Provision of Cervical Screening
(7 years, 10 months ago)
Commons ChamberRead Hansard Text Read Debate Ministerial Extracts
Paula Sherriff (Dewsbury) (Lab)
It is an honour to follow the hon. Member for Harrow East (Bob Blackman), who is no longer in the Chamber. He has worked incredibly hard to gest a very important and much-needed Bill through this House.
I declare an interest as chair of the all-party group on women’s health. I am thankful for the opportunity to hold this debate today because this week is Cervical Cancer Prevention Week. The phrasing is important, because cervical cancer is notable for being not only treatable but preventable, under the right screening conditions. The events of this week are all about trying to ensure that those conditions exist for as many women as possible throughout the UK.
I start by acknowledging the invaluable work of Jo’s Cervical Cancer Trust, which I believe is unique in the UK in being dedicated to this issue. I thank it for its work in raising awareness during this week, such as through its #SmearForSmear campaign—there is still plenty of time to take up the offer to do your selfies, gentlemen—in which women, and indeed men, are encouraged to take a selfie with smeared lipstick to raise awareness of smear testing. I look forward to seeing those pictures later.
Vicky Foxcroft (Lewisham, Deptford) (Lab)
That is a fantastic idea. Only this week, I went for my own smear because of the campaign and the highlighting of the issue. All of us might want to join together to do #SmearForSmear, and tweet the pictures after the debate.
Paula Sherriff
I absolutely agree. I definitely expect the Minister, at least, to partake in such activity.
I thank Jo’s Cervical Cancer Trust for the work that it does all year round towards the eradication of this disease. It has been my pleasure to work with it, through the auspices of the all-party group, on issues to do with access to cervical screening, and I look forward to doing so again in the future.
I am glad that the Minister is sitting down, as I would also like to break with my habit in this House by giving a word of praise for current Government policy. As almost all cervical cancers are caused by persistent human papillomavirus—HPV—I welcome the Government’s commitment to the HPV vaccination programme, even though I feel that its effect could be amplified with compulsory sex and relationships education in our schools.
Successive Governments have developed a successful cervical screening programme and, to their credit, this Government have maintained it. It is responsible for saving an estimated 5,000 lives a year. That is to be applauded, but it should not be taken for granted. Recent years have seen a drop in cervical screening coverage, and this risks an increase in the incidence of cervical cancer and the danger of further unnecessary deaths when we have been very close to making a breakthrough. We need to be vigilant if we are to maintain the progress we have already made and make up further ground in tackling the disease.
Even with the progress that we have made on screening, some 3,000 people a year are diagnosed with cervical cancer, and an astonishing 890 a year people die of it. The figures for 2015-16 show that the coverage in England sits at 72.7% of eligible women, which is the lowest for 19 years. This is in spite of the so-called Jade Goody effect, when the TV star’s death from cervical cancer in 2009 resulted in 400,000 more women getting screened. Sadly, that effect has now been completely reversed. The numbers of screenings have been falling year on year, and they now stand at 3% lower than they were in 2011. Screening coverage rates across all age groups are falling.
I cannot stress strongly enough how significant and worrying these statistics are. They mean that more than a quarter of women in this country are leaving themselves open to a cancer that can be prevented, but that can easily be fatal if left undetected. As we all know, the general rule of cancer is that early diagnosis leads to a better prognosis, and cervical cancer is no different. The later the diagnosis, the poorer the health outcomes, and the more invasive and personally costly the treatment options. It benefits everyone involved if cervical cancer can be prevented, or detected and treated early.
Let me address one of the groups with the least coverage: young women. Women are invited for smear tests from the age of 25, but new research by Jo’s Cervical Cancer Trust has shown that more than a quarter of women in the 25 to 29 age bracket are too embarrassed to attend one. Shockingly, the same research also suggested that 70% of young women did not believe that smear tests could reduce a woman’s risk of cervical cancer. Let me be clear: they absolutely can. We know that 75% of cervical cancers can be prevented from developing through regular smear testing, yet more than 220,000 of the 25 to 29-year-olds invited for a test in England in the past year did not attend.
The research found several other causes for concern, including the fact that 24% of young women were unable to recognise a single symptom of cervical cancer, and that only just over half of them recognised that bleeding outside of periods was a symptom. That is the most common symptom of cervical cancer. Additionally, fewer than half knew that smear tests look for pre-cancerous cells, and almost a quarter incorrectly thought that the test was for ovarian cancer.
This problem is not unique to the younger generation. The 25 to 29 age group remains the group with the lowest coverage, but the 45 to 49 age group has seen the fastest decrease in coverage in recent years. Women over 50 display a similar tendency to put off or ignore smear testing, with a third having delayed or not attended their test. A shocking one in 10 have delayed for more than five years. This is particularly disconcerting because women aged 50 to 64 are the most likely to receive an advanced stage diagnosis, with half of those being stage 2 or later. As I mentioned earlier, this means more invasive treatment and risks poorer outcomes.
