NHS Cancer Services

John Baron Excerpts

Friday 14th September 2012 Commons Chamber

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

May I start this important debate by congratulating the Under-Secretary of State for Health, my hon. Friend the Member for Broxtowe (Anna Soubry), on her appointment to what many of us consider to be an important position in Government? May I also pay a warm tribute to her predecessor, the right hon. Member for Sutton and Cheam (Paul Burstow), who did an excellent job in understanding the issues and pushing the case for cancer care? We wish him well for the future. The all-party group on cancer, of which I am chair, looks forward to enjoying the same constructive relationship with this Minister. However, I secured today’s debate because we believe that after making excellent progress on cancer care the Government now risk making a gross error, which could be very costly indeed, when it comes to cancer treatment.

As the Minister is new in her post, I will, if I may, briefly provide some background information. Cancer survival rates have steadily improved over the past 40 years, but they still lag considerably behind those in Europe and in other countries. Comparisons are never easy, but although we compare with, say, France when it comes to the four or five cancer centres of excellence, it is generally accepted that we lag behind the rest of Europe. The Government have recognised and accepted that point. In January last year, they set themselves the target of saving an additional 5,000 lives by 2014-15, but that would bring us up only to the European average, not even the best.

Why do we in this country trail behind the rest of Europe when it comes to cancer survival rates? In 2009, the all-party group undertook a major inquiry into cancer inequalities that looked at that very issue. What we found was most revealing. We discovered that patients in this country who make it to the one-year survival point stand as much chance as anybody on the continent of making it to five years. Where we fall down badly is in getting patients to the one-year survival point. That led to the conclusion, which is backed up by lots of evidence from those working in the NHS, that the NHS is as good as any other health care system at treating cancer once it is detected, but very poor at detecting it in the first place. It is a national disgrace that nearly one quarter of all cancers in this country are detected only at A and E. That is far too late and it obviously affects survival rates.

The Minister will be fully aware that very rarely in life is there a golden key—an Act or policy through which one can find unbounded riches. However, when it comes to cancer, I would suggest to her that there is a golden key—earlier diagnosis. The earlier a cancer is detected, the greater the chance of survival and the better the survival rate.

Our key recommendation from the 2009 report was the introduction of a one-year survival outcome measure, in order to get the local NHS to raise its game. There is no point in the Department of Health trying to micro-manage primary care trusts; it is better to put up in lights the one-year and five-year outcome measures and to get the local NHS to introduce the various measures and initiatives needed to encourage earlier diagnosis. Those measures could involve greater awareness, earlier or better screening, better use of diagnostics or a combination of those. We should leave it to the local PCTs, while encouraging them to put up in lights the one-year and five-year outcome measures. Such initiatives at ground level would encourage earlier diagnosis, which would result in better one-year and five-year survival rates.

The all-party group campaigned hard on this issue. We raised it in Parliament and at our annual Britain Against Cancer conference—which is the largest of its kind and which is often addressed by Secretaries of State—and elsewhere. We had some success. We were pleased to see the inclusion of one-year and five-year cancer survival rates for breast, lung and colorectal cancer as indicators in the national outcomes framework, which, as the Minister knows, holds the NHS Commissioning Board to account.

Of the two big ideas in the Government’s NHS reforms—the focus on outcomes and the restructuring of the commissioning arrangements—we always thought that the focus on outcomes was by far the most important. We believed that the heat, rather than light, generated by the debate on commissioning structures was unfortunate, to say the least.

In many respects, the national picture has been taken care of. We have the one-year and five-year figures in the NHS outcomes framework, which holds the NHS Commissioning Board to account. Locally, however, it is the clinical commissioning groups—the CCGs—that will play a key role in delivering better cancer care. They are held to account by a different outcomes framework: the commissioning outcomes framework, known as the COF.

The COF will do much to set cancer priorities locally, and it is therefore vital that we get this right. Up until last month, we were led to believe that the five-year survival indicator was to be included in the COF, and the all-party group was lobbying hard to get the one-year indicator included as well. After all, both derive from the same data set. We fully participated in the National Institute for Health and Clinical Excellence consultation in February this year. We learned last month, however, that the NICE COF advisory committee had decided not to recommend the inclusion of either the one-year or the five-year survival rates in the first iteration of the COF. Instead, only the under-75 mortality rates were recommended for inclusion.

I suggest to the Minister that that is a major error. Given all the evidence on how the measure of the one-year and five-year survival rates encourages earlier diagnosis, the Government should not allow this major step backwards in cancer care. The NHS Commissioning Board is, at this very moment, deciding on the make-up of the COF, and the all-party group is calling on it and the Government to include the one-year and five-year cancer measures in this important outcomes framework.

