Cancer Priorities

James Clappison Excerpts

Thursday 13th February 2014 Commons Chamber

[Mr John Baron (Basildon and Billericay) (Con)]

I beg to move,

That this House has considered the All-Party Parliamentary Group on Cancer report on cancer priorities in the NHS.

The motion stands in my name and those of other hon. Members.

It is not an exaggeration to say that thousands of lives, if not tens of thousands, depend on our getting the cancer strategy right. That is the scale of things. I therefore thank the Backbench Business Committee for granting the debate and allowing the all-party group on cancer to debate its recent report, “Cancer across the Domains”. I thank fellow officers, Macmillan and the secretariat to the all-party group, particularly Tim Nicholls and his team, for their support and hard work.

The all-party group on cancer is recognised as the wider cancer community’s voice in Parliament and has a proud campaigning track record. It was an early advocate of the need to focus on survival rates as a means of promoting earlier diagnosis. It has campaigned on a range of other issues, including cancer networks and the cancer drugs fund. As hon. Members will know, the group hosts the annual Britain Against Cancer conference, at which the cancer community comes together. Last December, it attracted about 500 delegates and heard excellent speeches from the Secretary of State for Health, the shadow Secretary of State and other experts.

[Mr James Clappison (Hertsmere) (Con)]

I warmly congratulate my hon. Friend on his sterling work in this field. He mentions cancer survival rates. The most recent European study, published in December last year, showed that UK survival rates are still lagging behind those of comparable western nations in most, if not all, cancers. Does he therefore agree that the need to focus on cancer survival rates is as great as ever?

[Mr Baron]

My hon. Friend makes an excellent point. The fact remains that, although there have been good increases in survival rates and there has been progress when it comes to cancer care generally, we still lag behind European and international average survival rates. That alone means they are costing this country thousands of lives. Thousands of families are suffering as a result of our not being able to match international averages on cancer care. That is not to say that cancer care has not improved over recent decades—it has. Survival rates have improved, but they have done so in line with survival rates across the world. That is good, but it somewhat masks the fact that we remain well behind international averages.

Despite all the additional funding, we still have not managed to catch up with other health care systems and thousands of lives are being lost as a result. My hon. Friend alluded to the fact that if we matched European averages on survival rates we could save an additional 5,000 lives a year. The OECD recently ranked Britain towards the very bottom of the 35 countries whose survival rates it measured, and it suggests that up to 10,000 lives could be saved if we matched international survival averages. Indeed, the Secretary of State for Health himself, speaking at the Britain Against Cancer conference in December, described survival rates as disappointing.

Reliable predictions suggest cancer incidence is on the rise. The World Health Organisation suggests its incidence will increase by 70% in the coming decades. Macmillan Cancer Support estimates that by 2020 almost one in two people will receive a cancer diagnosis—a phenomenal increase. The challenge for the NHS is to ensure that the significant structural change it has seen in recent years is not allowed to obstruct the much-needed improvement in cancer services and survival rates that are necessary if we are to catch up with our neighbours and save those thousands of extra lives.

The report by the all-party group on cancer should be seen in this context. We now have an NHS based around five domains, each with a responsibility for delivering improved outcomes. The report makes recommendations across each of those domains, and is the product of an extensive consultation with the cancer community, from NHS England right through to cancer patients, carers and charities. The recommendations of this year-long project can therefore truly be said to reflect the views of the whole cancer community. I should take a brief moment to thank all those who are involved in the production of the report, from those who responded to the consultation to the charities that devoted significant time and expertise to crafting it, including Macmillan Cancer Support, Cancer Research UK, Prostate Cancer UK, Teenage Cancer Trust and Breakthrough Breast Cancer.

“Cancer across the Domains” makes 18 recommendations and believes that the Government have an important role to play. Although the recommendations are specifically aimed at NHS England—the body that now has responsibility for commissioning services—it is the Health Secretary who retains overall responsibility for health services. The support of his Department is invaluable in achieving these goals, so my first question for the Minister is: will she formally respond to the recommendations set out in the report, or commit her Department to do so?

Other hon. Members will address other parts of the report, but I want to focus on the importance of earlier diagnosis and accountability. There are very few magic keys— where someone can open a door and suddenly untold opportunities lie before them. In cancer, such a magic key does exist: earlier diagnosis, the importance of which cannot be overestimated. When the all-party group on cancer produced its 2009 report, “Tackling Cancer Inequalities”, we found that patients in this country who reached the one year point stood as much chance of making it to five years as most other health care systems. Where we fall down is in getting patients to the one year point. We came to the conclusion, which expert witnesses confirmed at the time, that this clearly showed that the NHS was as good, if not better, at treating cancer when it was detected, but very poor at detecting it in the first place, and that is why we fell so far behind on survival rates.

We sat down with the cancer community and asked: what is the remedy? Do we bombard the NHS with more targets and regulation to try to encourage earlier diagnosis? Should we adopt a much simpler approach—and this is what we concluded—and put up in lights one and five-year cancer survival rates, broken down at a local NHS level, then primary care trusts, now clinical commissioning groups, to encourage earlier diagnosis? We all know that late diagnosis makes for poor survival rates. Therefore, putting the survival rates up in lights and broken down by the local NHS should encourage underperforming CCG management to promote initiatives, at primary care level, aimed at promoting earlier diagnosis. It would be up to them to choose which initiatives suit their local populations: better prevention and awareness campaigns, better uptake of screening programmes, better diagnostics at a primary care level or better education or information for GPs. There could be a host of initiatives in isolation or in combination, but the bottom line is that it would be up to local CCGs to introduce them. Those at the bottom of the table would be particularly encouraged to do so. That was the logic behind the idea of one and five-year figures. We are happy to say that, with the rest of the cancer community, we now have one and five-year figures as outcome measures in the DNA of the NHS. This is to be welcomed. It is in the NHS outcomes framework and it is in the CCG outcomes indicator set governing CCGs at a local level. I will come back to the five-year outcome measure at the outcomes indicator set level a little later, but that is all encouraging.

