The Parliamentary Under-Secretary of State for Health (Jane Ellison)
Before addressing only some—I fear—of the many points raised in this debate, I would like to thank the all-party group, which, as the shadow Minister and others have said, does astonishing work. It rightly, and regularly, holds Ministers’ feet to the flames—my feet regularly feel the heat—but that is a good thing, because this is about driving up standards and pushing us all to work harder and do the right thing in this important policy area.
I also pay tribute to my hon. Friend the Member for Basildon and Billericay (Mr Baron), who brought this debate, and to the Backbench Business Committee—it used to be more fun being on it than responding to its debates—and I also warmly welcome the contribution from, and the presence of, the hon. Member for Ashton-under-Lyne (David Heyes), whose personal testimony greatly enhanced the debate this afternoon. We should also pause to think of our colleague, my hon. Friend the Member for Filton and Bradley Stoke (Jack Lopresti), who is being treated for bowel cancer; our thoughts are with him.
I shall try to reply to some of the many points raised in this fascinating debate. I shall try to respond, to some extent, on the structure of the report and the different domains, and to pick up on some other points made, and I absolutely undertake to get back to colleagues where I cannot respond substantively. As my hon. Friend the Member for Basildon and Billericay said, this is part of an ongoing dialogue, and I am delighted that he will be meeting the national clinical director soon. Out of that dialogue, I think we can progress in some of these areas. Some of the issues are inevitably a work in progress. However, important points have been made and I shall try to respond to as many as I can while updating the House more generally on what the Government are doing.
Many of the report’s recommendations are for NHS England. As I said, I am pleased that the national clinical director is to meet the all-party group later this month. He will find the meeting a helpful opportunity to discuss the report in detail. As I prepared for this debate, I was particularly struck by the fact that NHS England is considering the report in great detail—indeed, it contributed during the consultation phase. I am really encouraged by that, as NHS England is absolutely critical in our new health structures. It is very aware of its responsibilities. Some of the challenge today has been about how we interact and how those new responsibilities settle.
I want to set out some of the actions under way that I hope will provide reassurance about the Government’s and NHS England’s commitment to delivering on our ambition, articulated by other Members, to make England among the best in Europe on this issue. My hon. Friend the Member for Hertsmere (Mr Clappison) said that we had major challenges and a long way to go in that regard, although the shadow Minister was right to say that we are beginning to make significant progress in some areas. However, we recognise that we have a long way to go.
I was first asked to respond formally to the report, and it would be improper if I did not respond to such a thoughtful and well put together piece of work. Obviously, I hope to respond to some degree today, but I will take the report away and certainly respond formally later. Some of that will be about the Government’s responsibilities in holding NHS England to account. I will think about how we can do that.
The first domain that the report addresses is preventing people from dying prematurely. It raises concerns about responsibilities and accountability in the new health system. It is right to challenge on such issues; we cannot pretend that, when there is such major change to a system, everything will immediately be settled and clear. I accept that there is a challenge. Our progress must be as speedy as possible in understanding who is responsible for what—particularly in understanding how we make accountability as transparent as possible and a driver of change and improvement.
We are responding to the new system and the inevitable tensions between devolving power on delivery in a way that empowers clinicians while also being accountable to Parliament. No one could pretend that that is not challenging. I certainly feel that challenge as a Minister; the responsibility for delivering most of that clinical care sits somewhere else, so the issue is about how we respond and account to Parliament for that.
I gently say that we should be careful not to suggest that, in such a large and complex health economy, all was perfectly clear and beautifully directed from the centre before. I respect the shadow Minister’s enormous knowledge of the NHS and I know that neither she nor anyone else is suggesting that. However, in highlighting concerns about where the new system is settling down, it is sometimes tempting to think that previously Ministers had a big lever under their desks that they could pull to make everything right. Even if that was the theory, it certainly was never the practice, as is evidenced by our persistent lagging in some of the key survival statistics discussed today.
The challenge is to respond to the new system and get clarity where there is none at the moment. A number of Members, including the shadow Minister, have mentioned how we hold people to account at the most local level. That issue emerges from this debate as the one on which we have the most work to do and to which we must give the most thought.
I want to discuss how the system is set out. I accept that the way in which we make it work in practice is not necessarily the same as that, but I will go through how we have set out the different frameworks and processes of accountability.
The indicators in the NHS outcomes framework provide the basis against which the performance of the NHS will be monitored. NHS England is responsible for delivering year-on-year improvement and is accountable to the Secretary of State. Those arrangements are set out in the Health and Social Care Act 2012, under which the Secretary of State set out the strategic priorities for NHS England through the mandate. The mandate makes it clear what is expected of NHS England with regard to contributing to the prevention of ill health through the better early diagnosis and treatment of conditions such as cancer.
