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.
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.