Cancer Targets

John Baron Excerpts

Tuesday 1st May 2018 Westminster Hall

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

I beg to move,

That this House has considered NHS cancer targets.

I thank Mr Speaker for granting this important debate, and I thank you, Mr Streeter, for chairing it and the Minister for taking time out of his busy schedule to address it.

The matters I will raise today, as briefly as possible, are matters I have raised throughout my nine years at the helm of the all-party parliamentary group on cancer. As I near the end of my chairmanship, I thank all those parliamentarians, and the wider cancer community, who have supported and continue to support the group. They have been great stalwarts; the group has achieved much and has much to achieve. I look forward to remaining involved, but at the same time I look forward to handing over the reins.

Despite the fact that, when in government, both main parties have highlighted improving survival rates and supported process targets as a means of driving change, it remains an inconvenient truth that cancer survival rates in England and, indeed, the rest of the United Kingdom continue to lag well behind the international average. What is more, there is only limited evidence that we are catching up. In 2009, the Department of Health estimated that we could save an extra 10,000 lives a year if we matched European average survival rates. In 2013, the OECD confirmed that our survival rates rank near the bottom compared with other major economies, and for some cancer types only Poland and Ireland fare worse.

Of course, Health Ministers are right to point out that cancer survival rates continue to improve. That is welcome news, but it is not the full story. As our survival rates have improved, so have those of other countries, and there is very little evidence of our closing the gap with international averages, despite the considerable increases in health spending in recent decades. The major inquiry by the APPG on cancer in 2009 uncovered the main reason our survival rates are so far behind international averages. It is not that the NHS is worse at treating cancer—once cancer is detected, NHS treatment generally bears up as strongly as that of other healthcare systems—but that it is not as good at catching cancers in the early stages when treatment has the best chances of success. Late diagnosis, therefore, lies behind our comparatively poor survival rates, and addressing that is the key to improving our cancer performance. Early diagnosis is cancer’s magic key.

So how can we best achieve it? Since the publication of our 2009 report, we as an all-party group and the wider cancer community have come together and successfully campaigned for a one-year cancer survival rate indicator to be built into the DNA of the NHS, especially at a local level. Clinical commissioning groups are now held accountable for their local survival rates through both the delivery dashboard and the Ofsted-style scores.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Gentleman: we all know the hard work he does through the APPG and his personal passion for the subject. It is important to put that on the record, because we know why he is here. I have apologised to him, and I apologise to you, Mr Streeter, because I cannot stay. I have a meeting with a Minister at 3 o’clock, so unfortunately I cannot make the contribution that I would have liked to have made. I am sure that the Minister is disappointed, but none the less he will hear from me again in the near future.

Is the hon. Member for Basildon and Billericay (Mr Baron) aware that the target for 95% of patients with an urgent referral to wait no longer than 62 days for first treatment has not been met at all in the past year and, further, that the target for 98% of patients to receive first treatment within 31 days of a cancer diagnosis has also not been met in any of the last four quarters? Does he share my concern and, I am sure, that of the Minister?

[Mr Baron]

I thank the hon. Gentleman for his kind words. I am aware of those statistics, and I will come to the 62-day target specifically later in my address. He is right to say that many CCGs and cancer alliances are not close to achieving many of those targets. That is obviously a problem when treating cancer, but it highlights a bigger issue: we should be focusing on outcome indicators rather than process targets as a means of encouraging earlier diagnosis. I will address his point specifically in a moment.

We tried very hard to get the one-year survival rates into the DNA of the NHS. The Government listened, and we now have CCGs being held accountable for their one-year survival rates, which is good news. The logic is simple: earlier diagnosis makes for better survival rates, so by holding CCGs to account for their one-year figures and, in particular, the actual outcomes, we encourage the NHS to promote earlier diagnosis and therefore improve detection.

A key advantage of focusing on outcome measures is that it gives the local NHS the flexibility to design initiatives tailored to their own populations to improve outcomes. CCGs can therefore choose whether to widen screening programmes, promote better awareness of symptoms, establish better diagnostic capabilities in primary care, embrace better technology or perhaps improve GP referral routes—any or all of those, in combination—to try to promote earlier diagnosis, which in turn will improve the one-year cancer survival rate figures.

Rather than the centre imposing a one-size-fits-all policy, the local NHS has been given the freedom to respond to and focus on local priorities, whether that be lung cancer in the case of former mining communities or persuading reticent populations to attend screening appointments. As an all-party group we try to do our bit. Each summer, the group hosts a parliamentary reception to celebrate with the 20 or so CCGs that have most improved their one-year survival rates. Successive cancer Ministers have supported that in the past, including the incumbent.