I will not complicate issues by going on about the importance of introducing other proxy measures at a local level, such as staging and emergency admissions. We have recommended those initiatives, and they have been taken up as complementing the one and five-year figures at a local level because of the smaller population sizes of CCGs compared with PCTs. The campaign has been a success, but it is a success only in that we have managed to get these measures included. Actions speak louder than words and the true success will be judged on what effect these measures are having on survival rates. On that measure, the jury is still out.

That brings me on to my next point: accountability. There is no point in having these wonderful initiatives on one and five-year figures, staging and emergency admissions to try to promote earlier diagnosis if it is not followed through and there are no teeth in the system or levers of change to ensure that underperforming CCGs raise their game on behalf of their local patients. Key questions therefore remain on accountability.

How accountable is NHS England to Parliament? NHS England’s annual report is laid before Parliament, but it is the Secretary of State who must assess performance. The extent of ministerial accountability remains unclear. Parliament seems to have a very limited role in this process. So does the Minister agree that there appears to be limited scope for Members to scrutinise NHS England’s performance? Furthermore, how will the Department of Health monitor NHS England’s performance on cancer care against the NHS outcomes framework and address areas that need improvement?

If that is one concern, a greater concern I have is the accountability of CCGs themselves. While some cancer services, as hon. Members will be aware, remain the responsibility of NHS England, owing to their specialised nature, many vital services are CCG-commissioned, hence the importance of the CCG outcomes indicator set as a means of monitoring performance. What remains unclear is the extent to which NHS England will hold underperforming CCGs accountable. For example, what happens if a CCG is continually at the bottom of the one-year survival rate figures? Where are the levers of change to correct that? The mathematicians in the House will understand that if we raise the game of those at the bottom of the table, it will have a disproportionate effect on averages in general, and that is what we are talking about: catching up with European and international averages on survival rates.

We need clarity, therefore, about what action will be taken should CCGs continue to languish in poor performance. What support would NHS England give to a CCG to improve survival rates, and, should CCGs continue to languish, what powers will be used, what levers of change will be implemented, to ensure that improvements are made at a local level? There is no point having the CCG OIS if failure is not addressed and there are no teeth to the correction regime. We need clarity, both to ensure that corrective action is taken, if needed, and because CCGs need to know that the regime is in place.

Other questions remain, which our report addresses, about the differences between the last two CCG OIS iterations, and perhaps a little clarity from the Minister would be helpful to the wider cancer community. In the 2013-14 OIS, our call for indicators for one and five-year survival rates for all cancers was accepted, and in the 2014-15 OIS, our call, in the “Cancer Across the Domains” report, for indicators on staging and emergency presentations was also accepted—all very good news—but the indicators for the five-year survival rates were dropped from the 2014-15 OIS.

NICE argued there were potential problems with the five-year indicator, as the numbers were small, but those arguments had been made before, when we campaigned for one and five-year survival rate inclusion. Will the Minister help the House and the wider cancer community by explaining what changed in the data between 2013-14 and 2014-15? That would be helpful. We now have an NHS outcomes framework that retains one and five-year indicators, but a local CCG OIS that does not have the five-year indicator. This suggests a disconnect. It is important that the NHS speaks with one voice, yet it has measures nationally different from those at a local level. How will her Department work with NHS England to address this apparent disconnect?

While earlier diagnosis increases survival rates, without data on longer-term survival rates, it will be harder for NHS England to ensure that early diagnosis is being improved by CCGs. Will the Minister re-examine the case for five-year survival rates in the next iteration of the CCG OIS, or at least communicate to the cancer community the logic behind the move and carry the community with the Department so that it is clear for everyone to understand. It remains to be answered, however, why there was a difference between the 2013-14 and the 2014-15 iterations.

The removal of the five-year survival rate indicator raises questions about the process. The development of the CCG OIS is complex; suffice it to say that the system provides for newly suggested indicators, but does not appear to recommend indicators for removal. In the development of the 2014-15 OIS, while emergency diagnosis and stage of diagnosis were flagged for inclusion, five-year survival rates were not flagged for exclusion, meaning that the removal does not appear to have been consulted on. I find this particularly alarming.

The cancer community campaigned hard for the inclusion of one and five-year survival rates, both nationally and locally, to promote earlier diagnosis, but then, at the last minute and without any consultation, was made aware, practically on the last day before Parliament rose before Christmas, that the five-year figures were being removed. There was a lack of communication, and certainly the process itself raises questions. Will the Minister comment on this process? Why does she think it delivers appropriate transparency? It was not clear to the wider cancer community that the five-year indicators would be removed until the final document was published.

On 17 December, the hon. Member for Scunthorpe (Nic Dakin) asked the Minister whether five-year survival rates would be included, and he received an unequivocal answer:

“NHS England will be publishing the 2014-15 CCG OIS next year…which will set out measures aimed at supporting improvements in the five-year cancer survival.”—[Official Report, 17 December 2013; Vol. 572, c. 594W.]

However, the OIS released three days later, on 20 December, excluded the five-year figures, and it would help to know why the position apparently changed completely in those three days.

I thank the Minister for responding to this debate. I appreciate that she has drawn the short straw, given that this is the last debate before the half-term recess, but the all-party group would welcome a detailed response to all our recommendations, if not in this debate, certainly subsequently. She has a great responsibility. She is well aware that few ministerial posts can literally save thousands of lives if policy is got right, and she brings to her post a dedication and professionalism that are welcomed across the cancer community, but I remind her, on behalf of that community, that the Government’s goal to save an additional 5,000 lives every year by 2015 will not be achieved unless the NHS raises its game, particularly on earlier diagnosis. With that thought in mind, I look forward to her response to our recommendations.

--- Later in debate ---

[Mr James Clappison (Hertsmere) (Con)]

I congratulate my hon. Friend the Member for Basildon and Billericay (Mr Baron) on securing this debate and his work in the all-party group on cancer. I commend the group’s work and its recommendations to the Minister, and I hope she will respond positively to them. I am sure she will; as has just been rightly said, she is a very forward-thinking Minister.

