Cancer Treatments

John Pugh Excerpts

Tuesday 19th June 2012 Westminster Hall

[John Pugh (Southport) (LD)]

I thank all the people, from a variety of organisations, who made submissions before this debate in the hope that I could do justice to their thoughts and considerations. I may not succeed in doing so adequately, for which I apologise in advance, but other people in the Chamber, who are far better informed than me, can supplement any good, important or salient points that I fail to make.

It is a fact of the human condition that we are cell-replicating machines. I believe it is true—I am not totally certain, but I believe it is a truth—that none of the cells that were elected to this place in 2001 under the name of John Pugh are now here. They have all gradually been replaced, and some of them may actually be replaced during the course of the morning. That process goes on and on, and it is a very sophisticated one. When someone looks into the details of cellular biology, they are amazed that it occurs correctly as many times as it does. However, the longer we live, the more likely it is to go wrong, and when it goes wrong, we get the disease we know as cancer. It is a sad truth that the more we are saved from other diseases by progress in medical science, the more exposed we are to cancer.

Current stats show that, due to human longevity and the like, one in four of us are likely to die directly of cancer or a cancer-related condition. That will apply no matter what our success in investigating the environmental triggers for or the lifestyle causes of cancer.

We can all point to progress along those lines. We are no longer vulnerable to all the industrial causes of cancer, such as asbestos, and we took a momentous step forward in this place a few years ago when we backed the smoking ban, which remains the most useful thing I have done in Parliament, because it will undoubtedly reduce one of the major triggers for cancer. We now have to address other issues linked to cancer, such as obesity.

The disease is aggressive in youth and progresses slower with age, but, frankly, the longer we live, the more vulnerable we are to it. It is also true that many people will die with, but not of cancer. The challenge to any health system confronted with that crude biological fact is straightforward, and it is the same for any health system anywhere on the planet. I have divided the challenge under four headings. First, any health system needs to try to comprehend better the causes of cancer and initiate research. Secondly, any health system needs to try to prevent cancer and forfend its incidence. Thirdly, any health system—this is, of course, paramount—needs to cure people of cancer, where possible. Finally, any health and social system in any civilized society must help people living with cancer. Those four challenges are precisely the same for any health system anywhere, no matter how they are configured or delivered.

We have made substantial strides in the UK and our record should not be demeaned or lessened. During the passage through Parliament of the contentious Health and Social Care Bill, cancer stats were referred to and international comparisons were used to justify some of the changes. The oncology community had some misgivings about that, because its members felt that their real and substantive achievements were overlooked and that, for political purposes, people dwelled on what they had not achieved rather than on what they had.

The debate pack includes a good account of research by the King’s Fund and others on success in dealing with cancer. On European and international comparisons, an article in the pack states:

“While cancer deaths fell everywhere, England and Wales saw the biggest drop in mortality among males aged 15-74”—

that is, most males. The article continues:

“While mortality among women the same age declined by less, at 19%, that was the third biggest improvement”

in any civilised developed country in the world. We can, therefore, bank appreciable benefits and progress.

The difference between good and not-so-good policy is determined by the efficiency and effectiveness with which we approach the four fundamental tasks of comprehending the causes of cancer, curing people of cancer, trying to prevent cancer and trying to help people living with cancer, and by how intelligently we prioritise those tasks. An enormous amount of resources could be provided to address the problems presented by cancer, but such resources are not unlimited and we have to consider how we prioritise in every one of the four tasks. That applies to research, where people are continually examining how to prioritise the appreciable sums of money at their disposal in the most effective way. There are many debates about how we are to prioritise prevention and public health. Moreover, on prioritising treatment, recent discussions have centred on whether treatment for the elderly should be rationed or limited, because they may live longer with cancer but not actually die of it. There is also considerable debate, spearheaded by the likes of Macmillan Cancer Support, about the welfare provision for cancer patients.

I would like to turn briefly to public health, although it is not my main bone of contention. There has been a debate about how accurately we pitch our public health campaigns. Some have been excellent, particularly that on screening for bowel cancer, which I think has had an immediate and dramatic beneficial effect. My former colleague John Barrett is the former MP for Edinburgh West—he was elected in 2001—and he was diagnosed with bowel cancer through the screening programme shortly after leaving Parliament. He had absolutely no symptoms, but it is believed that it was caught in time. In fact, he was in Parliament recently and looked in pretty good shape to me. However, had the cancer not been detected—remember that he had no symptoms—it would have progressed as the years went by.