There is strong evidence, however, that that outcome indicator is being sidelined by hard-pressed CCG managements, who are focused on those process targets that are connected to funding. If the process targets are missed, there is a cost; if the one-year figures are missed, there is not. In recent decades, the NHS has been beset by numerous process targets that, instead of measuring the success of treatment, measure the performance against process benchmarks, such as A&E waiting times.

[Mr Jim Cunningham (Coventry South) (Lab)]

I pay tribute to the hon. Gentleman, because I know he has a strong interest in this issue for a number of reasons—as we all have, because cancer in one form or another touches nearly every family in Britain. I agree with him that it is the outcomes that matter, not the input. I wonder whether the targets are in the wrong place; I may be wrong, and the hon. Gentleman knows more about it than I do, but I think he has made an important point. The problem seems to be how to get the NHS to implement that.

[Mr Baron]

I completely agree. The problem as I understand it is that, according to the House of Commons Library, there are something like nine process targets focused on cancer alone. Briefly, it is an inconvenient truth that, if we look back over the past 20 or 30 years, we will see that the NHS has been beset by process targets from both sides and for the best of reasons. The bottom line is that we have not caught up with international averages in any meaningful way over those 20 to 30 years, so we must start to question the efficacy of those process targets when what we are trying to do is to improve survival rates. If we get the NHS focused on one-year survival rates, it should look at the journey as a whole, not just a small part of it, in trying to promote initiatives to encourage earlier diagnosis, which at the end of the day is what we all have to do if we are to improve survival rates.

[Karen Lee (Lincoln) (Lab)]

I am the mother of somebody who died of breast cancer and I would argue that this is about the lived experience. It is not just about survival; it is also about the journey—getting there. If care is not adequate or good enough along the way, whether somebody survives or not—well, it is better to survive, of course, but I would argue that this is absolutely about the journey. Targets are meaningless if they are not about people and their lived experience.

[Mr Baron]

I completely agree. My worry about targets is that they focus on a very small, specific part of the journey when we should be talking about the journey as a whole. What I have not mentioned so far is that it was not just the one-year figures but the five-year figures that we were arguing for. We have to take a longer view of the journey in order to ensure that we take into account all aspects of it, including the support, the surround sound—the way of living—and so on. We have to ensure that those who survive receive enough support, but my central point is that if we really are intent on encouraging earlier diagnosis, the process targets have been too blunt a weapon. We all love them. Politicians love them. Both sides love them, and the Opposition can hit the Government with them if they are missed. It is a short-term approach. In reality, they have not improved survival rates to the point where we are catching up with international averages, and that is the key problem.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I echo the hon. Gentleman’s concern about process targets being just waiting times, particularly when we know that the wait for a patient to get up the courage even to go to see their GP will often be much longer than the wait on the pathway. Does he share my concern about not having a focus on the clinical evidence of what treatment should be? My concern about leaving everything to CCGs to decide is that we are not then sharing what we know to be the best way to treat any particular cancer. We need clinical standards that are also measured.

[Mr Baron]

I have a lot of sympathy for what the hon. Lady says, and that is why I think that cancer alliances have a decent role to play. They can take more of an overview and more responsibility for ensuring that best practice spreads and is learned from, but they can also take more of a role when it comes to clinical evidence in relation to treating cancer. My suggestion to the hon. Lady is this: if we get the NHS properly focused on improving its one-year figures and, therefore, its five-year figures, it will come closer to embracing the journey as a whole and coming up with initiatives, particularly at primary care level, that are designed to encourage earlier diagnosis. I fully accept that that is not the only answer—it is about supporting people and so on—but at the end of the day we are using blunt weapons to try to improve cancer survival rates, and the evidence clearly shows that we are not succeeding.

I will make some progress, but I will be happy to take more interventions later. In recent decades, the NHS has been beset by numerous process targets, as we have just discussed. Those have a role to play. It would be too revolutionary for me to stand here and say that we should discard them all and just bring in the one-year figures. I think that that would be too much for the NHS to grasp, but I do believe that process targets are too blunt a weapon. They offer information without context and, in my view, can hinder rather than help access to good treatment, especially when financial flows are linked to process targets, which has been the hallmark of our NHS since 1997. What is more, those targets, being very ambitious, have a tendency not to be met—a point made by the hon. Member for Strangford (Jim Shannon)—except in the very best of circumstances. They can easily become, as I have suggested, a political football between parties eager to score short-term points when in reality a longer-term approach is required. All sides are guilty of that.