I also commend the sterling work of Macmillan Cancer Support in bringing the issue to the attention of the public and Parliament. So many of our constituents hold that charity and other cancer charities in high regard. As my hon. Friend the Member for Harrow East (Bob Blackman) has said, few families have not been touched in one way or another by cancer, and mine is certainly no exception. It was also very good to hear the personal views of the hon. Member for Ashton-under-Lyne (David Heyes) in his courageous and outstanding speech. It is always good to hear from personal experience.

Medical science has given hope to many people where no hope existed in the past, and survival rates are much better than they were 20 or 30 years ago. It seems to me, however, that the material question is whether this country harnesses the benefits of advances in medical science as well as other countries do. That raises many questions, as I suggested in my intervention on my hon. Friend the Member for Basildon and Billericay.

Across the health services of the constituent nations of the United Kingdom, across the years and under Governments of both the main political parties, there has been a gap in survival rates for cancer compared with those of other countries. There is a gap in how well we harness the advances of medical science, certainly relative to comparable economies in Europe, other western nations and the United States.

It is a material question whether we are managing to close the gap. I drew attention to that in a debate about the cancer patient experience in Westminster Hall in October. Since then, further statistics have been produced by Eurocare. In December, it published a survey of cancer survival rates across Europe, which looked at the five-year relative survival rates of adult patients who were diagnosed with cancer from 2000 to 2007. I am indebted to the House of Commons Library for providing me with the results, which are the material comparisons we should make. Eurocare is a cancer epidemiology research project on the survival of European cancer patients, which is based on collaboration between some highly esteemed cancer registries and specialists, with results from 22 European countries.

I am afraid I have to report to the House that the survey of 22 countries suggests that the gap in cancer survival rates remains considerable. The clinical outcomes for cancer patients in this country lag behind those of many other countries. For every type of cancer, the United Kingdom is certainly well behind Scandinavian countries, and it is well behind western European nations with similar economies to our own, including France and Germany. We are also behind southern European nations for every type of cancer except, perhaps understandably, skin cancer.

The economies of those countries are certainly no larger than ours—in some cases, they are smaller—but it appears that their cancer survival rates are higher. For example, the prostate cancer survival rate is 9% higher in Portugal than in this country; the breast cancer survival rate is 6% higher in Italy than in this country, while that for stomach cancer is 15% higher; and the stomach cancer survival rate is 8% higher in Spain than in this country. We have to ask why that is the case. We are ahead of eastern European countries for most of the common cancers, but we are behind even them for some types, particularly stomach, lung and ovarian cancers. Why is the stomach cancer survival rate 5% higher in the Czech Republic than in this country, when it laboured for so many years under a very undeveloped communist system?

I invite the Minister to address those questions. As my hon. Friend the Member for Basildon and Billericay and the Government have rightly said, we could save the lives of thousands of cancer patients in this country if we brought our survival rates just up to the European average. Why does this advanced economy, which is doing very well economically compared with other countries, have cancer survival rates that are so much lower than those of comparable nations? That question must be asked over and over again.

Some excellent points have been made about the early detection of cancer. I hope that the Minister will make a full response to those points. I invite her to respond on the question of cancer survival rates for older patients. Many people believe that older patients do not get as good a deal in this country as they do in comparable European countries. Will the Minister tell me—if she does not have the statistics to hand, I would be happy if she wrote to me—whether the gap that still exists is being closed? Have we made any progress over the years in closing the gap between ourselves and those European countries? Is it the Government’s ambition to close that gap? What specific measures does she think would help us to achieve that?

There is no reason why this country should have a lower cancer survival rate. The advances in medical science are as available to us as to other countries. We can afford them because we have a developed economy. This country has wonderful pharmaceutical companies that produce world-beating research. We also have excellent clinicians, doctors and nurses, and very good hospitals. Why is it that we have this stubborn gap in cancer survival rates, with survival rates for common cancers being much lower in this country than in comparable western nations?

I applaud the Government for their ambition, but I urge Ministers to focus on closing that gap. It is a stubborn gap that has been there for many years under Governments of both main political parties. There is no reason why the public in this country should have to put up with it.

[Liz Kendall (Leicester West) (Lab)]

Like other hon. Members, I thank the Backbench Business Committee for providing time on the Floor of the House for us to debate this excellent report by the all-party parliamentary group on cancer.

I commend the hon. Member for Basildon and Billericay (Mr Baron) for his tireless work on this issue. Like the hon. Member for Salisbury (John Glen), I have been in this place for four years and have been amazed at the work that the hon. Member for Basildon and Billericay has done and at his forensic attention to detail. He never gives up and I am sure that he never will. I am grateful to him for that. I also pay tribute to the work of my hon. Friend the Member for Easington (Grahame M. Morris) and the noble Baroness Morgan of Drefelin, who are officers of the group.

The hon. Member for Harrow East (Bob Blackman) was right to say that hearing the words “You have cancer” is one of the most frightening things that can happen to somebody. It is frightening not only for the person who is given the diagnosis, but for their family. He was also right that more and more of us will hear those words in the future. As we live for longer, the prevalence of cancer increases. Just last week, the World Health Organisation warned that the world faces a “tidal wave” of cancer, with the number of cases globally set to reach 24 million a year by 2035. We often think of cancer and heart disease as issues of the western, developed world. In fact, long-term conditions are becoming the primary health conditions in developing countries as well. We have made big strides in tackling conditions such as malaria and HIV, but long-term conditions such as cancer are big issues in developing countries.

In the UK, 330,000 people are diagnosed with cancer each year. That figure has gone up by 50,000 in a decade. The primary reason for that is the ageing population. Cancer Research UK has highlighted a number of other risk factors: alcohol and the increase in obesity are two of the biggest drivers of that change.