[Glyn Davies (Montgomeryshire) (Con)]

I thank the hon. Gentleman for giving way and allowing me to associate myself with the point that he is making. I am one of those whose cancer was found early, and I received treatment and survived. A younger friend of mine was diagnosed at the very same time, but his cancer was more advanced and he died aged 31. This is about catching it early and I want to emphasise the importance of screening, which saves a huge amount of lives. I have played a big part in driving forward the screening programme in Wales. Screening for bowel cancer is one of the best ways possible to save people’s lives.

[John Pugh]

I am sure that the hon. Gentleman is right and that he is also aware that there have been debates about screening for cervical cancer, breast cancer and so on, and about the age at which that should be done and the effect it would have. Although it is possible to screen everybody all of the time, that is not the most rational way to use resources, so any screening programme needs to be judged in the light of its subsequent evidence, which is very strong indeed for the bowel screening programme.

I was slightly, not amused, but distracted by the recent Department of Health advertisements—there were big adverts on buses—stating that anyone who has been coughing for three weeks should definitely go to see their doctor, because they might have lung cancer. When the advertising programme was launched, a horrible virus had gripped my office, the most lingering symptom of which was a cough that lasted for three to five weeks. Had we all trooped to our doctors’ surgeries saying that we might have cancer, a good deal of national health service time would have been wasted. Any campaign needs to be sophisticated and reviewed in the light of evidence. The one thing that we do not want a public health campaign to do is provoke alarm, because that would distract doctors from the things that we genuinely want them to address. People are not slow to be alarmed by any suspicion of cancer, which, I believe, after pornography and some other subjects, is one of the most researched topics on the internet. It is frequently referred to on various medical sites as a suspicion, rather than a diagnosis.

The academic community also has to prioritise. A lot of people leave substantial amounts of money for cancer research and it needs to be used as effectively as possible, as do welfare payments to cancer patients. Those issues need to be prioritised—Members may care to discuss that in the context of the Government’s ambitions for the outcomes framework.

I want to concentrate on the connection between treatment and health policy. The clinical armoury and tools available to medical science are pretty well known and can be put under four headings: chemotherapy, radiotherapy—possibly supplemented by more sophisticated treatments, such as proton beam therapy—drugs and surgery. A cocktail of those methods is used to treat cancer. All, in their place, can be extraordinarily useful and effective interventions, but the key thing that determines whether they have the maximum effect on and benefit for patients is whether they are used with skill—the right skill at the right time in the right place, and probably in the hands of the right doctor or consultant.

I learned relatively recently that, although we talk broadly about categories of cancer, there are sub-categories within those categories, and not every sub-category is responsive to the same treatment. Knowing which treatment is best tailored to which patient is a genuine art, because patients and their histories are all very different, as are the remedies that work with them.

Improved outcomes are to some extent determined not simply by having the tools but using them with better and greater skill. It is the skill or its absence that explains differential outcomes. There are differential outcomes across the UK. The chance of recovering from certain cancers in some areas is greater or less than in others. The chances of acquiring certain cancers appear to be greater in some areas than others. Genuine skill—knowing what to use on what person at what time—is in extraordinarily short supply. That sort of skill, the really effective intervention, is often allied with establishments that not just treat cancer, but research into cancer. Great skill is often, not unsurprisingly, aligned with a greater understanding of what is being dealt with. Treatment of cancer is not usually a journeyman matter or one of bog-standard clinical intervention and practice. That is why organisations such as the Christie hospital have such a well-established reputation.

I know the Government have put extra money into the drugs fund. Using the right drug in the right place at the right time is a fairly refined process. People can be given drugs that work with a cancer in general, but not for that particular patient or not at that stage in the disease, by organisations relatively unaware of the futility of the intervention. Therefore, we have all understandably come to the conclusion that we need clinical networks. We need to have people dealt with in the appropriate centres of excellence. There is a genuine readiness by patients to travel as far as they need to get the treatment. Most people in my constituency who contract any form of cancer travel across Liverpool, normally to Clatterbridge on the Wirral, generally without too much complaint, to get the treatment they want. The same group of constituents has been extremely angry and provoked by the need to travel 11 miles down the road for A and E assessment and triage.

[Mr John Leech (Manchester, Withington) (LD)]

My hon. Friend may not be aware that the Christie hospital has opened satellite centres in Oldham and Salford, so that patients do not necessarily have to go all the way to Christie, as they would have had to in the past. They still get Christie service, but in their local community in Salford or Oldham.