Cancer has been no stranger to process targets. As I have mentioned, the House of Commons Library suggests that no fewer than nine process targets currently apply to cancer, most notably the two-week wait to see a specialist after a referral and the 62-day wait from urgent referral to first definitive treatment. Process targets, as I have suggested, can pose a particular problem when the NHS’s performance against them is used as a metric to control financial flows, which tends to skew medical priorities. Such targets are only part of the journey when trying to improve one-year survival rates, yet CCGs, although held accountable for outcome measures, in practice follow process targets, because they are the key to unlocking extra funds. That is one of the key issues that we need to explore further in the months and years ahead. I am talking about the fact that process targets account for only part of the journey when we need a longer-term view.

I also suggest that process targets are not the best means of helping when it comes to rarer and less survivable cancers, which for too long have been the poor cousins in the cancer community. Rarer and less survivable cancers often fall between the cracks of process targets. Data on those cancers is not used routinely in much of the NHS. That encourages the NHS to go for the low-hanging fruit of the major cancers. That has to change. Given that rarer cancers account for more than half of cancer cases, serious improvements in cancer survival will not be possible unless rarer and less survivable cancers are included. Outcome measures have the advantage of encouraging their inclusion when seeking to catch up with average international survival rates.

The all-party group’s most recent report, launched at the Britain Against Cancer conference in December, highlighted an example of how process targets can act against patients. In 2016, as I think all hon. Members in the Chamber will be aware, NHS England announced £200 million of transformation funding, intended to help the newly formed cancer alliances to achieve the standards set out in the five-year cancer strategy to 2020, and bids were invited. This should be straightforward. An extra £200 million is coming in and is being handed over by the Government to NHS England. The money should be going where it is most needed—to help cancer services at the front-line to deliver on the cancer strategy.

However, after the bidding process closed, a requirement for good performance against the 62-day target was introduced retrospectively. That was after the deadline—by some weeks, if not months. It resulted in multiple alliances whose performance was not deemed good enough not receiving their expected funding allocation. Oral and written evidence was taken by and submitted to the all-party group last autumn. I see members of the group in the Chamber. For those who arrived late, I point out that I have thanked the members for their help and stalwart support over the years. The oral and written evidence given to the group when we were conducting our inquiry suggested that the retrospective application of the 62-day condition was causing real problems at the frontline. We heard in effect a cry for help from those at the frontline of our cancer services. Our December report, as the Minister will be fully aware, called for a breaking of the link between the 62-day target and access to the transformation funds. Let us break that link and get the transformation funding down to the frontline, where it is needed to help to implement the cancer strategy.

It is an iniquitous situation, as the conditionality on process targets prior to funding release means that high-performing alliances receive even more money, while those that are struggling and could therefore most benefit from the extra investment do not receive the extra support. That is against the whole spirit of transformation funding.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

I congratulate my hon. Friend on securing the debate and thank him for all that he has done to raise these important issues consistently during his time in the House. I, too, must leave a little before the end of the debate, so please accept my apologies, Mr Streeter. With regard to funding, notwithstanding the fund that my hon. Friend has mentioned, NHS core funding often tends to be diverted to prop up the acute sector during winter crises; that happens year after year. We are now missing cancer targets, whatever we think of them—they have ceased to be meaningful to many trusts at local level. Does he therefore agree that, if we are to make a difference, we must ensure that more of the money from the core NHS budget goes to community services and cancer services?

[Mr Baron]

I broadly agree. Although a system as big as the NHS must always be able to respond to short-term emergencies, such as the winter crisis, longer-term thinking is needed to address key issues such as cancer survival. At the moment we have an absence of long-term thinking, let alone long-term funding, which is harming patients to the extent that we are not focusing on outcomes. In 2009 the then Department of Health’s own figures showed that 10,000 lives were needlessly lost because we were not meeting European averages for survival rates. I agree that we need longer-term thinking, and that is where outcome indicators, such as one-year and five-year cancer survival rates, would encourage not just long-term thinking, but long-term funding.

[Karen Lee]

That is a problem right across the NHS. We need to take the NHS out of the political arena. The absolute bottom line is that we need a proper, long-term strategy.

[Mr Baron]

I thank the hon. Lady for her support. I have been non-partisan on this matter, as I have been as chairman of the all-party group. Both sides have been guilty of trying to score political points on the back of process targets, because no Government have met them all in their entirety; we play this short-term political game when in reality what we need to do is, as best as possible, take the NHS out of politics and encourage long-term thinking. The best approach, at least with regard to cancer, would be to get the NHS to focus on those one-year and five-year survival rates. We could then stand back and say, “You are the medical experts and we are the politicians. We will hold you accountable, but use your expertise now to come up with the best plans to improve your one-year and five-year figures.” That would certainly encourage longer-term thinking and funding.