The outcomes framework sets out different measures against which we hold people to account, and the Department has quarterly accountability meetings with NHS England, through which NHS England’s progress in delivering those improved outcomes is monitored. We will continue to monitor its progress in delivering against the mandate. The evidence showing how it has met the mandate is published, and forms the basis on which Ministers can ultimately judge the success or otherwise of NHS England’s performance.
I entirely accept the point that that is quite a macro way of looking at things, and that Members are also seeking a sense of what can be done on the ground. Perhaps I need to respond in more detail after the debate on the challenges relating to the role of the strategic clinical networks. Cancer has been made a priority for those networks. Making the new networks work is also a challenge for the national clinical directors and other colleagues in NHS England. Their role in relation to cancer is obviously to drive quality and innovation in prevention and screening, survivorship and end-of-life care. I know that NHS England is keen to see the links between the national clinical directors and those respective networks strengthened. There is clearly more to do, and I welcome the fact that the all-party group is in direct dialogue with the national clinical director. I will pick this up with the group and with him after their meeting.
With regard to clinical commissioning group accountability, NHS England is responsible for ensuring that the CCGs secure the excellent outcomes that we want, through commissioning. The assurance framework provides the basis for that assessment. It is an integral part of the agreement of improvements to be delivered locally. When CCGs are found to be at risk of failing to deliver improvements, NHS England will provide the necessary support. Statutory intervention powers exist, but they are to be used as a last resort only when CCGs are demonstrably lacking the capacity to make improvements.
Through “Everyone Counts”, the planning guidance for 2014-15, NHS England has asked CCGs to set a level of ambition for reducing premature mortality as part of their strategic and operational plans. They will be expected to demonstrate progress against those plans. The 2014-15 CCG outcomes indicator set is used as a tool by CCGs to understand trends in outcomes and to help them to identify potential priorities for improvement. It has a range of new cancer measures covering early detection, stage at diagnosis, and diagnosis via emergency routes. I pay tribute to the all-party group for championing the inclusion of those indicators, which have now been adopted, as the hon. Member for Basildon and Billericay said. The indicators will help to ensure that progress is being made on early diagnosis and, in turn, on survival rates.
With regard to the various bits of data, we will shortly have the one-year cancer survival information for patients diagnosed in 2012, which will tell us the stage at diagnosis. This will allow us to calculate stage-adjusted one-year survival, and that will probably represent the most accurate and timely cancer data that have ever been available in England. Using those data, we will be able to populate important indicators in order to drive up improvement, including the public health outcomes framework and the CCG outcomes indicator set, in relation to the proportion of cancers diagnosed at stages 1 and 2—the early stages.
On the five-year data, I am sorry that things have changed since the answer that I gave to my hon. Friend the Member for Basildon and Billericay at Health questions. That was the information that I was working on at the time. NHS England has been working with the London School of Hygiene and Tropical Medicine to establish whether the five-year indicator was statistically valid. When I answered my hon. Friend’s question, the data had not been fully gathered in. Having gathered them in, however, the conclusion was that because of the small number of survivors at five years, disaggregating the data down to individual CCGs would not leave the data statistically robust enough to draw conclusions. It would therefore be unsafe to do so. They are not therefore planning to publish at the CCG level, but they are considering how it can be published at a level that is not only meaningful and helpful, but statistically safe. I understand that this has been disappointing, but I think that the all-party group and Members will understand that the data set is so sensitive that if it was not felt to be safe and robust, it could not be published in that way. We will talk to NHS England about it.
Mr Baron
I very much welcome that explanation, which goes a long way towards explaining the reason for the change in such a short period. May I leave the Minister with the thought that there appeared to be almost a complete disregard of the need to consult? Although I accept that this is NHS England’s ultimate responsibility, the cancer community came together on this issue and it seemed to be completely ignored from the point of view of consultation. Perhaps the Minister will look at that.
Jane Ellison
That is a fair challenge, and I will certainly take it up and raise it. On what we can do with data and transparency at the local level, the Department is looking at a number of things. The Government have tried to use data transparency in lots of different ways to drive improvement and accountability, and we are currently looking at some other ideas which I hope will produce a far greater sense of what is happening on the ground and in someone’s local area. We are very open to suggestions, and some have been made during the debate. I am happy to look at those, but this is an area under active consideration.