[John Pugh]

I think that is becoming the common pattern and could create some problems, given the way we intend to structure the NHS. However, it is a wholly desirable pattern. Clatterbridge is looking at a similar arrangement across Liverpool in collaboration with the Royal Liverpool University hospital. There is a sensible willingness on the part of the ordinary district general hospital to refer patients into an area where the maximum competence exists and where it is a matter of life and death. That is a totally laudable example of integrated service.

We can all accept there is a need to have an adequate clinical network, particularly for the more common cancers—lung, colorectal, prostate and breast cancer—in pretty well every area. That is a template that either is rolled out across the land or we wish to see rolled out around centres of excellence. We must always bear it in mind that, with cancer, a certain number of standard procedures can be done locally, without the full expertise of the top consultant.

There are certain cancers where that is not the case, for which we need national centres of excellence. To return briefly to the Liverpool Cancer Research UK Centre, that deals with pancreatic cancer almost as a speciality, with people there researching it very intensively. Its view is that there are probably about only two cases in the UK—and there may only ever be, given the relative distribution of that disease—where whatever treatment the patient gets can make a difference to outcomes, because the cancer is almost invariably fatal. It is necessary to vary the mix depending on the cancer in question. However, for the most common cancers, having a centre of excellence, having hubs around which standard procedures can take place and having a clinical network that works, is the way to go.

That sort of network does not happen by accident. Other hon. Members, apart from me, have asked how under the new regime it will be maintained and sustained. The construction of such networks in the past was the function, duty, mandate and overview of the strategic health authorities and they, of course, are to go. I saw in the notes that they would still be dealt with under the strategic health authority bundle within the NHS Commissioning Board. Clearly, “strategy” is the word to be used here. The hon. Member for Leicester West (Liz Kendall) was fond of saying that during the passage of the Health and Social Care Bill. The key point is that the strategy and the template are clear; the question is how to get them in place, sustained and maintained over time under the new regime. I would like the Minister to reassure me on that point.

It is not obvious how such a desirable template would emerge through simple market forces, or through bottom-up agreements by local commissioners. Even if those things could happen, it is not obvious that that would represent the most secure or quickest way to bring about the outcome. That is especially so when one acknowledges that the best treatment often occurs in environments where there is not only integration between providers, but research is taking place. I repeat the point that there is a need to deliver various levels of intervention and care in various settings. That will not happen by accident, or without some institutional resistance. One proposal in Liverpool is to move some of the activities currently conducted in Clatterbridge to the Royal hospital and get very substantial funding for that. That proposition, though supported by the bulk of people, is not supported by all. A certain amount of controversy may still arise about the level of care that could be delivered or result from such changes, which are not effortlessly brought about.

I guess that I am trying to say that ironing out the inequalities in cancer outcomes, ensuring there is the same provision and that each network is as good as any in every area, is possibly susceptible to a more dirigiste approach or Stalinist-like solution. I understand that the chief executive of the NHS was once a member of the Communist party—I hope I am not maligning him. That approach has its attractions. If the NHS Commissioning Board, which shelters the skeletal remains of the strategic health authorities, could play a dirigiste role, acting like the Politburo to impose the right template in every place, one could see how facilities could be aligned and personnel put in the right place. There would also be an opportunity to use central funding to effect. The Government have set up some central funding both for drugs and other purposes.

I have no issue with that way of doing things, provided it is rendered accountable. However, under the new dispensation, I can see problems in going down that particular road. Some of the provision we would want in place, for example, proton beam therapy, will require substantial capital investment. Under the new regime, if I understood what the Minister said during Health questions, substantial capital investment is primarily the responsibility of providers. So we have to hope that, in all places across the UK, all providers dealing with the common cancers feel obliged to make the same level of investment. I am not sure that there is an easy way to ensure that that happens. Clearly, the NHS Commissioning Board can commission clinical networks, just as it can commission any other piece of health provision. However, providing a substantial capital grant to a provider might create problems, particularly if it is contested by other providers. Providers may be reluctant to provide the kind of intensive capital resource that might be required when they have budgets to meet and control.

Last Tuesday, an hon. Member talked nostalgically about the days when we used to have fundraising for all kinds of scanners in hospitals. That does not seem to have taken place in the past decade or so because the money has been flowing a little more plentifully. However, we could be back in that territory if providers have difficulties in acquiring appropriate capital investment, or do not see a business case for doing so, without subsidy, by themselves.