Cancer Research UK produced a report in December, which showed that cancer deaths have dropped by 20% over the past 20 years. I am proud of the Labour Government’s contribution to that record. We launched the first ever national cancer plan in 2000 and made cancer a top priority. That work was led by Professor Sir Mike Richards who, as Members will know, is now the chief inspector of hospitals. The plan was backed by increased funding and, crucially, by reforms to drive improvements in cancer care, including better diagnosis, reduced waiting times for treatment and better standards of care. As a result, survival rates have improved steadily and cancer deaths have fallen by 50,000 a year.

Many hon. Members have rightly highlighted the need to ensure that patients with cancer have the best outcomes and survival rates, and that we narrow the gap with other countries. Many figures have been cited, but in some areas we have seen the gap narrow. An article by John Appleby from the King’s Fund in the British Medical Journal in January 2011 reminded us that death rates for lung cancer in men peaked in the late 1970s, but they have steadily come down and are now lower than those for French men. There has been a similar trend in breast cancer mortality for which we have virtually closed the gap with France. As the all-party group on cancer report rightly said, however, we need to do much more to prevent, treat and cure cancer, which means raising awareness of the symptoms of cancer among members of the public and GPs.

[Mr Clappison]

I am grateful to the hon. Lady for expanding my point because, as I made clear in my speech, I am not out to make any political point about this. According to Eurocare statistics, which I have been supplied with by the House of Commons Library and which refer to December last year—more recent than the article the hon. Lady mentioned—the survival rate for lung cancer in Frenchmen is 4% better than for people in this country. For lung cancer we lag behind nearly every other country in Europe, certainly western Europe.

[Liz Kendall]

I am not a statistician; I am reporting something from the British Medical Journal. There are different ways of cutting the statistics and different reports, but I absolutely agree that we need to do more to catch up with other European countries. There are a variety of statistics on that, and in some areas—but not enough—we have made big improvements in recent years.

We must raise awareness of the symptoms of cancer among members of the public and GPs, to ensure that everyone gets the earliest possible diagnosis. We must tackle variations in treatment so that everyone gets the best possible care, and we must provide better support to cancer patients and their families as they go through treatment, not just in terms of physical care, but emotional and social support such as help with finances, benefits and work. The hon. Member for Harrow East made an important point about how when they go through such a terrible time, many patients have a problem with their finances and benefits. I visited a brilliant multidisciplinary cancer team at Leicester Royal Infirmary, where Macmillan Cancer Support had a brilliant network of people providing financial information and support, as well as emotional support. That joined-up care is exactly what we need.

We must also ensure that people who have recovered from cancer can cope with life after cancer. People’s experience of the condition, as many hon. Members will know, does not end—hopefully—with the all-clear, because there are all sorts of emotional problems after that. As the hon. Member for Salisbury said, we must ensure that patients who cannot be cured, and their families, have real choice and control over the last days of their life, including where they die. The hon. Gentleman has probably not been reading the Hansard reports of the Care Bill Committee, but there is cross-party support for moving more quickly on that issue. In that Committee, the Minister of State, Department of Health, the hon. Member for North Norfolk (Norman Lamb), said that he was personally committed to getting that up and running and sorted out quickly.

As the hon. Member for Salisbury said, we should help people to stay at home with the right social care and support, including support for family members. It can be quite frightening to think that one’s loved one may be dying at home, and people can feel panicked about that. If we can provide the right social care support, and Macmillan specialist nurses to sit with people through the night, it can be better for those families and also provide better value for money. I hope that when the Care Bill reaches Report, we will get some clearer commitments.

The overarching question that the all-party group focuses on is how we can make such things happen on the ground. It takes the new structure within the NHS and asks, “How are we going to make this work?” The Health and Social Care Act 2012 reform was not perfect, and it was clear that cancer networks took the lead in driving changes and improvements in cancer services. As my hon. Friend the Member for Ashton-under-Lyne (David Heyes) has said, we had 27 cancer networks that brought together the commissioners of services and the providers of cancer care to plan high-quality services in their areas. They were staffed by people with specific expertise in cancer care and local knowledge of the different hospitals and services. They worked across primary and secondary care and on a wide range of issues such as increasing the uptake of screening, improving training for staff on the best possible treatments, spotting early symptoms and signs, and championing a focus on the patient experience and the patient’s pathway through the system.

As the all-party group’s report states, there is concern, including among organisations such as Macmillan, that the good work and vital expertise of those networks are being lost. I was first alerted to the problem by Dr Mike Peake, a lung cancer specialist at Glenfield hospital. He is also the national clinical lead for cancer and responsible for the national cancer intelligence network. The worry is that the Government’s reorganisation means that the dedicated cancer networks have been abolished and subsumed into 12 generic strategic clinical networks, which cover a larger geographical region and have fewer dedicated staff. The fundamental concern is that moving from a specialist to a generic focus will reduce the ability, which we desperately need, to drive improvements in cancer care.

Members on both sides of the House, and clinicians and staff, are saying that in every other part of the health system we need to concentrate specialist services like cancer services to improve outcomes, rather than having them delivered through every district general hospital. It does not make sense to people: we say that we want clinical advice to drive clinical improvements and change, but then we go the opposite way—from specialist to generic. That is a cause for concern.

There is also confusion about how the strategic clinical networks will work with all the other parts of the new system—the 10 specialist commissioning hubs, the 19 commissioning support groups, the 211 clinical commissioning groups, the 27 local area teams, the 152 health and wellbeing boards, NHS England, Public Health England and Health Education England. The new system is very confusing. People have to work together, so clear lines of responsibility and accountability are important.

We urgently need clarity on two points. First, will the Minister update Members on what is happening in the strategic clinical networks, and, specifically, how is the cancer expertise being protected? Secondly, will she outline precisely how the strategic clinical networks will work with other parts of the system?

The all-party parliamentary group report makes many excellent recommendations and raises many issues. I cannot go into all of them in detail, but will focus on the two that I believe are the most important for patients. The first, as most hon. Members have said, is early diagnosis. The second is improving the patient experience, which we have not discussed in detail.