There has been a lot of discussion in this excellent debate about awareness and early diagnosis, and we know that it is one of the keys to getting better survival rates. It is central to meeting our ambition of saving the additional 5,000 lives each year by 2014-15, and we have committed more than £450 million in funding to achieving that and doing more on early diagnosis. To date, we have run national campaigns on tackling bowel and lung cancers; we have the Blood in Pee campaign, which hon. Members will be aware of, to raise awareness of bladder and kidney cancers; and we are currently running a breast cancer campaign for women aged 70 and over. The early response to that campaign has been really encouraging.
The shadow Minister raised some of the core public health issues which I spend much of the day job discussing: obesity, alcohol and smoking. I am slightly surprised that we have had relatively little discussion of those in the context of early diagnosis and prevention. Public health has been devolved to local authorities. They have more than £5 billion of ring-fenced money over two years, and all the local authorities I speak to—I was at the Local Government Association public health conference two weeks ago—are excited by the possibilities that that holds for them. There is a fair challenge about where the responsibility sits, but if everyone is doing work on awareness and early diagnosis, that can only be a good thing. Many local authorities are taking seriously the challenge of raising their game locally, and that is in addition to the national campaigns.
As hon. Members will be aware, many of the indicators are very mixed; there is a variety of statistics and variation around the country. I pay tribute to my local Wandsworth authority, whose six-week “get to know cancer” pop-up shop closes this Sunday. A local shopping centre gave the authority an empty unit and it worked with NHS London, staffing the unit for six weeks during the same hours as the shopping centre. It was run on a walk-in basis, and hundreds of people in my local community have popped in to that non-threatening environment to talk to trained nurses and get advice about cancer and some of those important awareness issues. Such local initiatives can only help us in our ambition to do much better.
My hon. Friend the Member for South West Bedfordshire (Andrew Selous) has had to leave us for a constituency engagement, but he touched on the work of charities. I met people from the excellent HeadSmart charity recently and I undertook to write to health and wellbeing boards about its work, so I will give him that assurance when I next see him. I also pay tribute to the work that Cancer Research UK has been doing on pilots dealing with melanoma, which my hon. Friend the Member for Mid Derbyshire (Pauline Latham) mentioned.
NHS England works with Public Health England and the Department to determine the focus of campaigns and to manage the development of the Be Clear on Cancer campaign. Decisions on the 2014-15 campaign activity will be based on the evidence and learning from the evaluation campaigns of the past two years, and it will be subject to all the normal clearances in terms of delivering really good value for money.
To deliver access to the best treatment, we have committed more than £173 million to improve and expand radiotherapy services. That includes £23 million for the radiotherapy innovation fund, which has supported centres to deliver increased levels of intensity modulated radiotherapy—a more accurate form of treatment that can reduce side effects.
The cancer drugs fund featured heavily in the debate. More than 44,000 patients have benefited from the fund so far, and last September we announced a further £400 million to extend it to the end of March 2016. Going forward, we will consider what arrangements can be put in place to deliver access to drugs previously funded through the CDF at a cost that represents value to the NHS. I recognise the nervousness that exists among those who understand what the fund has done and the impact it has had on individual patients. My hon. Friend the Member for Mid Derbyshire highlighted that matter, but clearly it is something that NHS England will be taking forward, and it will be aware of the concerns that have been expressed in the House.
Regarding the all-party group’s specific concern about NHS England’s duty to promote research, NHS England recently carried out an open consultation on a draft research and development strategy to deliver its statutory responsibilities and the NHS mandate duties. Again, we will learn more about that when the meetings take place, and as NHS England delivers that project.
The all-party group rightly highlights the importance of supporting cancer survivors. Increasingly, cancer is viewed as a long-term condition—that was certainly not the case when many of us were younger—as more are living with and beyond the disease. In March 2013, the Department’s national cancer survivorship initiative published “Living with and beyond cancer: taking action to improve outcomes”. It set out key recommendations to improve survivorship care, which were drawn from two years of evidence gathering.
I understand that the national clinical director is working closely with Macmillan, which provides the secretariat so ably to the all-party group, to encourage implementation and spread of the recommendations, including around stratified care pathways. The all-party group will be pleased to learn that ensuring all survivors benefit from the survivorship recovery package is a priority work programme.
We want to support people to stay in and return to work. A specific concern of the all-party group is how NHS England intends to support people to do that, as set out in the mandate. I can confirm that NHS England has issued an invitation to tender for a piece of work to examine the factors that impact on the employment rate of people with long-term conditions and to identify the useful interventions that can be made. It will be looking to consider the next steps. I think it is expecting to report on that in 2015.