I imagine that there are concerns about patterns of referrals within clinical networks, which, again, will test the new system. For example, dermatology providers that are unable to cope with cancer and oncology outcomes—there are such dermatology providers; I think they are now called Virgin Medical—will, under any willing provider, be one of the first ports of call for referrals, especially if they have partners in GP practices who are inclined to use them. At the same time, that may not be the right thing to do clinically, given its complexity. As incidences of melanoma have increased, it may be far better to refer people not to a dermatology provider that cannot do oncology, but to a dermatology provider that can—essentially, the existing hospital base. I can see that being a good thing clinically, but something that is contested in practice if it becomes a settled pattern.

I think we all know where we want to get to. I know that many other things need to be said and I hope other hon. Members will say them. My question is, given that there is a whole raft of agreements and evidence about the objectives and the point at which we want to end, how, under existing or future arrangements, will we ensure that the best outcome is delivered? In other words, how do we get the right clinical configuration to achieve the right clinical outcomes?

--- Later in debate ---

[John Pugh]

I am glad the hon. Gentleman mentioned that, because two close friends of mine died rapidly of pancreatic cancer. One point made by the people in Liverpool to whom I spoke was that, given the almost invariably fatal outcome from this cancer, it would not be a bad idea if some of the rules regarding drugs approval were relaxed a little bit, so that people could find out what worked, because in this case there is very little to lose.

[Jim Shannon]

I thank the hon. Gentleman for that valuable contribution and agree wholeheartedly. If it comes to the stage where people’s life expectancy is minimal or reduced, I believe that they would be quite happy to take advantage of new drugs, if those were available.

All hon. Members know that finances are finite in the health budget. That being so, we are grateful for the many charities that do such magnificent work, including Cancer Research UK, Macmillan Cancer Support and Marie Curie Cancer Care. However, we must get a handle on our treatment process and outcomes, which can only come through the correct use of funding. I hope that the Minister will tell us how that will happen.

In the NHS document, “Improving outcomes: a strategy for cancer”, published in January 2011, it is clear what the Minister regarded as the way forward:

“In order to achieve these principles we must also ensure that every possible penny of money the NHS has is spent improving the quality of care and outcomes that patients experience. The Government protected the NHS in the Spending Review settlement, with cash funding growth of £10.6 billion (over 10%) by 2014/15. Compared to many other government departments, that puts us in an incredibly privileged position but this is the toughest settlement the NHS has faced in a long time.

At the same time, we need to respond to the longer term pressures the NHS faces; of an ageing population and the new demands created by new treatments and technologies. That means that, as set out in the Spending Review and the 2011/12 Operating Framework, over the next four years the NHS will need to achieve up to £20 billion of efficiency savings. These savings will be reinvested back in continuing to give patients the care that they need.”

Will the Minister say whether we are on target to make those savings? If so, when will that money go back into the system?

The document contains many examples of cost-efficient care, such as people having certain treatments as day procedures and then care at home, which makes a lot of people feel more secure as well as being cost effective. We understand the reasons and the thinking behind that: it is essential that the patient is at the heart of any decision made and any strategy must incorporate this.

I am not an argumentative person—far from it, I try to get on with most people in this world—but the hon. Member for Southport commented on the advertising campaign “Have you had a cough for three weeks or more?” We do not know how successful it was. The campaign has a role to play, and those who have had a cough for more than three weeks might well have a problem. We do not know how many people went to see their doctor and, as a result, have been made aware of problems. That is perhaps a different opinion from that expressed by the hon. Gentleman.

[John Pugh]

I said that all those things need to be reviewed in the light of evidence, that there were good campaigns and bad campaigns, and that evidence decided which category they fell into.

--- Later in debate ---

[The Minister of State, Department of Health (Paul Burstow)]

I congratulate my hon. Friend the Member for Southport (John Pugh) on securing the debate and on setting out—as he always does so admirably—the terrain that he wished us to traverse. Other hon. Members have done just that, and it is helpful to have this opportunity to mention the progress that has been made since the publication of the Government’s cancer outcome strategy in 2011. The annual report that we published last December set out that strategy in greater detail than I fear I will be able to provide in the time available today, and I commend it to Members.

Interestingly, one common theme in this debate has been touched on, quite rightly, by most of those who have contributed. Health inequality has been raised in the context of patient experience surveys—with which the Government will continue—and of age. The Government take health inequality so seriously that we have placed for the first time clear duties on commissioners and other parts of the NHS to act to reduce it, and we will say more about that soon when we publish the draft mandate for the NHS Commissioning Board.