By far the biggest risk factor in developing cervical cancer is not attending cervical screenings, but Jo’s Cervical Cancer Trust has found that attendance declines with age. The charity’s long-term modelling has shown that if screening coverage continues to fall at its current rate, incidences of cervical cancer will have increased by 16% among 60 to 64-year-olds, and by a shocking 85% among 70 to 74-year-olds, by 2040. If screening coverage falls by another 5%, the mortality rate among 60 to 64-year-olds will double.
Age is not the only determining factor of one’s likelihood of being screened. One area of particular concern is that only 78% of black and minority ethnic women knew what a cervical screening test was compared with 91% of white women. This fell to 70% when looking at Asian women alone. Worryingly, only 53% of BAME women thought that screening was a necessary health test. This needs to be addressed, both nationally and within those communities.
The anxieties that all women were found to have about being screened, including embarrassment, worries about taking their clothes off in front of a stranger or discomfort with their body in general, are all heightened in particular ethnic communities with certain cultural norms. I have heard examples of mothers in certain minority ethnic households intercepting NHS screening invitation letters, leading to distress among younger women, who may experience cultural pressure that they should have maintained their virginity. If such factors put young BAME women off getting screened, that exposes them to significant risk of the disease. Particular focus should be paid to ensuring that mothers in those communities appreciate the dangers of cervical cancer, and that such cultural norms are not worth risking their daughters’ lives over.
We must ensure that coverage does not continue to fall. Indeed, it must be raised to an acceptable level, but the current outlook is mixed. A new report by Jo’s Cervical Cancer Trust for this year’s Cervical Cancer Prevention Week found that local provision is confused. While there is some evidence of best practice among local authorities and clinical commissioning groups, almost half of local authorities and almost two thirds of CCGs in England have not taken steps to increase cervical screening attendance in the past two years. The report also found regional disparities. In Yorkshire and Humber, 65% of CCGs had taken steps to increase screening, compared with just 18% of CCGs in the west midlands and the north-east. Similarly, 78% of local authorities in the north-west have taken action compared with just 33% in the east midlands. Perhaps most shockingly of all, in London, where coverage lags behind the rest of the country at just two thirds of women, 20 out of 32 local authorities reported no activity at all towards increasing screening coverage. That has all the appearance of a postcode lottery. We risk coverage continuing to fall in some areas of England while other areas make progress. Nobody wants a situation in which someone’s likelihood of developing cervical cancer is determined in no small part by the area in which they live. The Government should play their part to ensure that improvement happens across the board.
What can be done? We must seek to make access to cervical cancer screening as easy as possible. Screening takes five minutes and can save a life. Great strides have been made in recent years in making another simple test—blood pressure—available at every opportunity, which has been remarkably successful. There is every reason to expect that we could do the same for cervical cancer screening. However, I fear that the Government have taken a step in the wrong direction in recent years. Cuts to sexual health funding have led to a significant reduction in the provision of cervical screening through sexual health services. Jo’s Cervical Cancer Trust found that screening is available to all women through sexual health services in less than a third of areas, which again points to a postcode lottery. That seems like a grave misstep when over a third of women in the 25 to 29 age group expressed a wish to access screening through such services, while one in five women over the age of 50 wanted more flexibly timed access to screening. My GP practice offers cervical screening only every Tuesday morning, making access difficult and deterring many women from going for an appointment. I hope that the Government will look again at how much their cuts to local government funding have affected sexual health services, particularly the accessibility of cervical screening.
We must also move with the times. In addition to the cultural issues about invitation letters that I mentioned earlier, the use of letters is now old fashioned. While I appreciate that many NHS services across the country now use text message reminders, we should ensure that reminders to come in for screening are, to the greatest possible extent, accessible in the format of the patient’s choice, be that text message or email. Digital accessibility is necessary in the modern world. We must also be cautious about the wording of the reminders. It has been brought to my attention that the current NHS literature sent out with reminders reads:
“It is your choice whether to have a cervical screening test or not. This leaflet aims to help you decide.”
I fail to see how that in any way contributes to the aim of urging as many women as possible to attend cervical cancer screening. We already know that far too many women across all age groups and ethnicities are already content to put it off for a potentially dangerous length of time. I implore the NHS to reconsider the wording of the leaflets and to include a greater degree of urgency, because the phrasing will undoubtedly have an effect.
You will note, Madam Deputy Speaker, that I might not have been my usual challenging self this afternoon. Because of the gravity of the issue at hand, I happily recognise where the Government are on the right path. The inclusion of a commitment to increase cervical cancer screening in the 2015 cancer strategy is particularly welcome, as is the Government’s commitment to HPV primary screening, the implementation of which could prevent at least 400 cases of cervical cancer a year.
