noble Baroness, Lady Finlay, my noble friend Lord Clement-Jones and the noble Lord, Lord Wills, referred to the one-week commitment. The previous Government proposed this policy with considerable fanfare, although they were a little quieter about how it would have been paid for. The price tag attached is very considerable, reflecting the serious practical implications that the policy entails. The coalition’s view is that a blanket one-week access target would not be the best use of the resources that we have and that the proposed target was not based on clinical evidence.
Patients with suspect symptoms are already placed by their GPs on the two-week urgent referral pathway. On average, that pathway is being adhered to. My noble friend Lady Hussein-Ece rightly emphasised early diagnosis. The cancer reform strategy review is looking at what we need to do to tackle late diagnosis of cancer, such as encouraging patients to recognise and present cancer symptoms, supporting GPs to diagnose cancer earlier and improving primary access to diagnostic tests for cancer. The new outcomes framework will give a consistent set of measures and expectations for the NHS to follow. GPs will make their referral decisions based on the best clinical evidence on what achieves the best outcomes.
Of course, good information is the key to this. If commissioners can see what others are spending their money on and what results they are achieving, they are in a better position to make the right choices for their patients. The department is already helping commissioners to interpret the data that they have in order to support better decisions. This includes the latest information on access to cancer services. The noble Baroness, Lady Finlay, asked whose responsibility it will be to ensure that early diagnosis happens once the reforms have taken place. In future, the new public health service will have an important role to play in promoting awareness of symptoms of disease and in encouraging early presentation. Of course, the public health service will need to work closely with the NHS, which will be responsible for having the services in place. We continue to publish diagnostic test and referral-to-treatment waiting times so that service commissioners and providers can address any long waits and variations in waiting times and so that patients can take this information into account in deciding where they want to go for their diagnostic tests. Patient decision aids are one way of helping patients to make better decisions with their doctor about their care and treatment. We are seeking views on the use of patient decision aids as part of the consultation that is under way on greater choice and control.
The noble Baroness, Lady Finlay, asked about the sanctions and levers in the system. The NHS commissioning board will be responsible for ensuring that consortia are accountable for the outcomes that they achieve, for their stewardship of public resources and for their fulfilment of the duties placed on them. The board will intervene in the event that a consortium is unable to fulfil its duties effectively or where there is a significant risk of failure.
Screening is another key way of detecting cancer earlier. As noble Lords will know, NHS screening programmes save many thousands of lives each year. Breast cancer screening alone saves 1,400 lives, making it one of the most effective programmes in the world. However, people should go into screening programmes with their eyes open, aware of what the procedure involves and what the risks and benefits are. Concerns have been raised about overdiagnosis and overtreatment of breast cancer due to screening. We are now redrafting the leaflet that all women receive prior to screening so that those risks are made clear. The new leaflet will be published in the near future.
The noble Lord, Lord Wills, spoke about prostate cancer screening and we heard a powerful contribution on prostate cancer from the noble Lord, Lord Kinnock. As both noble Lords will know, the Government work closely with the Prostate Cancer Charity—as did the previous Government—through the Prostate Cancer Advisory Group. Overarching the advice on screening that we receive is the work of the National Screening Committee, which advises on, and continues to review the evidence for, screening programmes. The noble Lord, Lord Wills, asked whether we would introduce screening for prostate cancer. The NHS constitution states:
“The NHS … commits … to provide screening programmes as recommended by the UK National Screening Committee”.
We have said that we will support the rollout of screening programmes for common cancers where the evidence supports this. On 22 October, the committee’s consultation on screening for prostate cancer came to an end and it will make recommendations to Ministers in due course.
We believe that the new flexible sigmoidoscopy for bowel cancer could save up to 3,000 lives a year. The National Screening Committee met yesterday to discuss how this procedure could be used to deliver best results. The noble Baroness, Lady Finlay, spoke about this, as did the noble Lord, Lord Beecham, in his very moving speech. The National Screening Committee has just met to review the evidence for a bowel cancer screening programme using flexible sigmoidoscopy. The recommendations will be in front of Ministers shortly. The noble Lord, Lord Beecham, also referred to stoma nursing. The Government recognise the valuable role that specialist nurses, including stoma nurses, provide. The noble Lord may wish me to write to him on that subject, which I am happy to do.
The noble Lord also spoke about colonoscopy. I have it on good authority—that of the noble Baroness, Lady Finlay, who has kindly passed me a note—that colonoscopy is helpful but looks only at one point in time. It is not a pleasant procedure and it is not risk-free either, so overall many clinicians believe that there can be better approaches to diagnosis.