NICE offered two reasons for the exclusion, but they simply do not stack up. First, it said that survival rates were dependent on the socio-economic status of an area. However, the all-party group has heard from a broad range of experts working in the NHS that the most effective way to incentivise early diagnosis is to measure the NHS against cancer survival rates, specifically at one year. The inclusion of cancer survival indicators in the COF is the best way of guaranteeing that CCGs prioritise early diagnosis.

NICE’s second objection related to the application of survival data at local level. However, my understanding, from conversations with the National Cancer Intelligence Network and others, is that cancer survival figures for CCGs can be produced—sliced up, if you like—once the boundaries are known. At the very least, CCGs could then be measured against one-year and five-year survival rates for breast, lung and colorectal cancer, and so be included in the 2013-14 COF, thereby bringing it in line with the NHS outcomes framework.

In our opinion, it is vital that survival indicators are included in the COF, but the all-party-group has also called for proxy measures such as staging and cancer-diagnosed A and E admissions to be included in the COF to complement the one and five-year figures. We have been calling for this because of the smaller population sizes of CCGs compared to what they are replacing—the PCTs. Proxy measures would help to provide a more complete picture of what is happening on the ground, and would help commissioners to identify the bottlenecks to early diagnosis. Will the Minister update us on the progress made on these proxy measures?

Before I conclude and while I have the Minister’s ear, let me quickly raise two further points. Although perhaps a little less urgently than in respect of our main concerns about the COF, the all-party group would like to see both the outcomes framework and the COF to include all cancers. In our view, if all cancer patients are to benefit from the Government’s correct focus on outcomes, it is vital that the rarer cancers be included, thereby narrowing the unacceptable survival gap between the rarer and more common cancers. After all, breast, lung and colorectal cancers account for only 40% of all new cancers. I add that we are somewhat concerned about Government talk about a composite cancer benchmark or indicator because we fear that such a composite would hide failings perhaps in respect of rarer cancers by focusing on improvements made in the more common cancers. We need to narrow that unacceptable survival gap between rarer and the more common cancers.

[Naomi Long (Belfast East) (Alliance)]

I join the hon. Gentleman in welcoming the Under-Secretary of State for Health, the hon. Member for Broxtowe (Anna Soubry) to her new role.

One way of treating more difficult cancers can be the use of very specialist radiotherapy techniques. I have spoken before about stereotactic body radiation therapy and other treatments, which have the potential to improve outcomes, but because they are novel treatments they are advised for use only in clinical trials. Many health trusts are afraid to refer patients because there is no clinical evidence that they are successful for particular cancers. There is a vicious circle here, which needs to be broken so that rarer and harder-to-treat cancers can be treated, at least at that test phase.

[Mr Baron]

The hon. Lady raises a very good point. I believe that cancer networks have a particularly important role when it comes to treatments that span CCGs such as radiotherapy. I know that local cancer networks would help to look into those treatments in order to address the concerns the hon. Lady has rightly raised.

Let me touch briefly on the second point, which is the importance of improving the patient experience. The all-party group recommends that the national cancer patient experience survey should be conducted annually and should be included as an indicator in domain 4 of both the NHS outcomes framework and the COF, as we believe that that would be a solid way of getting the NHS to focus on the importance of improving cancer patients’ experience at all levels.

In conclusion, important though those last two points are, let me return to the central concern of the all-party group and the point of this debate. We think it a very bad decision to exclude the one-year and five-year survival indicators from the COF, and we ask the Government to think again. It sends out the wrong message, defies all the evidence and risks different parts of the NHS focusing on different messages—the outcomes framework on the one hand and the COF on the other. If one thinks about it, there is no reason why the one and five-year measures cannot appear in the COF if they are in the outcomes framework; the numbers can be sliced once the boundaries are known.

Our message is clear: we risk a major traffic accident here, which really could set back cancer care and treatment in this country. We raised this issue with Ministers outside this place prior to the reshuffle, and we raise it again with the Minister in this Chamber now. We urge the Government to think again. A lot of cancer patients are watching this space very closely.

[The Parliamentary Under-Secretary of State for Health (Anna Soubry)]

I congratulate my hon. Friend the Member for Basildon and Billericay (Mr Baron) on securing the debate. I am aware of the excellent work that he has done with the all-party parliamentary group and with cancer charities to promote the inclusion of relevant cancer indicators in the NHS, public health and commissioning outcomes frameworks.

As you will know, Mr Deputy Speaker, there is a lot of terminology in the Department of Health—to which I am very pleased to have been appointed—and I apologise at the outset for any jargon that is used. One thing is certain: my hon. Friend will be more than familiar with it. However, I hope to explain the position in as much plain language as possible.

