Access to Radiotherapy

Maria Caulfield Excerpts

Wednesday 12th January 2022 Westminster Hall

[The Parliamentary Under-Secretary of State for Health and Social Care (Maria Caulfield)]

It is a pleasure to serve under your chairmanship, Mr Davies. I should declare an interest before I start: I am still working as a cancer nurse in the Royal Marsden Hospital in London. I have spent 20 years looking after patients who are having chemotherapy, radiotherapy and surgery, so no one is more passionate than I am about this issue.

I congratulate the hon. Member for Easington (Grahame Morris) on securing this important debate, raising the profile of radiotherapy and the important work that the all-party parliamentary group does. Very few of us have not been impacted by cancer in some way, whether as a patient—the hon. Gentleman and the hon. Member for Rhondda (Chris Bryant) eloquently described their experiences—or as a relative, friend or healthcare professional. We know the devastation that cancer can bring, whether through the diagnosis and living with the disease, experiencing the side effects of treatment or, unfortunately for some, the effects it can have on life expectancy.

I reassure colleagues that during the pandemic, cancer has remained an absolute priority. We have kept cancer services going throughout periods of lockdown. There is no doubt, though, that patients were reluctant to come forward with signs and symptoms, particularly during the first lockdown. We actively encouraged many patients with a cough not to come and see their GP as a first point of contact. Since then, however, an absolute tsunami of patients has come forward—so much so that we are working through more than 10,000 cancer referrals a day.

I encourage Members to look at the data for actual treatment. Data such as that about the 62-day rule shows that the cancer backlog is not necessarily in treatment—in patients waiting for surgery, chemotherapy or radiotherapy—but in the diagnostics procedures. They are where the greatest pressure is at the moment.

[Grahame Morris]

I appreciate the Minister’s giving way. Statistics are important as a tool to identify where the obstructions are in the system. I completely agree about the importance of early diagnosis, but will the Minister publish the radiotherapy datasets that will be available next month, so that we can see the true nature of the backlog?

The profession—the frontline—tell a story rather different from the impression that the Minister has just given: that there are issues with treatment, and not just with diagnosis. The radiotherapy datasets, which have not been published for over a year but are available, will clarify that position.

[Maria Caulfield]

I thank the hon. Gentleman. I am not saying that there are no pressures on the treatments for cancer patients, but the greatest pressure is at the diagnostic end. We will be publishing data, but I caution Members on the data for radiotherapy. A lot of the cancer data is based on first treatment and, as Members will know, radiotherapy is often an adjuvant treatment given further down the line. The measurement of access to radiotherapy, compared with treatments such as surgery or chemotherapy, is much more difficult to establish.

I also caution colleagues, a number of whom have said similar things in this morning’s debate. Radiotherapy is a specific specialist treatment. As the hon. Member for Rhondda pointed out, for many cancers it cannot necessarily be given instead of surgery or chemotherapy; it is part of a package of treatment and these are clear, clinical decisions that need to be made jointly by the oncologist and their patient.

[Grahame Morris]

We have a little bit of time and these are important points. Many of us have been making them, not just to this Minister—who, to be fair, is newly in place—but to her predecessors.

There are points of contention about the effectiveness of radiotherapy, but there have been some incredible advances in recent years. I am not claiming expert technical knowledge, but radiotherapy has been applied very effectively against lung cancers; that was never the case before. There is now a possibility of expanding the service to provide much more effective treatments, for cases which previously could be treated only through surgery and chemotherapy.

[Maria Caulfield]

I do not disagree with the hon. Gentleman. I may be a new Minister, in post for weeks rather than years, but I have 20 years of oncology experience, and in my experience radiotherapy has a fantastic role to play. It is indeed the case that significant progress has been made, particularly in the field of lung cancer, with stereotactic radiotherapy to specific areas. However, radiotherapy will target a specific area; it will not give systemic treatment, like adjuvant treatment to prevent recurrence or neoadjuvant treatment for metastatic disease, where the disease is in multiple parts of the body. As Members of Parliament, we need to be cautious that we do not give patients the impression that they should be asking for radiotherapy instead of surgery and chemotherapy. There needs to be a discussion with their oncologist and their medical teams as to the appropriateness of radiotherapy. Yes, it is often cheaper than chemotherapy to give. Yes, it is a quicker treatment and sometimes—not always—has fewer side effects. But it has to be a clinical decision. There are important reasons why radiotherapy is given to some patients and not others. That is something that patients really need to have a discussion—

[Chris Bryant]

We all understand that clinical decisions have to be made. Our anxiety is that clinical decisions sometimes end up being made because there is not enough availability of facilities or staff, or—the third aspect to this—because lots of patients simply are not presenting at the moment. They are not coming in the doors of the NHS because of covid. That potentially means—for instance, in relation to bowel cancers, lung cancers and melanoma—that we will see people presenting much later and therefore there will be a much more dangerous prognosis for them.

[Maria Caulfield]

I absolutely take that point on board. There are clinical reasons, if a patient has presented later, why radiotherapy may or may not be suitable. Again, they are clinical decisions that a patient needs to be discussing with their oncologist.

The hon. Member for Westmorland and Lonsdale (Tim Farron) raised the issue of satellite units. Again, I would just be slightly careful. Cancer alliances are mapping out cancer services in their areas, and I am very happy to meet colleagues who would like better provision in their local area, but they also need to meet their cancer alliances, which are looking at service provision locally.

