Cancer Treatments

Debate between John Pugh and John Leech

Tuesday 19th June 2012 Westminster Hall

[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?