Health: Cancer

Baroness Finlay of Llandaff Excerpts

Thursday 11th November 2010 Lords Chamber

Moved By

[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.

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[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.

Motion withdrawn.