The hon. Member for Leicester West (Liz Kendall) referred to age and the differences in outcomes from cancer services for older people. I approved funding for a joint piece of work by Macmillan Cancer Support and Age UK to explore some of the obstacles and barriers that may prevent people from taking up cancer treatment or accessing it in the first place. We recently visited Barts Health NHS trust, which is taking part in that pilot programme, and we are looking at issues such as comorbidity and services in the community. We will report accordingly and take action to ensure that lessons are learned. The hon. Lady was right to raise the issue, and the Government have decided to implement provisions on age with regard to goods and services in the NHS and social services. On taking office, one of my first responsibilities was to take the necessary decisions to ensure that no part of the NHS would be exempt from those provisions, and key decisions needed to be taken to make it clear that age can be used only on an objective basis in health care and social care decision making.

I will say something about the NHS outcomes framework, and then respond to as many of the points that have been raised as I can in the time remaining. Recognising that many people have more than one medical condition, we have deliberately taken a generic approach to the NHS outcomes framework, rather than focusing on specific diseases. We recognise, however, that cancer is a big killer, and we have said repeatedly that improving health outcomes for cancer patients is a priority for the Government. We have aimed to reflect that in the framework by including seven specific indicators on cancer. Those include the under-75 mortality rate from cancer, and the one and five-year survival rates for the three major cancers, to which other hon. Members have referred: colorectal, breast, and lung. In addition, two overarching indicators include data on cancer: potential years of life lost from causes considered amenable to health care; and life expectancy at 75.

The indicator “under 75 mortality rate from cancer” is shared with the public health outcomes framework. By having that shared indicator, with joint accountability for delivery, Public Health England and the NHS Commissioning Board will have the incentive to work together to improve cancer mortality and survival. That relates to the question about the commissioning of public awareness campaigns. I can confirm to the hon. Member for Leicester West that Public Health England and the NHS Commissioning Board will have a joint responsibility, and a clear obligation, to commission in that regard.

[John Pugh]

On the point about indicators, a clear theme throughout the debate has been late diagnosis. Late diagnosis is not the same as late treatment. With GPs probably under more pressure than ever before not to make unnecessary referrals to secondary health settings of one kind or another, do the Government keep or have they any intention of keeping statistics on whether, where people are diagnosed late, the cause of the late diagnosis was that they presented far too late or that the GP and whoever they saw figured out what was wrong with them far too late?

[Paul Burstow]

I am coming to that. It relates to the point raised by my hon. Friend the Member for Basildon and Billericay (Mr Baron), who chairs the all-party group, about staging data. I will say more about that in a minute.

Outcomes for cancer patients and survivors will also be covered by other areas of the NHS outcomes framework. For example, we will measure patients’ experience of the NHS by looking at different patient surveys. We have been talking about that in this debate.

In addition to the indicators in the outcomes frameworks, the cancer outcomes strategy sets out a commitment to improve cancer survival rates generally and—we have heard the figure—to save an additional 5,000 lives a year by 2014-15. The strategy is supported by more than £750 million of investment for implementation during this spending review period.

Our aspiration is to have cancer survival rates as good as the best in Europe, but we have to stage progress to that goal. Our ambition during this spending review period is to halve the gap between England’s survival rates and those of the best in Europe. The estimate, based on the latest figures available, is that that would save an extra 5,000 lives. To deliver on that ambition, we must tackle survival rates for all cancers. To realise our goal, we are taking action to achieve earlier diagnosis of cancer, to extend existing screening programmes for breast and bowel cancer and to improve access to radiotherapy.

Let me deal specifically with early diagnosis. My hon. Friend the Member for Southport referred to the recent lung cancer awareness campaign—the “coughing” campaign as I think he described it. Obviously that campaign has not just dropped out of thin air into the broadcasts of our media around the country. It is the product of a detailed process of testing, trialling and evaluation. Indeed, the original idea came from a local campaign in Doncaster. Then there was a series of regional pilots to see how it would affect behaviour and what benefits would arise from that. I will be more than happy to send my hon. Friend the details of that and, as we evaluate the national programme, how that is going as well.