After diagnosis, surgery tends to be a key part of the clinical response. New and less invasive surgical techniques are being developed, notably keyhole surgery, but of course access to the new techniques requires trained, specialist surgeons who treat enough patients to keep their skill levels up and the safety risks down. As NICE guidance tells us, this may mean consolidating specialists into regional centres of excellence, where there are sufficient volumes of patients.
The noble Baroness, Lady Wall, spoke about postcode prescribing. I agree that this has been a worry for some time. We need to expand access to cancer drugs in particular. That is why last month the Government launched a consultation on the cancer drugs fund and confirmed that from next year the NHS would receive £200 million a year on top of the £50 million provided for the rest of this financial year. Patients are already benefiting from the interim funding. The Rarer Cancers Forum has said that the fund could help more than 2,000 patients this year alone.
For 2011-12, the cancer drugs fund will continue to be run through strategic health authorities. We believe that that is the best way of balancing responsiveness to patients with consistency and fairness across the system. The noble Baroness, Lady Thornton, questioned whether this was a wise use of NHS money. I simply say to her that I do not see this as an either/or situation with regard to early diagnosis; we need to do both. We believe that, from 2012 onwards, the fund should be taken over by the NHS commissioning board, which will look at how it administers the fund locally. Although the noble Baroness, Lady Finlay, suggested that a postcode lottery was emerging in the cancer drugs fund, we do not have any evidence that that is the case. However, if she has that evidence, I should be very glad to hear about it.
Of course, treatment is not just about chemotherapy; radiotherapy is another key area. We are putting an extra £43 million into proton beam therapy treatment over the next four years, which will benefit up to 400 patients a year by the end of the spending review period. We want patients to benefit from the most sophisticated techniques, such as intensity-modulated radiotherapy. Some services may be more appropriately commissioned by the NHS commissioning board than by GP consortia—again, an area raised by the noble Baroness, Lady Finlay—where large populations are needed for planning and commissioning. Radiotherapy could well be an example of that. I say to the noble Lord, Lord Hameed, that improving cancer awareness and early diagnosis is likely to increase demand for radiotherapy. We need to ensure that capacity is in the right place and that the most effective use is made of existing capacity. We are planning ways in which to boost services so that we can offer radiotherapy to all those who would benefit from it.
Sadly, even with a focus on improving survival rates, some patients lose their battle against cancer. In these sad circumstances, we need to do everything that we can to improve the palliative and end-of-life support that they receive, improving pain relief and emotional support and joining up acute and community services so that more people can die at home rather than in hospital.
My noble friend Lady Hussein-Ece mentioned the recent medical paper on palliative care for patients with metastatic non-small-cell lung cancer. The Lung Cancer and Mesothelioma Advisory Group is currently reviewing this study and will consider its findings as part of its advice to the Government.
My noble friend Lord Howard, in his excellent speech, took us right to the heart of the issue of palliative end-of-life care. The Government recognise the valuable role that hospices play in delivering end-of-life services, in particular for cancer patients, and their good work of course extends far beyond the buildings that they occupy. We demonstrated our commitment to supporting hospices when the Treasury reconfirmed the £40 million capital grant scheme for hospices in the current year, originally announced as part of the end-of-life care strategy. We are concerned to improve the quality of end-of-life care for everyone, regardless of diagnosis, and we look forward to working with the hospice movement to achieve that aim.
My noble friend Lord Bridgeman also spoke on that theme. Too often, a person’s needs and those of their family and carers are not adequately assessed and addressed, including finding out a person’s preferences for the type of care that they would wish to receive and the setting or location in which they would wish to be cared for at the end of life. I agree with my noble friend that advanced care planning is a helpful way of addressing these issues. That was highlighted as a key area within the end-of-life strategy. We recognise the need to ensure that the care that people receive at the end of life is compassionate and appropriate and that it supports the exercise of choice. We confirmed our commitment to improving quality and choice in palliative and end-of-life care in the White Paper that we published in the summer. This includes the commitment to move towards a national choice offer, supporting people’s preferences about how to have a good death.
The noble Baroness, Lady Finlay, asked about cancer centres. The NHS commissioning board will provide leadership for quality improvement through commissioning. This will include setting commissioning guidelines on the basis of clinically approved quality standards developed with advice from the National Institute for Health and Clinical Excellence. However, we recognise the excellent work that is currently done by cancer centres and indeed by cancer networks.