I will finish by asking several questions of the Government. Will the Minister commit to a national campaign to prioritise an increase in cervical screening attendance? How will the Government encourage co-operation between the different levels of the health service to ensure that we see cervical screening rates rising once again? Will the IT systems for HPV primary screening be up and running as planned, or will we experience unnecessary delays that could result in avoidable diagnoses? Will the Minister look at the quality and outcomes framework incentives for general practitioners to make sure that GP practices are really incentivised to improve cervical screening coverage? Finally, how do the Government intend to address problems with the accessibility of cervical cancer screening among particularly hard-to-reach groups, such as BAME women?
It is not unthinkable that we could see the effective eradication of cervical cancer if we take the necessary action. Although I applaud the Government’s existing programmes and their commitment to tackling cervical cancer, I hope that the Minister will take note of the research from Jo’s Cervical Cancer Trust—perhaps he will even work with it to identify where there are still gaps in provision—and take that action now.
Madam Deputy Speaker (Mrs Eleanor Laing)
Just before I call the Minister, I say to the hon. Lady that Jade Goody lived in my constituency. When she died, I wrote to her mother to say that her daughter’s death had not been in vain because it had drawn attention to the situation and had warned generations of women of the action that they must take to protect themselves and give themselves a chance.
I am shocked that the hon. Lady has drawn to the attention of the House this afternoon the fact that that has not been the case. I sincerely hope that her bringing this debate to the House this afternoon and the Minister’s attention to the points she has made—I am sure he is about to address them now—will reverse that situation.
The Parliamentary Under-Secretary of State for Health (David Mowat)
Thank you for those comments, Madam Deputy Speaker. I thank the hon. Member for Dewsbury (Paula Sherriff) for her constructive speech, which was challenging towards the end. She raised four important points, which I will try to address in my remarks.
I also thank the hon. Lady for her work with the all-party parliamentary group on women’s health to lead the charge on cervical screening. On Jo’s Cervical Cancer Trust and the #SmearForSmear campaign, during her remarks I was able to check with both my Parliamentary Private Secretary, my hon. Friend the Member for Kingston and Surbiton (James Berry), and the Whip, my hon. Friend the Member for Daventry (Chris Heaton-Harris), and we will be delighted to take a selfie with her that we can use for #SmearForSmear. This debate is about asking challenging questions, but it is also about awareness. We will do anything we can to help a charity such as Jo’s Cervical Cancer Trust do its job better. Perhaps we can take the selfie together after we finish.
As the hon. Member for Dewsbury said, nine women a day are being diagnosed with cervical cancer and two to three women a day are dying. It is a cancer that is almost entirely preventable through screening although, as she said, the symptoms are hard to detect, which I will cover. She said that the cancer strategy, which is being led by Cally Palmer, covers screening in some detail, including how we will proceed, and addresses the need right across the cancers for clinical commissioning groups to take a consistent approach to survival rates, early diagnosis, 62 day referral-to-treatment times and the whole cancer experience.
One of the things that I always say when we in this place have a debate about cancer is that we spend too much time—I am as guilty, or have been in the past, as any other Member—discussing the bricks and mortar of the health service and not enough thinking about some things that probably matter more to our constituents, such as one-year survival rates for cancer. We should be evaluating and holding our CCGs to account much more often over differential one-year survival rates, because, in the end, they probably matter to more people and have more impact on their lives than perhaps some of the accident and emergency reconfigurations that we discuss.
There is a cervical cancer screening programme, and the hon. Lady made some good points about take-up. She did not talk about the campaign that has been waged in some areas on screening under the age of 25. I do not think that that is something that Jo’s Cervical Cancer Trust wants, but I will cover it and the reasons we do not do it.
The hon. Lady mentioned the importance of the enhanced HPV screen that is coming in, asking a question about the IT systems to support that. We are planning that that will be in place—I have confirmed that; I think written questions have been tabled on the issue—by April 2019, when it will be rolled out. That will be in place. I can give her that assurance.
I want to talk a little about the point the hon. Lady made about GP awareness and clinical practice, because, as she said, there is not enough awareness of the symptoms of cervical cancer. It is hard to detect the symptoms, such as abdominal bleeding and its many causes. I will also cover the fact, which she rightly referred to, that the UK is doing a lot in the area of vaccination, which is probably what will achieve the most progress in the future and make the biggest difference in getting rid of this disease, which is, as you said, Madam Deputy Speaker, quite preventable.
On screening, I will start with the good news: we have screened 3 million women a year between the ages of 25 and 49. Every three years, a screening is available. After that, to the age of 64, it is every five years. The view is that, if that screening were not being done, there would be about 5,000 more deaths a year, rather than the 700 to 800 that are happening now.