Getting early diagnosis right is the key to improving survival rates. Several things would make a difference, but I shall describe the most important ones, the first of which is raising public awareness of symptoms. If the Government want to meet their target of saving an additional 5,000 lives by 2014-15, we must arm people with knowledge of the warning signs and symptoms. Once again, the Government’s reorganisation means that the responsibilities for public health are split between lots of different bodies and we are not clear how they will work together. The APPG report says that the responsibilities for increasing public awareness must be more clearly spelt out for NHS England, the Department of Health and Public Health England, and for local authorities and health and wellbeing boards. I hope the Minister will set out exactly who will be responsible for running public awareness and other campaigns.

Secondly, we have to improve the ability of GPs to spot signs and refer people to specialists for early diagnosis. As the report states, more than a quarter of people diagnosed with cancer see their GP three times or more before they are referred to a specialist. Under the old system, before the Health and Social Care Act 2012 and the reorganisation, cancer networks absolutely led improvements in training for GPs and other health professionals, but it is not really clear who is going to do that now. How will NHS England work with Health Education England, the royal colleges and other education providers to ensure that training programmes for health professionals are really there on the ground?

Thirdly—this is probably the most important point in the report, one which the hon. Member for Basildon and Billericay emphasised—how are we going to hold clinical commissioning groups to account for the one and five-year survival rates? The report states:

“NHS England has not provided any guidance on how the one- and five-year survival rates will be used to drive improvements in CCGs.”

The data may be available, but what will happen to them? Will NHS England identify poor performers? Will it make practical support and guidance available to CCGs? How will we know whether actions and steps have been taken? How can we hold them to account? As a local MP, I would certainly want to know how my CCG rates, what the problems are, what it has not been doing, what its action plan is and when it is going to report back. We do not know any of that. The survival rate targets are excellent, but we have to make sure we can deliver. At the moment, we simply do not have the mechanisms to do that.

The other point I want to focus on is improving the patient experience. This is not only absolutely central for patients, but a key driver of improvements in the quality of care and better value for money. As such, it should be a much higher priority in the NHS. We all know, whether from personal experience, the experience of those we love or those in our constituencies, that a good experience makes patients feel as though they have been supported and respected as an individual. A bad experience makes them feel at best that their needs do not matter, and at worst that their basic human dignity has been denied. Cancer patients I have spoken to, for example those at the Macmillan Cancer Support group in my constituency, constantly emphasise their experience of care and how they are treated by NHS staff. That would be important at any point, but for someone going through such a frightening time, it is even more important.

The importance of patient experience goes far beyond the personal value to individuals. There is now strong evidence that good patient experience is consistently and positively associated with better health outcomes, and safer and more clinically effective care. The British Medical Journal published a systematic review of 55 studies last year, which provided very clear evidence. Patients who have a good experience are more likely to stick to their recommended treatments and medicines, and more likely to use preventive services such as screening and healthy living programmes.

There is also increasing evidence, although I would say that it is from the US and not the UK at this stage, that a good patient experience is linked to getting better value for money. It is associated with reduced length of stay in hospitals and fewer problems with patient safety—the so-called “adverse incidents”. A good patient experience is also associated with higher staff retention rates and, in turn, lower staff turnover. That is common sense: when staff feel valued and respected they are more likely to treat patients in that way.

For all the reasons I have outlined, the patient experience in cancer care should be given an even higher priority. The cancer patient experience survey introduced by the previous Government has made a big difference in trying to drive improvements. I welcome the assurances given to the all-party group on cancer that the survey will continue, but for how many more years? We must ensure that we use that information to drive changes on the ground, and I will make some concrete proposals on how to do that. First, commissioners should be held to account through the inclusion of a cancer patient experience indicator in the CCG OIS. If that is how we hold them to account, we have to include patient experience. Secondly, patient experience should be much more central to the hospital inspection process led by the chief inspector of hospitals. Currently, out of 150 CQC indicators, only two concern patient experience. We need more patient experience indicators in the work of the CQC, including one specifically for cancer teams or services.

Thirdly, we need to look at how we improve professionals’ training in patient experience. I want to highlight a brilliant example from my own constituency that I hope the Minister will look into. Under a joint Macmillan and De Montfort university partnership project, people training to be nurses, pharmacists and NHS managers get training from Macmillan in patient experience and how to talk to and support patients. In return, those students volunteer for Macmillan in the community in order to increase awareness about cancer, particularly among black and minority ethnic groups—Leicester is a very diverse city. That is something to think about. Has the Minister spoken to Health Education England and the royal colleges about how to improve training in patient experience for professionals, and will she speak to Ministers in the Department for Business, Innovation and Skills to see what other universities could do to learn from the fantastic work at De Montfort?

To conclude, Members on both sides of the House want to see big improvements in cancer care. The new system in the NHS is confusing. Both as MPs and as people with families and friends, we want the right people held to account so that they take the right action, but it is not yet clear how that accountability will work. For me, that was at the heart of the all-party group’s report. The Minister might not be able to respond to all the many questions she has been asked in this debate, but if she cannot, I hope she will write to me about the specific issues I have raised. This is about improving patient experience and early diagnosis and ensuring that CCGs are held to account. We as MPs must hold them to account on behalf of our constituents.

Cancer Patient Experience

James Clappison Excerpts

Wednesday 30th October 2013 Westminster Hall

[Mr James Clappison (Hertsmere) (Con)]

Mr Owen, it is a pleasure to have you chairing the debate on a subject that is important to many families up and down the country. Some 2 million people in the UK are living with or beyond cancer, and that figure is set to rise to 4 million by 2030. Although it is a cause for celebration that more people than ever survive after a diagnosis of cancer, a significant challenge must arise in ensuring that their clinical and human needs are met and that patients have the best possible experience.