The all-party group has also said that it would like to see wider use of the patient reported outcomes measure—PROM—data. This month, we have already seen the publication of “Quality of life of cancer survivors in England—one year on”. That is a survivorship update commissioned by the Department, which provides important information on recovery, unmet needs and the consequences of treatment. NHS England has already begun work to extend the PROM programme. A new pilot PROM data collection has recently started looking at quality of life issues for survivors of womb, ovarian and cervical cancer. For men, NHS England is supporting Prostate Cancer UK on a nationwide PROM data collection.
The all-party group makes a number of recommendations on the national cancer patient experience survey, which was referred to by the shadow Minister. I think we all acknowledge that it has been an invaluable tool in driving improvement in cancer care. When I first heard about it and looked at it in response to an earlier debate in Westminster Hall, I was very impressed with the level of detail that it can drive down to individual trusts. It uses what the best are doing to drive performance among those that are not meeting the highest standards.
NHS England recognises the value of the survey and currently has no plans to halt the programme. NHS England is the lead, but I think the more often we in Parliament recognise how important the programme is, and show how much parliamentarians value it and regard it as central to understanding the cancer patient experience, the more NHS England will feel that it is the right decision to go forward with it. I know that NHS England intends to examine the potential for a survey-related indicator as part of the future development of the clinical commissioning group outcome indicator set. That is a good thing. The shadow Minister made some interesting points and constructive suggestions in that regard, which I will happily look at after the debate and draw to the attention of NHS England.
The all-party group was concerned that more could be done to understand the experience of those who are close to people affected by cancer, and its members might be interested to know that following the NHS’s commitment to carers event, held last December, a number of priorities for supporting carers were identified. An action plan is in development and although it focuses more on the experience of carers in general, NHS England will consider cancer care as part of that. The 2014 cancer patient experience survey will begin in March and report in late summer. I am sure that there will be parliamentary interest in that report.
In order to realise the Berwick report’s vision of the NHS as an organisation devoted to continual learning and improvement, NHS England and NHS Improving Quality will establish a new patient safety collaborative programme to spread best practice, build skills and capabilities in patient safety and improvement science, and focus on actions that can make the biggest difference to patients in every part of the country.
NHS England is undertaking work to improve the collection and analysis of patient safety data, including introducing “safety thermometers” for medication error, maternity care and mental health, and revising the NHS serious incident framework further to support best practice. It is working with the Care Quality Commission and others to provide consistent and clear information for all on what patient safety data are available.
Let me try to pick up on some of the points made by hon. Members. My hon. Friend the Member for Hertsmere expressed a concern about older people with cancer. I will respond to him in more detail after the debate, but we know that older people sometimes do not get the support they need and what happens during diagnosis is often the primary driver of poor outcomes. He might be interested to know that we have worked on a £1 million project with Macmillan Cancer Support and Age UK to improve uptake of treatment in older people. That has established some key principles for the delivery of age-friendly cancer services and, as I mentioned earlier, we are seeing encouraging take-up of the over-70 breast screening programme in response to the current campaign.
Finally—I apologise, Madam Deputy Speaker, but I had many points to respond to and although I have not reached all of them, I will draw my remarks to a close—I am advised that NHS England will engage with the vision for the management of complaints and concerns developed on the recommendations of the right hon. Member for Cynon Valley (Ann Clwyd) and Professor Tricia Hart. I think the whole House acknowledges the amazing work done by our parliamentary colleague in that regard. The plan is to establish an advisory group of patients and patient representatives to feed into the complaints improvement work.
My hon. Friend the Member for Salisbury (John Glen) talked about palliative care. Work is going on in that area and I shall write to him after the debate. He might also be interested to know that NHS England is considering the potential for an indicator based on death in a preferred place of care. I will get back to him with more detail on that.
My hon. Friend the Member for Harrow East (Bob Blackman) mentioned issues to do with work and pensions, which I shall refer to the Department for Work and Pensions. He also talked about procurement issues and smoking. I am afraid that at the risk of sounding a little boring after Monday I must put on the record the fact that the Government have not yet made a decision about standardised packaging. We have instead introduced regulation-making powers so that we can make a decision when we have received the Chantler review and considered the wider aspects of that policy while taking its findings into account. Ministers will make the final decision. I am sure that my hon. Friend understands why we must put that rather legalistic sounding statement on the record.
In conclusion, I apologise for the length of my response, but this was such a good debate and many interesting points were made. I will take away those that I have not been able to respond to in detail. Once the all-party group has met the national clinical director, that might be a good time for us to meet again, to reflect on the meeting and to consider what more we can do to take this important work forward. I thank everybody who has contributed to the debate, and the all-party group for its continued detailed work and the challenge it puts out to us all to do better in this area on behalf of all our constituents.