I am fully aware of the frustration felt by my hon. Friend, his all-party group and the cancer charities over the recommendations from the National Institute for Health and Clinical Excellence about the indicators for the commissioning outcomes framework and the difficulties that are likely to occur in 2013-14, but I can assure him that a methodology for possible one-year and five-year survival rate indicators for potential inclusion in COF is under way. I hope he will accept that that is good news, as is the fact that work is also under way to investigate composite cancer survival indicators at both national and clinical commissioning group level. I will say more about that, but I wanted to begin by reassuring my hon. Friend that we had taken his previous points fully on board.

As my hon. Friend knows, the Government published “Improving Outcomes: A Strategy for Cancer” in 2011. It set out our ambition to halve the gap between England’s survival rates and those of the best in Europe. My hon. Friend spoke of the disappointment that many people feel about our survival rates, and said that everyone wanted them to improve. It is estimated that halving that gap would save 5,000 more lives every year by 2014-15. The strategy is intended to reflect the importance of improving outcomes through the five domains—or areas, as I would call them—of the NHS outcomes framework: preventing people from dying prematurely, improving the quality of life for people with long-term conditions, helping people to recover from illness or injury, ensuring that people have a positive experience of care, and treating and caring for people in a safe environment and protecting them from avoidable harm.

In recognition of the fact that cancer is a big killer—more than 130,000 people die of the disease each year—we have included seven cancer indicators in domain 1 of the NHS outcomes framework. They cover the under-75 mortality rate from cancer and one and five-year survival rates for three major cancer killers, namely colorectal, breast and lung cancer. In addition, two overarching indicators will include cancer data: potential years of life lost from causes considered amenable to health care, and life expectancy at 75.

My hon. Friend has urged us previously to consider other indicators that would reflect improvements in survival rates for rarer cancers, and he mentioned them again today. I can confirm that we have asked the London School of Hygiene and Tropical Medicine to develop composite indicators that might allow improvements in survival rates across all cancers to be assessed. We hope to be able to make a decision in time for the NHS outcomes framework for 2013-14, which is due to be published later in the autumn.

[Mr Baron]

I am heartened by what the Minister is saying, but does she appreciate our view that a composite index should complement the one and five-year survival indicators rather than replace them? We fear that a composite index will mask bad news on rarer cancers with improvements on the more common cancers, which would have greater force in the index because they are more numerous.

[Anna Soubry]

I thank my hon. Friend for making that point, and I certainly take it on board. If there is anything that I am not able to cover in the short time that is available to me today, we will write to him; and, as he knows, my door is always open so that we can continue the debate. It is important, and it is especially important that we do things right.

The NHS Commissioning Board will translate the national outcomes goals for the NHS into measures that are meaningful at a local level in the commissioning outcomes framework. The board authority is now working with clinical commissioning groups and other stakeholder organisations to discuss the shape of the commissioning outcomes framework for 2013-14 and beyond. COF will play an important role in driving up quality in the new system. Covering £60 billion in services commissioned by CCGs across the NHS, it will translate the NHS outcomes framework into clear, comparative data on the quality of services that CCGs commission for their local populations and the outcomes achieved for patients.

Concerns have been expressed that the NICE COF advisory group recommended only one indicator for inclusion in COF and, in particular, that the group recommended no survival rate indicators. NICE’s advisory group is independent of both the Department and the NHS Commissioning Board. NICE was asked to give advice on potential measures to include in the framework, based on the best available evidence. It is now for the NHS Commissioning Board to decide on its final shape for 2013-14.

The NHS Health and Social Care Information Centre has been asked to work with the London School of Hygiene and Tropical Medicine and the Office for National Statistics to develop a methodology for one-year and five-year survival rate indicators for potential inclusion in COF. These will be composite indicators, because of the difficulties associated with getting statistically valid indicators for individual cancers at CCG level.

[Mr Baron]

The national one-year and five-year figures for the three main cancers have been calculated. They must have been drawn from local figures. Experts in this area tell me that once the boundaries are known, it should be possible to slice those figures to show the one-year and five-year picture at a local level.

[Anna Soubry]

The difficulty is that the numbers in each CCG might be very small indeed, and therefore the statistical benefit will be limited. It may well be possible to look at the situation in respect of the health and well-being boards, however; we might be able to look at this at a local authority level.

[Mr Baron]

The Minister is being very generous in giving way, and one of the purposes of Adjournment debates is to enable us to have a bit of a discussion. I take on board her point, but the CCGs are larger than was originally estimated. I would also say that we have suggested the use of proxy measures such as staging and accident and emergency admissions figures to complement, but not replace, the one-year and five-year figures, because they would give a more complete picture at the local level.