I am conscious that other hon. Members want to contribute, so I will not bore everyone with the ins and outs of the all-party group’s efforts to encourage the Government to break the link between the 62 days and the transformation funding, because discussions are still ongoing. However, I will share with the House the fact that I raised the issue at Prime Minister’s questions back in December. During a positive subsequent meeting in March, the Prime Minister agreed that all transformation funding should be released immediately, provided that relevant cancer alliances promised to produce a 62-day plan—the promise is the important thing; they did not have to produce them.

I am now in discussions with officials from No. 10 and the DHSC, because the system has been slow in following through what was agreed at that meeting. Following my further question at Prime Minister’s questions last Wednesday, the Prime Minister has agreed to meet me again, should we continue to make insufficient progress. Negotiations are now in train and I hope that we can get the funding released as quickly as possible, without waiting for the alliances to actually hit the 62-day target. The Prime Minister clearly said that she wants the transformation funding released on the promise that they will produce a plan to hit the 62-day target.

In the long term, the NHS needs to rebalance its focus away from process targets in favour of outcome indicators, such as the one-year cancer survival rates, that best help patients. If outcome measures are good and being hit, it follows that the processes will also be good; one cannot have good outcomes if there are not good processes. Patients will be seen and diagnosed in a timely fashion appropriate to their illness. These outcome measures will also have the benefit of allowing the NHS to design services and pathways flexibly, and without the straitjacket imposed by blunt process targets. That is the key issue here: focusing on the outcomes encourages the NHS at the frontline to devise ways of encouraging earlier diagnosis, including better awareness campaigns, wider screening uptake, better GP referral routes and better diagnostics. The NHS is encouraged to make those decisions at the frontline in order to drive forward earlier diagnosis.

[Mr Gregory Campbell (East Londonderry) (DUP)]

I congratulate the hon. Gentleman on securing the debate and on the excellent work that he has done, not only with the all-party parliamentary group, but on a wide range of events over recent years. On the transformative nature of events, does he agree that we need to see international best practice, which he alluded to earlier, employed in the United Kingdom to ensure that cancer sufferers here, and their friends and families, can see the benefits?

[Mr Baron]

I completely agree. Our inquiry into cancer inequalities in 2009 found that the NHS is as good as any other healthcare system internationally, if not better, at treating cancer once it is detected; the problem is that we do not detect it early enough and we never catch up. The line of international averages compared with UK averages shows that we are always behind, and there is little evidence that we are catching up. We get behind at that early one-year point, because we are not diagnosing as early as other healthcare systems, and no matter how good our treatment, we do not catch up. That is how we are losing those tens of thousands of lives, because we are not matching the European averages for survival rates.

[Paul Girvan (South Antrim) (DUP)]

Having been through treatment in the past, I appreciate that early diagnosis can, if dealt with correctly, save an absolute fortune. Everyone has heard the saying, “A stitch in time saves nine.” Unfortunately, leaving it too late, rather than intervening early, and having to treat the symptoms as they progress costs the health system a lot more money.

[Mr Baron]

I completely agree. I have not mentioned that aspect, because I have been focusing on patients, but the hon. Gentleman is absolutely right. If we were to diagnose earlier, the NHS could save a lot of money. We all know that, by and large, the more invasive the treatment, the more costly. Given how large the NHS is, too few health economists are trying to quantify this. When I ask my local CCG or cancer alliance, they do not know the cost savings associated with earlier diagnosis. That is a great shame.

[Dr Poulter]

My hon. Friend makes a good point. When we talk about quality-adjusted life years—there are other measures of the cost-benefits and cost-efficiency of treatments—it seems extraordinary that a more holistic view is not taken, particularly looking at quality-of-life indicators in cancer treatment. I am sure that he will want to press the Minister on that.

[Mr Baron]

I am sure that the Minister has taken that on board and I look forward to his comments. It goes without saying that the earlier we diagnose, the more money we save, which could then be ploughed back into frontline cancer services. We need to try to quantify that, and we are nowhere close to doing that at the moment.

That is why, in conclusion, I come back to the point that we need to take a longer-term view on our plans for cancer care—longer-term funding and thinking. Process targets actually act against that, because the focus is on specific issues, which can skew priorities, particularly when they are associated with funding. In the end, that has proven not to be in the best interests of patients, given our failure to catch up with international averages. Outcome measures retain the focus on accountability, which quite rightly governs our health service. They provide the best of both worlds: they encourage long-term thinking and long-term funding, while at the same time we as politicians rightly have to hold the NHS accountable. We are talking about £115 billion to £120 billion of taxpayers’ money. We have to ensure that there is the element of accountability in the system, but that is where outcome indicators could be very helpful.

