Colostomy Irrigation

David Mowat Excerpts

Thursday 2nd February 2017 Commons Chamber

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

I congratulate my hon. Friend the Member for Montgomeryshire (Glyn Davies) on his excellent speech. I want to congratulate him on three more things: first, on securing the debate two days before World Cancer Day; secondly, on rightly saying that this is the first time that we have had a debate on the subject in this place—it is good that we are doing so—and, thirdly, on talking so passionately about his personal story in such a matter of fact way, if I may use that term. He spoke candidly and clearly about a subject that sometimes carries with it a stigma, or that is a taboo.

I have been looking after the whole area of cancer for the past six months. It strikes me that when people come into the system, we are as good as anywhere in the world at treating them and dealing with the illness. Unfortunately, one problem we have is that too many people come into our system too late. As a result, first or second-stage diagnosis is not possible and their outcomes are worse. One of the reasons for that is awareness—my hon. Friend used that word—and such debates can only increase awareness, so it is good that we have them.

My hon. Friend rightly said that uptake of colostomy irrigation is low. We think that some 5% of all those who could do so use the technique, rather than an alternative. I will talk a little about why that is and what we might be able to do about it. We think that there are some 6 million people in this country with bowel incontinence issues. Of course, the majority of them are nothing like as serious as the story we heard this afternoon. Similar stories may result from bowel cancer, and perhaps also from other types, such as cervical cancer. The choice of whether to use irrigation or another technique is a personal one. There are pros and cons to each, and I will try to set them out. Before I do, perhaps I should talk a little bit about what the Government need to do, and what they are doing, regarding the prevention, screening and treatment of bowel cancer. Obviously, if we were more successful at those, we would reduce the incidence of the disease and the need for the techniques that we have heard about.

The Government’s approach is informed by the cancer strategy, which came out about 18 months ago. It included 96 recommendations, all of which were accepted. It has been fully funded, and its implementation is now being led by Cally Palmer and Bruce Keogh from NHS England. We are finding that survival rates are increasing —we know that they are increasing quite sharply for most cancer types—but there is probably still a gap between us and the best in the EU. We are determined to close that gap, and although we are doing so, there is still work to do.

Of the parts of the cancer strategy that relate most to this debate, I want to talk about screening and about living with cancer and beyond—we have heard a story about doing so over the past 14 years. I also want to talk about one of the things that I think will be most important in improving cancer awareness and outcomes: the whole area of transparency.

One of my hon. Friend’s points was that there are staffing issues in this area, particularly in relation to bowel cancer. He said that we do not have enough endoscopists—that is true. The Government are committed to training a further 200 by 2020. Indeed, we have not been able to do some of the things on screening that we want because of those staff shortages, but we are addressing that problem very firmly.

The current screening test is an FOB, or faecal occult blood test, which is in the process of being replaced by the FIT—faecal immunochemical test—from 2018. A contractor/supplier has been appointed. The expectation is that that will lead to a sharp increase in the incidence of screening, the numbers of people coming forward for screening and the efficacy of that screening, which is very important.

In parallel, we have introduced a bowel scope screening process for males and females at or around their 55th birthday. This one-off test involves a full endoscopy, as a consequence of which polyps are removed. Whether or not they are benign, that process sharply reduces the incidence and risk of future bowel cancer, which is also very important. In the interests of full disclosure, let me say that I have also gone through the procedure. It was not anything like my hon. Friend’s, but I nevertheless went through it successfully. The process is a very important part of this fight.

The second aspect of the strategy is living with and beyond cancer. When I gave a presentation to the all-party group on ovarian cancer, I was struck that a lady whom I met afterwards said that she had received a terminal diagnosis for that type of cancer, but was not receiving support. That is obviously not where we want to be. The Government’s intention is that, by 2020, everybody who has a cancer diagnosis will have an individually designed package, with a cancer nurse specialist assigned to them. We are undertaking that programme in conjunction with Macmillan. It is important because cancer is increasingly curable, so we must increasingly put in place softer packages, as it were, to help people afterwards.

The final area I want to touch on is transparency. One of the frustrations is something that I often reflect on after talking to colleagues about the NHS and its effectiveness. Many of them are very concerned—almost certainly rightly—about the bricks and mortar of their NHS establishments, because they are very visible. Changes in configuration also concern them and their electors. I have fewer conversations with colleagues who are concerned about cancer outcomes in their areas. Those statistics are now published, so we know which are the best clinical commissioning groups, which are the worst and which are average.

One way in which we will increase the overall standard and quality of outcomes is through dialogue—with Members and the public more generally to act on the pressure points—about the performance of CCGs. I would argue that whether a Member’s CCG is doing one of the best or one of the worst jobs in the country might be more important to their community than whether the accident and emergency department is open for 24 or 18 hours. However, we do not always have such dialogues in this place.

On innovations in treatment for bowel cancer, keyhole surgery is making a big difference to outcomes. There are very clever people doing very clever things, which are leading to better outcomes and successful operations.

For many, however, a colostomy is needed. Broadly speaking, there is a choice of techniques: the irrigation technique that we have heard about this afternoon; or an appliance, which is typically a bag. There are pros and cons of each but, as my hon. Friend said, the appliance route is chosen 20 times more frequently than irrigation. This must be a personal choice, and NICE guidelines state that choices should be explained, but that is an extreme difference. As my hon. Friend said, the difference is far greater than that in the United States. It might well be that there is not enough awareness, so this debate has been one way to address that.

A recent paper by Sir Norman Williams, the senior clinical adviser to the Secretary of State for Health, set out the benefits of irrigation: there is no need for an appliance; the individual has control over timing; there is some evidence that fewer drugs are required, with a consequent increase in general wellbeing; and an individual is able to have a more varied diet. Those benefits suit many people. The technique might not be suitable for people with heart or kidney diseases or Crohn’s disease, and some might find that the 45 to 60-minute process is too onerous. In addition, I think I am right to say that the best results from this technique tend to come if the process is carried out at roughly the same time every day, which might not suit everybody.

The NICE guidelines are very clear: both techniques should be offered by the clinician or stoma nurse. The choice should be based on facts and personal preference. Whichever technique is selected by the patient, the nurse is responsible for teaching the process and supporting the patient until they are up and running, because it is extremely important to get it right.

I again congratulate my hon. Friend on securing the debate and raising awareness of the issue. He has talked frankly about a process that has been a massive help for many people in their day-to-day lives.

Question put and agreed to.