Early diagnosis is central to our strategy. It is one of the areas to which our international benchmarking has pointed us. By diagnosing cancer earlier, we will improve patients’ chances of being successfully treated, as other hon. Members have said. Through the national awareness and early diagnosis initiative, we have worked with the NHS and other stakeholders to run a number of campaigns to raise awareness. That is about getting people to talk about things that they would not necessarily normally want to discuss—getting them to overcome embarrassment, because embarrassment never killed anyone, but not turning up at the GP’s and asking key questions about particular cancers certainly does.

The hon. Member for Leicester West asked about support for GPs. A range of support is available to help GPs assess when it is appropriate to refer patients for investigation of suspected cancer. Obviously, there are the National Institute for Health and Clinical Excellence referral guidelines. However, we need to do more and we are investing in better GP access to diagnostic tests. I will say a little more about that in a moment. The national cancer action team, Cancer Research UK and Macmillan Cancer Support are working together to develop a broader GP support programme for the coming years. That includes working with the Royal College of General Practitioners.

The hon. Member for Strangford (Jim Shannon) raised the issue of pancreatic cancer. We are working closely with Pancreatic Cancer UK. In fact, we will be working through many of the issues of early diagnosis in a workshop specifically on pancreatic cancer next week. I will be speaking at that event.

We know from the latest diagnostic waiting times and activity figures that despite increasing demand, the proportion of people waiting more than six weeks for an endoscopy has decreased during 2011-12. I hope that hon. Members will join me in congratulating the NHS on the way in which it went about preparing for and dealing with the increased work load that arose from the bowel cancer symptoms awareness campaign that ran between January and March this year.

The Department is working with partners to support the NHS to improve the management of diagnostic demand. There are a couple of things that we are doing in particular. We are promoting the uptake and spread of efficient and productive service models. Some places have no problem in utilising the capacity that they have. Other trusts have struggled, and we are using NHS Improvement to target the trusts where the highest waits have occurred. We are also providing a variety of tools and information to support commissioners. Data are a key component in driving improvements, and we have a new data set for diagnostics, which is providing a wealth of new information.

In our cancer outcomes strategy, we said that access to appropriate treatment, delivered to a high standard, was critical to improving outcomes. That is why we have made available £150 million more over the spending review period. In April 2012, we confirmed plans to develop proton beam therapy services in Manchester and London by the end of 2017. Those services will have the capacity to treat up to 1,500 people a year. Much has been achieved with regard to access to radiotherapy in recent years. Radiotherapy waiting times are now within the 31-day operational standard for both first definitive and subsequent radiotherapy. Modelling shows that that improvement saves 2,500 lives annually in comparison with waiting times in 2007. Data are playing their part, and there are other issues around that.

I want to touch on investment. In answer to a question last week, I said that the first and foremost responsibility for maintaining equipment and identifying when it needs to be replaced does, of course, sit with the provider that uses that equipment. However, in March 2012, we announced the establishment of a £300 million fund, to be operated by NHS Supply Chain, to bulk-purchase medical equipment to achieve better prices for the NHS and to encourage trusts to keep their equipment up to date. It is therefore a combination of responsibilities, but we certainly see the foremost responsibility sitting clearly with providers in that regard.

About 1.8 million people living in England have had a diagnosis of cancer, and the number is growing. We know that we can do more to improve their quality of life, which is why we have been working in partnership with Macmillan Cancer Support on the national cancer survivorship initiative. The use of patient surveys has been a key aspect of that. We will publish a full analysis of the detailed work that we have undertaken jointly this autumn.

We have committed to the next cancer patient experience survey in 2012. We find those data invaluable. The shock to the system when a provider finds itself at the bottom of the tables is very powerful indeed and is leading to significant improvements.

The hon. Member for Ealing, Southall (Mr Sharma) talked about the limited scope of existing indicators. I can tell him and other hon. Members that we are considering how we can make progress on bringing a number of indicators together. My officials are working with the information centre to consider the resource implications of substituting existing indicators and whether it would be appropriate for a composite indicator to replace some of the individual survival rate indicators. Ensuring that we cover more cancers was a concern that several hon. Members raised in the debate.

On funding cancer networks, my right hon. Friend the Secretary of State has made the position clear. We have provided funding for the remaining year for which the Department is responsible. Indicative figures have been set out. A review is going on of clinical networks and how they are governed. That will ultimately determine precisely how much resource is allocated. There is no final figure at this stage.

Regretfully, I shall conclude now, as I am about to run out of time. There is much going on in respect of cancer. I will write to the hon. Members who took part in the debate so that they can see what I would have said if I had more time. However, the cancer outcomes strategy remains the guiding light for the Government to deliver the world-class cancer care that people deserve in this country.