One cannot cover everything in a debate such as this. I am glad that the HPV issue will be given a proper airing in tomorrow’s debate. I think that the vaccine should be extended to boys. I also think that the big issue of prevention is important. Healthier lifestyles make for lower cancer risks, but this specific debate is about targets. It has been a helpful debate and I thank everyone for their interventions. I look forward to other contributions and to the Minister’s comments at the conclusion.

[Karen Lee (Lincoln) (Lab)]

I do not want to repeat a lot of what the hon. Member for Basildon and Billericay (Mr Baron) has said because he has already said some of what I was going to say. I am here because when I was elected I was asked by Breast Cancer Now to be an ambassador and I readily agreed. I will highlight a few things on its behalf.

Breast Cancer Now says that although some CCGs meet diagnosis and detection targets, there are national geographical inequalities in the provision of care, and diagnosis and detection are taking priority over treatment for secondary breast cancer, which is an issue. Transformation funding has been mentioned, and Breast Cancer Now feels that such funding must be decoupled from waiting time targets immediately.

My CCG is failing to hit the targets, which means it does not get the funding. If it is failing to meet the targets, how will withholding the money make things any better? I want the Government to tell us how that makes things any better. I understand about targets and measures, but how does not giving CCGs money to treat people properly make things any better?

NHS cancer targets have tended to focus on early detection and diagnosis, which means there is less focus and resource allocated to supporting people after they have finished treatment and are living with secondary cancers. One in four people find that the end of their treatment is the hardest part and they do not always have access to a clinical nurse specialist. My daughter did not. Things moved fast for my daughter. She was diagnosed and died within 13 months. She was just 35 and she left a husband and three children behind. To get her back into hospital was an absolute nightmare. I knew all the right things to say to get her into hospital and I finally managed it, but the support was not there. People try and do their best, but the support was not right and it was not good enough. The treatment for secondary breast cancer is not good enough and that really needs to be looked at.

Every cancer patient coming to the end of their treatment should have a recovery package. A clearer picture of progress on the availability of health and wellbeing events for people living with and beyond breast cancer across England is urgently needed. The Government, as the agency that ultimately decides how our NHS is run, must deliver on that and answer for that.

I was asked to mention the collection of data and access to clinical nurse specialists, because there has been no progress. Breast Cancer Care’s 2015 research showed that only a third of NHS trusts were collecting full data on secondary breast cancer, and three quarters of NHS trusts and health boards say there is not enough specialist nursing care available. People with secondary breast cancer feel they are second rate. Lynsey used to say that. She said, “It was all right, Mum, when I was having chemo and radiotherapy and everybody was buzzing round me, but now there is nothing. There is no support at all.”

I spoke on Breast Cancer Now’s 2050 vision in Parliament a couple of months ago. If we all act now, by 2050 everybody who develops breast cancer will live, and I really hope that that happens.

[Mr Baron]

The first point that the hon. Lady made about the iniquitous position that many CCGs now find themselves in is a strong one. The Government have given transformation funding of £200 million to NHS England, but a lot of it is sitting there when it is desperately needed, particularly by those that need to do a lot of catching up. It was not meant to be withheld in such a fashion. It is iniquitous also that the 62 days was retrospectively applied.

[Mr Gary Streeter (in the Chair)]

The hon. Lady spoke most powerfully.

--- Later in debate ---

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I declare an interest; I was for 30 years a breast cancer surgeon, and I am co-chair of the all-party parliamentary group on breast cancer. Cancer affects one in three people in the United Kingdom at this point, but that is expected to rise to one in two for the population born after 1960. Part of the reason for that is that we live longer, and unfortunately still have not improved our lifestyles to a significant degree. In particular, we all know about smoking and cancer, but we should also be aware that obesity is the second most common driver of cancer, and is increasing.

The hon. Member for Basildon and Billericay (Mr Baron) spoke about process targets—particularly on waiting times. I remember when the cancer-specific waiting times came in, in Scotland, and I welcomed them. Before that, there was only the standard waiting time of 18 weeks. If a manager was told, “We are struggling to keep up with breast cancer,” but the 18 weeks had not been exceeded, there was no interest. That is the problem with any target; once a target is set, anything that is not subject to a target starts to be neglected. We welcomed targets at first. As the hon. Gentleman mentioned, the 31-day target is either being met, or is close to being met, because once people are diagnosed, all four NHSs switch into high gear and manage to treat people within the 31 days.