Before turning to the nature of the challenge and the points I wish to raise, I pay tribute to all those who work in and support the many charities and voluntary organisations that address the challenge posed by cancer. There are many such organisations, but, with utter respect to all those involved in the field, I shall mention just a few: Macmillan Cancer Support, Cancer Research UK, Breakthrough Breast Cancer, Marie Curie Cancer Care, Breast Cancer Care, Beating Bowel Cancer, the Roy Castle Lung Cancer Foundation and the Teenage Cancer Trust. There are many others. They all do fantastic work and much to improve patient experience and give hope to many of our constituents.

The Government have set great store by patient experience and all the issues that naturally interest cancer patients. I warmly welcome my right hon. Friend the Prime Minister’s ambition to give every cancer patient the opportunity to be a research patient if he or she so wishes; that must interest many people in that position.

The UK now leads the world in recruiting cancer patients to take part in research. One in five cancer patients in the UK takes part in some form of research, which compares with 3% of people in a similar position in the United States. I pay tribute to the research of Cancer Research UK in that regard. Last year, 36,000 patients took part in its trials in this country.

I welcome the fact that NHS England has said that it plans to continue the important national cancer patient experience survey. The results of the 2012-13 survey showed that there is room for improvement in some areas of care. I make that point not as a criticism of the NHS, but to highlight areas where there is room for improvement. Macmillan Cancer Support highlighted some such areas in particular, and has urged Ministers to take notice of and act on them. I urge Ministers to listen to the representations being made to them by Macmillan Cancer Support and others.

The national cancer patient experience survey highlighted several important issues, and I will mention three. The first is care planning and information. The most recent cancer patient experience survey reveals that before starting treatment, 45% of patients were not fully informed about the side effects that could affect them in future, that 78% were not offered a written assessment and care plan, and that 41% were not given enough support from health and social services after leaving hospital. As a result, not all patients felt that their families were given all the information needed to help care for them at home. That is clearly an area where there is room for improvement.

[David Simpson (Upper Bann) (DUP)]

I congratulate the hon. Gentleman on obtaining this important debate. He mentioned Macmillan, which says in the research paper on the survey:

“The lack of basic care, dignity and respect experienced by cancer patients in hospital is shocking.”

It also says that 15% of patients experienced humiliation. That should not happen to someone suffering from cancer.

[Mr Clappison]

The hon. Gentleman makes an excellent point, and some of the matters I will turn to in due course underline its strength. May I apologise to hon. Members? I mentioned NHS England, because that is what the survey covers, but I will turn to the situation in Northern Ireland, Wales and Scotland in due course. I am delighted that so many Members from Northern Ireland are here this morning.

The next issue is financial support. Cancer patients and their families obviously need financial support, just as everybody else does. Although significant progress has been made since the first cancer patient survey in 2010, almost half of patients who would have liked information about how to get financial help or benefits still do not receive it.

[Mr Robin Walker (Worcester) (Con)]

I congratulate my hon. Friend on securing this hugely important debate. He mentioned the importance of financial advice and support, but does he agree that service design is also important? I came across a case of one constituent, David Wilson, who, while undergoing chemotherapy, received 270 different pieces of paper from our city council in just one month—August this year. It is vital that we design services so that Her Majesty’s Revenue and Customs, local councils and the Department for Work and Pensions work together to make life for patients easier and simpler and to ensure that they understand the financial entitlements.

[Mr Clappison]

My hon. Friend makes an excellent point that I am sure the Minister will want to address. The last thing that somebody coping with the treatments and everything else wants is to be bombarded with different pieces of information and requests from central or local government bodies, which could do something much more coherent and easy to understand if they streamlined their services.

I would like to address relational care, which the hon. Member for Upper Bann (David Simpson) raised in his intervention. It covers matters such as communication, trust in nurses and being treated with respect, all of which are important for cancer patients. There is still room for improvement, according to the findings of the most recent survey. For example, 42% of respondents said that not all doctors and nurses asked what name patients preferred to be called by, which can be important to older people. It is a question of finding the right amount of kindness. Our clinicians—nurses and doctors—are marvellous, but that did emerge from the patient survey. Kindness can make a great difference to people in that situation.

Macmillan Cancer Support’s report showed that patient experience across the NHS is still not regarded as having equal importance as clinical effectiveness and patient safety. The Government’s decision to make patient experience one of the five domains against which the health service will be held to account should be warmly welcomed. It is clear, however, that a lot of effort needs to be put into the institutional framework to reinforce that priority.

The NHS mandate and outcomes framework needs a stronger focus on improving relational care. Hospital boards need to take a lead on prioritising patient care; a recent survey showed that its importance to different hospital boards varies considerably, which is clearly wrong, because all hospital boards should take it seriously. Commissioners of cancer services have a vital role to play, as does the chief inspector of hospitals. All such bodies need to reinforce the need for relational care and kindness in dealing with cancer patients.

[Nic Dakin (Scunthorpe) (Lab)]

I congratulate the hon. Gentleman on securing the debate, and I apologise for having to leave before the end. Does he think that it is also important that priority be given to communication skills between medical staff and patients? That is the core of what he has outlined.

[Mr Clappison]

I am grateful to the hon. Gentleman for that intervention. I agree that communication skills are important; the important factor is that kindness should be received by the patient.

I put a point to the Minister on behalf of Macmillan Cancer Support: I hope that the Government will deal with the matters we have discussed and put patient experience at the heart of the inspection process being put in place for our health service. One way of doing that is to use the results of the cancer patient experience survey to inform ratings at a cancer team and service level and to monitor and assess providers of care—for example, as part of the foundation trust assessment process.

In the light of all that, I have four specific questions for the Minister, on behalf of Macmillan Cancer Support and other charities. First, will the Government consider making relational care a priority area in the refreshed 2014-15 mandate to NHS England? Secondly, will the Government support the use of cancer patient experience data in the inspection regime of the Care Quality Commission, which is led by the chief inspector of hospitals?

Thirdly, will the Government work with commissioners and providers to ensure that the results of the national cancer experience survey continue to drive improvements in cancer care? Fourthly, and specifically on breast cancer, can the national cancer patient experience survey include a question asking whether the respondent has secondary breast cancer? The Breast Cancer Campaign specifically asks to have that included.