The noble Baroness also asked about foundation trusts and the possibility of the inappropriate retention of patients in certain circumstances. Our long-term vision for the benefit of patients and taxpayers is that care will be provided by responsive autonomous providers who will be accountable to Monitor and the Care Quality Commission. Where specific control mechanisms are needed for providers, these should take effect through regulatory licensing and clinically led contracting rather than through hierarchical management by regions or the centre.
A number of noble Lords, including my noble friend Lord Bridgeman and the noble Baroness, Lady Emerton, whom it is a great pleasure to see back in her place, raised the issue of one-to-one support for cancer patients. We want every cancer patient to have access to appropriate care, support and information, but this must be affordable and sustainable for the NHS. We are reviewing the evidence to see whether one-to-one support can improve care for people after a diagnosis of cancer, as well as ensure the efficient use of NHS resources. We are working with Macmillan Cancer Support to understand the costs and potential benefits of one-to-one support. The results of that work will be made available as part of the review of the cancer reform strategy later this winter.
I return to the powerful speech of the noble Lord, Lord Kinnock, on prostate cancer. He was right in so much of what he said. Survival rates for prostate cancer in England still lag behind those of comparable countries in Europe. Late diagnosis is likely to be a significant contributor and, again, the cancer reform strategy will be looking at what we need to do in this area. I should be delighted to have a one-to-one conversation with the noble Lord if he would find that helpful. I simply add that the prostate cancer risk management programme is in place and that the intention behind it, as I am sure he is aware, is that men without symptoms of prostate cancer should be able to have a PSA test free on the NHS.
My noble friend Lord Clement-Jones raised the important topic of lung cancer. Once again, our survival rates for lung cancer are low compared with those in Europe. We are committed to improving outcomes for those with lung cancer, which is one reason why we have asked the national cancer director, Professor Sir Mike Richards, to lead the review of the cancer reform strategy. I am pleased to learn that the British Lung Foundation contributed to the consultation on the review. We will be publishing in the strategy a future direction for lung cancer care. We know that early surgical intervention can be critical for lung cancer patients, but that is often not possible if the cancer is too far advanced. We have to look carefully at why there is variation, although I think that the low rate of lung cancer surgery is likely to be due in part to late diagnosis.
My noble friend also spoke about ovarian cancer, to which many of the same messages apply. Our public awareness campaign is focusing on the three biggest killers, but the Department of Health has worked with ovarian cancer charities to develop the key messages on the signs and symptoms of ovarian cancer.
The noble Lord, Lord Kakkar, raised the important issue of risk assessment for thrombosis during treatment in a range of settings. I can tell him that that will be an important issue for NICE to consider as it develops quality standards for cancer care.
The noble Baroness, Lady Emerton, powerfully emphasised the importance of chemotherapy at home. The NHS operating framework for this year confirmed the direction of travel towards having more services closer to home. Where there are skilled and experienced staff, chemotherapy in community settings can help to meet increasing demand and provide greater choice for patients.
The noble Baronesses, Lady Finlay and Lady Thornton, asked about our tobacco policy. At the moment, we are considering options for the display of tobacco in shops. We seek to balance public health priorities with reducing burdens on business. Those matters are under consideration by Ministers. It is probably premature for me to discuss the details of the options that we are considering, but an announcement will be made in due course.
I am aware that time has run out. Suffice it to say that I believe that this has been an excellent debate. I undertake to write to those noble Lords whose questions I have not been able to cover. I think that we all agree that advances in medical science mean that cancer is no longer the death sentence that it once was. That is a cause for satisfaction and for congratulating those cancer specialists in the NHS who do such wonderful work. We want to build on those achievements to take cancer care to new heights, to ensure that those beginning treatment for cancer do so with confidence and hope.
Baroness Finlay of Llandaff
My Lords, I thank the Minister for his reply and all noble Lords who have spoken in this outstanding debate. I particularly thank the noble Lord, Lord Howard of Lympne, for having decided for his maiden speech to contribute to this debate. He raised the tone even higher than that set by everyone else in this House.
There are some very clear messages here. People want the choice to be treated well at all times and, to cite the title of the book by the late Lady Beecham, to be moving forward with their cancer and living with it. Integration, not fragmentation, must be the way that the changes take us in the new world that we face. Outcomes can and must improve. Prevention must continue. We must not lose sight of tobacco control.
I finish simply. There has been a call for information from around the House. In the words of the late Vicky Clement-Jones, whom I had the privilege to know, knowledge is the antidote to fear. This debate has demonstrated that.