The problem is that that is only a little bit of the journey. The 62 days are meant to cover the time from seeing the GP to the referral to the clinic, from the clinic to the diagnosis, from the diagnosis to discussion and planning and a multidisciplinary team meeting, and from that point to the first treatment. If we look into it, the delay is often between being seen in the clinic and the diagnosis. With breast cancer we luckily tend to meet the 62-day target at around 95%, because our clinics are largely one stop. The patient usually gets all the tests on one day. However, in England the 62-day figure is below 83%, even though the 31-day figure is over 97%, and we can see how big the fall is, in trying to get people diagnosed. There is a huge workforce challenge in radiology, and in breast cancer a cliff edge is coming, because the generation who were appointed when screening started in 1991 are all retiring right now, and that is a real issue.

As I said earlier, in an intervention, it is not just a question of the time on the pathway; the biggest delay is getting people to go to see their GP. We need to get rid of the fear, embarrassment and stigma, particularly when a more embarrassing part of the body is involved.

We all run projects such as, in Scotland, Detect Cancer Early, and in England, Be Clear on Cancer, but it is important that such campaigns bubble along, rather than become intense. People need to see those adverts when it is in the back of their head that, yes, perhaps their bowel habits have changed, there is blood in their urine, or they find a lump. If that happened six months ago, it is no use. When we ran our first Detect Cancer Early campaign in Scotland with the comedian Elaine C. Smith, it was very humorous and well picked up. We got a 50% increase in people referred to breast clinics, but there was no significant difference in the diagnosis of cancer. It meant that the clinics were completely overwhelmed. We were doing clinics at night and at weekends to try to catch up, but the people who had cancer actually ended up waiting longer for their diagnosis. It is important that we generate not fear but education, and that first experience was taken into account in future campaigns.

Early detection has been mentioned, and screening is the best way of doing that if the cancer is screenable. Such screening will result in an increased incidence of cancer. People often do not think about the fact that if screening is introduced or expanded, or the technique is improved, more cancers will be diagnosed. The system must be ready to deal with that, and we need not to see it as a negative.

Since bowel screening was introduced in Scotland, there has been an 18% drop in colon cancer in men. Bowel screening, which was debated in this Chamber this morning, is not just a screening technique; it is actually preventive. When we test for blood in the stool, we can also diagnose polyps, which can then be treated to avoid them developing into cancer. That is a drop of almost one fifth over 10 years in our incidence of colon cancer. Bowel screening in Scotland starts from the age of 50 and runs to 75. Those over the age of 75 can request a kit, but they will not be sent it automatically. We have now moved to the faecal immunochemical test, which requires only one sample. It is also more sensitive, and there seems to be an almost 10% increase in uptake. Again, that will mean more colonoscopies and more diagnoses, and people must be prepared for that.

Process and outcome targets have been mentioned, but an important group of targets in between is those on quality of treatment. It is not good enough just to leave things to clinical commissioning groups or cancer alliances to work out the best way to treat various types of cancer. The data are international and national, and we need a group of experts to pool them together and come up with something that no one will quibble about, and that everyone agrees is what we should be aiming to achieve for various cancers, in people’s surgeries, after their diagnoses, and with their radiation or chemo.

In 2000, what is now called Healthcare Improvement Scotland developed clinical cancer standards for the four common cancers. I had the honour to lead on the development of breast cancer standards, and I led that project until 2011. We are now on the fifth iteration of our standards, and they have been slimmed down. We have moved from looking at four cancers in 2002, to 11 cancers in 2012, and now 18 cancers have detailed clinical targets for which they are audited, and for which peer review takes place. We do not set league tables, but we set standards that every unit can aim to pass. There is no point in being told, “The best unit is 500 miles away”; people want their local unit to be good.

The first two standards in our quality performance indicators state that every patient with breast cancer must be discussed at a multidisciplinary team meeting, and that patients must be diagnosed non-operatively by needle biopsy. When I started in my unit in the mid-1990s, our pre-op diagnosis rate was about 40%; it is now about 98%. If those two standards had been in place in England, the rogue surgeon Ian Paterson might have been picked up earlier. We now know that he tended to make his own treatment decisions, and he operated on women without proof of cancer. Obviously, the standards cover all sorts of things, including surgery, diagnosis, chemo and radiotherapy. Data are collected at the MDT meeting with a member of audit staff present. That means that they can capture evidence of recurrence and patients who develop metastatic disease, and everyone on the team is aware that that has happened.

To respond to the point raised by the hon. Member for Lincoln (Karen Lee), my unit discussed whether we would have separate cancer nurse specialists for those with recurrent or secondary disease, or whether it would be better if the original nurse followed the patient through, and that is what we went for—our nurses work between the surgical clinic and oncology, so that people see a face they already know. Having done it for years, I know that breaking bad news a second time is infinitely worse than breaking it the first time.