More generally, I welcome the Government’s ambitious plans to improve cancer care in the United Kingdom, including those they set out in January 2011 in “Improving Outcomes: A Strategy for Cancer”, which promised action on a number of important fronts, such as diagnosing symptomatic cancer earlier; helping people live healthier lives to reduce the incidence of preventable cancers; screening more people; introducing new screening programmes, as recommended by the National Screening Committee; and ensuring that all patients have access to the best possible treatment, care and support.

Those measures should save at least an additional 50,000 lives every year by 2014-15. Many of us will be aware of the efforts being put into those different fields, to encourage people to come forward for screening, to make screening available, to make members of the public more aware of symptoms and to encourage people to lead healthier lives. That has been much more evident than it had been hitherto. In the light of all that, it would be good to hear from the Minister what progress has been made on the ambitions that the Government set out in January 2011.

Furthermore, what progress has been made in tackling inappropriate regional variations in cancer outcomes? Many advances have been made in cancer treatment in the UK, of course, but historically there has been a disparity on cancer survival rates between the UK and other comparable western nations. That has been the case for many years, under Governments of all parties, but it was underlined most recently by a 2009 Eurocare study, which revealed a disparity between UK cancer survival rates and those achieved in countries with the best outcomes.

England rated 16th in the survey for both men and women. Wales was ranked just in front, and Scotland and Northern Ireland were just behind. Apart from Ireland, every other major western European nation performed better than the UK, and some of them much better. Sweden was the best performing country.

The 2009 analysis was a little old, because it was based on patients diagnosed between 1995 and 1999, although that had to be the case to detect survival rates. More recent surveys have also seen the same pattern, such as one comparing the USA with the United Kingdom. With older patients, there is an even more marked gap between the UK and other comparable nations and economies. I have seen figures from the British Journal of Cancer that show that for women over 70 with breast cancer, the three-year survival rate in the UK is 79%, but in Sweden, it is 91%.

[Mr John Baron (Basildon and Billericay) (Con)]

I congratulate my hon. Friend on securing the debate. Although comparisons are always dangerous, a further acknowledgement of how far we remain behind our European partners is that even if we met the Government’s laudable target of saving an extra 5,000 cancer lives over the next couple of years, that would still only bring us up to the European average on survival rates.

[Mr Clappison]

My hon. Friend makes an excellent point. I am sure he would agree that there is a lot of ground to make up. The important point is that we should not only take encouragement from the improvement of survival rates as a result of advances in medical science; we should judge ourselves by how well we use those advances compared with other countries. We should set ourselves the more ambitious target of not just improving survival rates, but improving them so much that we close the gap on other countries.

Members of the British public who fall ill with cancer and their families expect cancer treatment to be on a level with that of comparable countries, our neighbours and other western developed economies. Sadly, it is not at that level, although I hope the Minister will tell us that we have made some progress.

Yesterday, some encouraging statistics were released that showed a trend of increasing survival for patients diagnosed between 2007 and 2011. The Minister will agree that that is good news, but I look forward to hearing from her that the Government’s ambition is to close the performance gap between ourselves and other countries and that the gap is being closed.

In closing, I should like to pay the utmost respect to doctors, nurses and all clinicians working in the field. We owe them a great debt of gratitude and my comments are no reflection on them. We are all hugely indebted to their work and I am sure that many of our constituents would echo that sentiment. I am just drawing attention to how the system has operated in this country over a number of years, and the experience of the patients within it. I hope that the Minister can tell me that the Government have ambitious plans for improving the cancer patient experience and that there is evidence that those plans are on the road to fulfilment.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (Jane Ellison)]

Thank you, Mr Owen. It is a pleasure to serve under your chairmanship.

I congratulate my hon. Friend the Member for Hertsmere (Mr Clappison) on securing this debate. I am conscious that I am still relatively new to my post—I am in my fourth week—so if I am unable to respond in total detail to some of the points raised, I will undertake to get back to the relevant hon. Members.

This has been a very good debate. Many extremely constructive points have been made, and there have been some thoughtful contributions. Members, some of whom have not been able to stay for the end, have brought great insight and experience to the topic.

Cancer patient experience is close to our hearts, and I echo the tributes paid to NHS staff and, particularly, to the charities that campaign in this area. We have all taken part in moonwalks and Macmillan Cancer Support fundraisers or gone round at the back of the race for life year after year talking to cancer survivors and people running or walking with the names of loved ones on their chests, and we know what amazing work those charities do, particularly on highlighting patient experience.

In England, each year more than 250,000 people receive a cancer diagnosis. As we have heard this morning, being diagnosed with cancer can be a traumatic experience. Like the shadow Minister, a dear friend of mine has just had that experience, so I am going on that journey with my friend to understand how she will be cared for and treated as she goes through what I hope will be a full recovery.

We know that receiving personal care that is responsive to people’s needs is vital. The Government have committed to making England a global leader in producing great cancer outcomes. We are making strides, but we know there is further to go. We are improving access to treatments, including investing £750 million during this Parliament, and we are strongly committed to saving an additional 5,000 lives by 2015.

The cancer outcomes strategy remains at the core of what we are doing and what we hold the NHS to account for in terms of delivering. However, if the NHS is to deliver high-quality care, patients’ voices and experiences are vital, and I could not agree more with what everyone has said about the end-to-end experience of care being important and a big part of recovery.

My hon. Friend rightly asked that the NHS give parity of esteem to the patient experience, alongside patient safety and clinical effectiveness. I agree, and through the mandate we have asked NHS England to deliver continued improvement in patients’ experience of care. Domain 4, which is one of the key areas of the NHS outcomes framework, is

“Ensuring that people have a positive experience of care”.

I reassure my hon. Friend that that is of equal importance to the other key areas.

[Mr Clappison]

I was remiss in not welcoming the Minister to her post. I welcome her most warmly, and I am sure she will do an excellent job. Will she take on board the fundamental plea made by Macmillan Cancer Support and echoed in the debate that the patient experience be put at the heart of the inspection process and of the assessment of different NHS organisations? Will she ensure that that is made a real priority?