Although there are few areas of cancer treatment, performance and survival rates on which the UK could say that it is a world leader, the screening figures from the OECD show that we are No. 4 of the 30 OECD countries. We do more screening than countries such as Germany, Denmark and Austria. However, the hon. Lady raised the point, and she is right, that screening rates are going down. They are going down across the world and we do not wholly understand why. We need to do more to get them up, as about 25% of women who are entitled to be screened are not being screened, and that percentage increases for women coming for their first screen at the age of 25 to 29. That is arguably the most important one, but the percentage of those not coming is about 33%.
As the hon. Lady said, the incidence of that is higher among ethnic minority women and among women with learning disabilities. There is a correlation with social deprivation as well. Perhaps that is predictable, but it is nevertheless true.
On the reasons for that, the hon. Lady talked about, perhaps, embarrassment. I think Jo’s Cervical Cancer Trust has done some work on that. Some people say that they have no time to go to their GP, or they are scared about what the procedure involves or they think it is not important. We need to do what we can to improve that.
The hon. Lady raised some interesting points about the letter people receive, and she quoted from it. I am told that that correspondence is being reviewed, but it strikes me—she made the point in her speech—that we are all on the same side in this regard. One way forward might be for her and Jo’s Cervical Cancer Trust to come and speak to me about some of those suggestions, because they would be pushing at an open door. We can do that in the next few weeks.
We are trying to make the information more accessible, particularly for women with learning difficulties, because there are specific issues there—there are specific issues with their health in general, but particularly with regard to this issue. As the hon. Lady said, a lot of work is going on to target those GP practice areas and understand why they have such high incidence of no-shows. It is somewhat correlated with ethnic minorities, and it might involve some behavioural norms, for the reasons that were mentioned. I should say at this point that the Chancellor gave £650,000 from the tampon tax to Jo’s Cervical Cancer Trust, which has used that money to try to understand, behaviourally, why a quarter of women are still not coming forward for screening in spite of a second reminder, and to increase awareness. None of that is to say, though, that there is not more to do. I am happy to speak to her and Jo’s Cervical Cancer Trust about it.
From time to time there have been petitions and discussions about lowering the age limit for screening. I was pleased that the hon. Lady did not mention that, because it has been looked at again by the UK National Screening Committee, the World Health Organisation and, indeed, Jo’s Cervical Cancer Trust, and there is agreement that earlier screening would do more harm than good because it is particularly likely to lead to false positives, which would create a pressure for biopsies that are not necessary. Notwithstanding the tragic case of Amber Cliff, the view is that screening that cohort of women earlier not only would not be beneficial—it is not a question of it not being cost-effective—but would actually make things worse. In that cohort of women, about five a year die, so it is particularly important that they understand the symptoms and go to their GP as quickly as possible. I should emphasise that there is no EU or other UK country that screens women under the age of 25. I shall discuss vaccination in more detail in a moment, but it is one of the things that will make a difference to women in that age group, and it will help with the screening no-shows, because we are getting much better uptake numbers for vaccination.
The hon. Lady talked about HPV as a significant indicator of risk. One thing that is being introduced on the back of the normal, historical screening is screening for the virus on the first occasion. If it is present, the woman will be monitored much more closely going forward, because it is a very good indicator of the likelihood of cervical cancer developing. As I said, that programme will be rolled out nationally from April 2019. We are at the forefront of countries that are doing that around the world. I used to work with IT systems, and the hon. Lady is right to continue to ask about this one. The referral system and database will be ready to make that roll-out happen.
The hon. Lady rightly discussed the need for a GP outcomes framework. NHS England has done work to ensure that GP awareness is as high as it should be and that women, particularly those with mid-period bleeding, understand that it is serious and should be investigated and, if necessary, that they should be sent to a gynaecologist.
HPV, which is the indicator of this and other cancers, lends itself to vaccination, and we are one of the first countries in the world to bring in a very high volume of vaccinations of girls aged between 12 and 13. I am pleased to say that, last year, 85% of year 9 girls received the vaccination, which almost entirely takes away the likelihood of cervical cancer developing. That 85% is a higher number than the screening number, and it will help us to catch the people and the areas that have traditionally been hard to reach. Indeed, it is one means that we will use to address the issue of those hard-to-reach groups.
As HPV leads to other cancers, it has been suggested that the vaccination should also be given to boys. That is under discussion now, and we will be making a decision in the next few months. At the moment, only girls are vaccinated.
Let me finish by thanking again the hon. Member for Dewsbury for the points she raised, and for the way in which she did so. This is not a party issue—all of us are against cervical cancer. However, it is right that we challenge the postcode lottery that she mentioned and discuss ways to improve the take up of screening. If the five of us who are in the Chamber can do a selfie at the end of this debate and give it to Jo’s Cervical Cancer Trust it will perhaps show that, at least, the awareness part has been achieved.
Question put and agreed to.