In England there are screening data from breast cancer and guidelines from the National Institute for Health and Care Excellence. There are, however, no audit data that are peer-reviewed and compared. We get no financial reward for improvement in our targets. Money is not part of it; it is simple clinical pride, and a wee touch of competitiveness. In Scotland we meet every year in the breast cancer service, and our data are put up. That is open and public; people can look for any of our reports on the internet, and they will see all the details about the numbers of patients treated and what has been achieved. Peer review and peer pressure is a great way to drive up quality.

The hon. Member for Basildon and Billericay mentioned early diagnosis and the need for one-year outcome figures, but spending all the money to gain another couple of per cent in a waiting time is not necessarily the best way to go. A comparison was made between breast cancer treatment in the UK and in Denmark, and because of screening—the UK was one of the earliest nations to pick up breast screening as a population screening—we have a higher percentage of patients diagnosed at stage 1 than Denmark. We do not, however, have a better survival rate because we have very slow access to new drugs. It takes new, expensive cancer drugs three or five years to get into common use. Yes, if someone is diagnosed early they might not need those drugs, but if they are unlucky enough to have a really nasty, aggressive cancer, they may end up fighting to get them.

[Mr Baron]

For a whole host of reasons mentioned by the hon. Lady, one area that perhaps shows promise in improving early diagnosis is breast cancer. In general, however, we fall behind international averages at that one-year point. The whole point of focusing the NHS on one-year survival rates, and encouraging it to improve those rates, is to send a message down the line and encourage early diagnosis across the whole panoply of primary care services, including improving screening rates and participation.

[Dr Whitford]

I totally agree. People who have died before one year—that is, in essence, what is being measured by our one-year survival rate—are largely those who presented with an advanced or incredibly aggressive disease. We are measuring people for whom we did not have a treatment, rather than just early diagnosis, and we will see that much more in the five-year figures. I am not saying that we should not have those measurements, but if a clinician is just being told, “You have to get better one-year figures,” should they take a bigger margin? Do they use this chemo or that one? They need guidance on what evidence shows will provide better one-year figures.

On prevention, there has been a drop of more than 17% in men with lung cancer, because of the fall in smoking in men. Unfortunately, there has been a rise in lung cancer in women. There has also been a rise in malignant melanoma in men, because they are catching up with women in the use of sunbeds and overseas holidays. We still have a long way to go simply to try to prevent cancer, because the gold standard is not getting it in the first place. As I have said, obesity is the second most common cause of cancer. We do not need strategies that are just for cancer. We need health in all policies to try to make people healthier, and that way we will reduce the number of people who are suffering from cancer.

--- Later in debate ---

[Steve Brine]

I will not give way. I remember Mr Streeter’s ruling.

There are eight cancer waiting time standards and, since one in two of us born since 1960 will be diagnosed with cancer in our lifetime, they are an important indicator—to patients, clinicians and politicians and the public—of the quality of cancer diagnosis, treatment and care that NHS organisations provide to millions of our constituents every year. They are a component of the success we have had with survival rates, so it is good that we are discussing them here today. I use the word “target” cautiously, because I have always been clear that standards should not necessarily be targets. If someone has a suspected cancer, 28 days is 28 lifetimes too long—I will talk about the urgent diagnostic centres in a moment. Sometimes we are not trying to get to the maximum, so “target” can be a misleading term.

As has been said, we are currently meeting six of the eight standards. One of those we are not meeting is the 62 days from urgent GP referral for suspected cancer to first treatment, which is important because we want to ensure that patients receive the right treatment quickly, without any unnecessary delays. The standards contribute to cancers being diagnosed earlier—only “contribute to”—and that is crucial to improving our survival rates. However, our rates have historically lagged behind those of some of the best-performing countries in Europe and around the world. That is why we have the cancer strategy; we want to do better. The primary reason for those rates is late diagnosis. Early diagnosis is, indeed, the magic key. My hon. Friend the Member for Basildon and Billericay has used that term many times—I have heard him use it at the Britain Against Cancer conference—and he is absolutely spot on.

Going back to the 62-day standard and the recovery thereof, my hon. Friend the Member for Basildon and Billericay will know that due to factors such as an ageing population and the increase in obesity, which we have touched on, the incidence of cancer is increasing. The NHS is treating more patients for cancer than ever before. It is testament to the hard work of NHS staff across all four nations of our United Kingdom that we are treating more people, and do so with the care and compassion for which we know the NHS is world-renowned. However, those numbers are making the achievement of the 62-day standard challenging. To be perfectly honest, the standard has not been met since December 2015 and, although we do not yet have the figures for March 2018, it is unlikely to have been met in 2017-18 either. However, we remain committed to the standard and want to see it recovered. That is why, through this year’s mandate from the Secretary of State to NHS England, we have agreed that the standard will be achieved in 2018-19, while we maintain performance against other waiting time standards.