[Jane Ellison]

Absolutely, and I will talk a little about some of the ways in which that will be done, but I would make the point that the Secretary of State has made this an absolute priority. He could not have been clearer recently about the priority that the Government and he personally put on the patient experience. We have never given such high-profile attention to talking about the patient experience and patient care. I hope that gives some reassurance, but I will talk later about some specifics.

In the same vein, let me pick up some of the shadow Minister’s interesting points. I was interested in some of the initiatives she mentioned. Again, they all feed into the idea of putting patient care and the patient experience absolutely at the heart of things. I certainly undertake to look at some of the specific local examples she highlighted.

To drive a good patient experience, we must listen to patients’ voices. In December 2010, the Government published the first national cancer patient experience survey report. The survey was the first cancer patient survey to take place for six years, the first to involve patients with all types of cancer and the first national survey explicitly to use the word “cancer”. The survey revealed that, while there had been substantial improvements in the patient experience since 2000, there are still unacceptable variations in the quality of care people receive, as hon. Members have highlighted.

To drive improvement locally, reports were produced for individual trusts. This is where the transparency agenda the Government set such store by is really important. The data are openly available and published, and all of us—not just people in the NHS, but hon. Members, local councillors and local government—can hold commissioners and providers to account, based on that openly published data at local trust level. Commissioners and providers can be directly challenged and incentivised to improve. Providers can benchmark their performance against each other’s. Quality Health, which provided the survey, also visits poor-performing trusts to discuss their results in detail. A number of those discussions have led to really quick improvements in local outcomes, but there is always more to do.

The cancer outcomes strategy, which we published in January 2011, built on those results. We have acted to improve the patient experience at national level by implementing the cancer information prescriptions programme and expanding the Connected national advanced communications skills programme, which is a bit of a mouthful, but which is essentially about supporting thousands of clinicians to work more effectively with patients, picking up the many issues highlighted by my hon. Friend, the hon. Member for Strangford (Jim Shannon) and others regarding how seemingly small issues and small aspects of communication actually matter an awful lot at an intensely difficult time for patients and their families.

Since 1 April this year, NHS England has been responsible for delivering improvements in the cancer patient experience. That is one reason why I cannot just stand here and make particular commitments. Such debates are, however, useful because they help NHS England to know parliamentarians’ priorities in terms of where it should focus some of its attention.

Building on the work of the 2010 and 2012 patient experience surveys, NHS England published its report on the 2013 survey at the end of August. It showed improvements in many areas and some very positive experiences of aspects of care, including on privacy, being treated with respect and being listened to. Overall, 88% of cancer patients reported their care had been excellent or good, and there were some real highlights. As my hon. Friend highlighted, some of the percentages in key areas were in the 80s and 90s, although we are obviously interested in the areas where we could do better.

It is clear that many trusts acted on the findings between 2010 and 2013, and they are to be congratulated on that. Many have reorganised their pathways and services, retrained staff and created further mechanisms for patients. Cancer charities have been involved in further analysing the data to understand particular aspects of care and particular groups of patients and to create new information for patients, where needed. Much of that has been touched on this morning.

We have also looked at some of the variations in care. The hon. Member for Strangford and others mentioned care plans. Over the past three years, more work has been done on them, but given that only 22% of patients were offered care plans, everyone would acknowledge considerable improvement is still needed.

NHS England has convened a cancer patient experience advisory group to get direct input on priorities for service improvement. The group includes clinicians, experts concerned with cancer care and, crucially, patients. The group’s first meeting has now taken place. It examined the results of the 2013 survey, and actions have been agreed. As a result, NHS Improving Quality will develop a rapid-response programme to visit trusts with poor scores to discuss results and suggest improvements. I hope that gives Members some assurance about the fact that the survey does not just sit there; it is very much being acted on.

NHS England also wants to highlight high-performing trusts and identify best practice. It will put that information into toolkits that other trusts can use to develop better service in response to poor scores. NHS England is also encouraging the use of the Macmillan values-based standard and other patient-led tools, which engage patients and staff in co-creating and measuring some of the things that matter so much with regard to dignity and respect. All organisations involved in delivering care are urged to look at the survey and take it extremely seriously.

Time is a little short, so I will try to answer some of the specific questions raised. First, we recognise that making relational care a priority is important. That includes communication, trusting nurses and all the other things that have been talked about today. Rather than include references in the mandate, we have included important pledges in the NHS constitution, setting out what patients have a right to expect. All NHS services have a duty under the constitution when carrying out their functions, and we have a range of indicators to capture how well the NHS is performing in delivering dignified and personal care.

On the CQC inspection regime, I can reassure my hon. Friend that the CQC has made a commitment to listen and to take the experiences of people using services very much to heart. The new inspection teams include trained members of the public called “experts by experience”. In addition to public listening events, that will be an important way of putting patient experience at the heart of inspections.

A specific question was asked about including secondary breast cancer in the survey. NHS England is trying to ensure the survey catches the needs of all patients and looks across all cancers, but my hon. Friend’s point will have been taken.

I was asked about the future of the survey, including by the shadow Minister. NHS England has confirmed it will be run in 2014. The organisation will then undertake a review of all the surveys it runs. The debate will have highlighted to it the value that so many people place on the survey and the important role it has played in driving improvement. I cannot say whether NHS England will continue it, but I will certainly vividly describe to NHS England how strongly Members feel and what role they think the survey has had in driving change.

My hon. Friend’s last question was about using the survey to improve cancer care, and I have alluded to the ways in which we are trying to do that. In particular, I give him the assurance that the patient experience, putting the patient first and championing their care is absolutely at the heart of what all of us at the Department of Health are doing, taking our lead from the Secretary of State.

I thank my hon. Friend for highlighting the issue, and I echo his words from the start of the debate. I, too, thank the NHS staff and charities that do such amazing work in this area, and I hope hon. Members will continue to debate this important topic.