[Mr Baron]

Will the Minister give way?

[Steve Brine]

I will very quickly. I know that my hon. Friend wants me to come on to the funding.

[Mr Baron]

The Minister will be aware that about a quarter of all cancers are first detected as late as at an emergency procedure. What I would like him to do in the few minutes he has left is to focus on the need to break the 62-day target link with the transformation funding because it is unfair, penalising as it does those cancer services that need help most. Will he consider that?

[Steve Brine]

That is exactly what I was coming on to. I know that my hon. Friend has expressed concern, to put it mildly, about the methods used to allocate funding for the alliances in 2017-18, and in last December’s report by the all-party parliamentary group on cancer it was clear that the alliances should not be linked to achieving the 62-day target. I am aware that my hon. Friend has met with the Prime Minister to discuss the issue and I will reiterate what I am sure she will have told him. Achievement of the 62-day standard is not a prerequisite for funding. Instead, it provides a basis on which NHS England and NHS Improvement, along with senior clinical advice, can assess an alliance’s readiness to transform services.

The alliances are an important mechanism for us in improving performance on the 62-day standard from urgent referral to treatment. They bring together clinicians from primary and secondary care, ensuring collective responsibility for the multidisciplinary teams and the services that they provide, and enabling the leadership that is crucial to the transformation of services. But the bottom line is that it is taxpayers’ money that is being allocated, and it is right and proper that alliances can demonstrate their preparedness for the funding. In 2018-19, NHS England has modified how it will fund alliances, and I can confirm that all alliances will receive transformation funding to support earlier diagnosis and better quality of life for patients.

The national support fund is a genuinely new approach to distributing funding that we have introduced in 2018-19, within the £200 million over two years funding envelope announced in 2017-18. That was in no small part in response to advocacy by my hon. Friend the Member for Basildon and Billericay, and I pay great credit to him and to others for their work on the link—but not the pre-requisite—that was introduced in 2017-18 between transformation funding and 62-day performance.

The fund has a number of purposes. NHS England uses it to help iron out significant variations between alliances in the amount of funding for which they originally bid. The money will be used to support alliance activity to improve 62-day performance, as well as to enable all alliances to deliver priorities, such as accelerated pathways for lung, colorectal and prostate cancer, and other innovations, such as those we heard from the hon. Member for Scunthorpe, which are included in the 2018-19 CCG planning guidance. The Secretary of State, NHS England’s national cancer director, Cally Palmer, and I all agree that the link to the 62-day standard is the right approach and the right thing for patients. I hope that that clears the matter up, even if it does not go all the way towards satisfying Members.

Although I accept that there is anxiety in some quarters about the link between the performance and the funding, I and the Government are of the view that retaining the link is in the very best interests of patients. Ultimately, they must be our primary focus, and this is public money. We will keep the matter under review. I thank my hon. Friend for his advocacy on the subject.

By the end of the cancer programme, we want to have improved survival and provided equity of access to the highest standards of modern care across all our constituencies in England. As the cancer Minister, I seldom sleep and when I am not sleeping I think very little about anything else, because we are focused on meeting the recommendations in the cancer strategy and doing better for all our constituents—those who are here, those who will live with cancer, those who are living with it now, and those who have passed, who we all know. We are on our way to realising the transformation in services that we all want to see, to make our NHS the world leader in the treatment of cancer that I know it can be.

[Mr Baron]

I thank everyone who has participated in the debate, and the Minister for his response. No one doubts his genuine care and concern about cancer patients and the need to improve treatment. I will look closely at his words. The national support fund may not be quite as new as he thinks, but putting that to one side, all I urge him to do is to look at the pleas for help from the cancer frontline services. As far as they are concerned, there is a strong link between the 62-day target and the release of the cancer transformation funding. That is iniquitous, because the services that need it most are being denied it. I ask the Minister to go away and have another look at that, because many frontline services say that the link exists and because of it they are not getting the transformation funding they require to deliver on the cancer strategy. I will continue to pursue that matter until the transformation funding is released.

In the 15 seconds that are left to me, all I say is that a quarter of all cancers are first diagnosed during an emergency procedure. That is far too late; we all accept that. We also accept that we are failing to catch up with international averages when it comes to survival rates, despite all the talk about improving them. We have to focus on outcomes.

Motion lapsed (Standing Order No. 10(6)).