I would just caution Members on the issue of having multiple sites for radiotherapy. These are specialist treatments, needing specialist equipment and specialist staff. I went into oncology more than 20 years ago, when surgery was done by general surgeons. They were doing mastectomies on women and colostomies on bowel cancer patients. Moving surgery into being a specialist field, with specialist provision, has transformed the way that we are able to look after women who are going through mastectomies, and bowel cancer patients, who may not necessarily need a colostomy now, because surgical treatments have advanced so much. There is sometimes a rationale for those services to be offered by specialist units, rather than multiple satellite sites.

[Tim Farron]

I want to answer a point that the Minister made earlier. Obviously, during the pandemic, radiotherapy has been used as substitutionary treatment for people who would otherwise have had chemotherapy or surgery, because it is a covid-secure treatment. But my main point is with regard to what the Minister just said about satellites. Has she looked at the data and evidence from those satellite centres that have been opened in the last few years?

For instance, at Hereford, we saw a doubling of the number of patients being treated at that new satellite centre. Why? Well, there was an assumption that the parent centre people, from that postcode, were simply transferred to Hereford. No, it turned out that a lot more people, who would not travel or who were not referred because of the travelling distance for treatment at the original place, were then referred for treatment and therefore had a longer life expectancy because of the satellite centre. With more networking capability, it is of course possible now to treat in specialist ways, with the best people, remotely and through these satellite centres. The Christie has just opened its third satellite, so surely, for more rural communities such as mine, and also in east Lancashire, the time has come to ensure that no one is left behind.

[Maria Caulfield]

There are satellite services—absolutely. We have seen them not just for radiotherapy, but for chemotherapy and even surgery. But it has to be a local decision, because local oncologists have to feel that they are able to support the multidisciplinary team who support the radiotherapy process, ranging from diagnostics through to the treatment itself. That has to be in place, so it does absolutely need to be done on a local basis, but I am happy to meet colleagues if they feel that the case is not being heard locally.

I want to emphasise this point, because a number of hon. Members talked about the commitment to cancer services. Our elective recovery programme has committed £2 billion this year and £8 billion over the next three years to step up activity and tackle backlogs. That will have a knock-on effect in improving radiotherapy access, because some patients cannot have radiotherapy until they have had surgery. Ensuring that we are tackling some of the backlogs to treatment resulting from covid is absolutely important.

There have been huge improvements in radiotherapy over recent years, not just in provision but in technique. We are able to deliver more targeted treatment, resulting in fewer hospital visits, because we can now give radio- therapy to a more targeted area of the body, resulting in fewer side effects from the treatment, and also give fewer fractions of radiotherapy, so that patients can get their total dose much more quickly. That maximises service capacity and minimises patient time in hospital.

Furthermore, we have invested £250 million into two proton beam therapy facilities, one based at the Christie in Manchester and the other at University College London. In addition, all radiotherapy centres in England are now able to deliver stereotactic ablative body radiotherapy. Both these treatments are able to target radiation at cancer cells more accurately, improving patient outcomes. I am really pleased to say that, as part of this year’s spending review, £32 million was made available to support the replacement of 17 linear accelerators aged over 10 years, all of which are on order and will be delivered by the end of March 2022.

NHS England is committed to improving the facilities for cancer patients, and has also offered NHS radiotherapy providers the opportunity to participate in a cloud-based technology called ProKnow. To date, 43 of the 49 radio- therapy providers have joined up. This technology, which will help satellite units, enables clinicians to collaborate virtually within and across organisations, to plan treatments, undertake peer-review assessments and participate in large-scale audits and quality improvement processes, ultimately benefiting patients.

A number of Members talked about the cancer workforce, because it is great to have state-of-the-art technology and multiple units providing radiotherapy, but if we do not have the staff to manage them and provide treatment we shall not make progress. Health Education England is continuing to take forward the cancer priorities identified in the NHS’s long-term plan. It is prioritising the training of 250 nurses to become cancer nurse specialists, 100 chemotherapy nurses and 58 biomedical scientists, and it is updating the advanced clinical practice qualification in oncology.

Further than that, particularly around radiotherapy, Health Education England is investing £52 million in the cancer and diagnostic workforce, increasing the number of clinical endoscopists and training more radiographers in image interpretation. That is all part of the radiotherapy process. As of August there have been an additional 4% of doctors working in clinical oncology, which is the field that manages radiotherapy, and there have been a further 5% working in radiology since August 2020.

We are making progress, but it is not just about the numbers of staff; it is about the skill mix and ongoing staff training. Very often, not being able to expand a role or take on exciting and innovative developments can make staff feel frustrated, but the cancer workforce is growing. Between 2016-17 and 2019-20, the cancer workforce grew by 3,342 full-time equivalents, compared with the ambition of 2,943. We are ensuring that there are more staff coming through into the workforce to deliver radiotherapy.

The shadow Minister touched on the importance of not only recruiting staff but retaining and developing them. I fully take on board colleagues’ comments and concerns. We are committed to investing in radiotherapy equipment, the staff that deliver radiotherapy and the innovation in radiotherapy. We are also committed to making it more accessible to patients, and to reducing the side effects—there are side effects from radiotherapy as well—and to making sure it is a fundamental part of cancer treatment, whether that is in the neoadjuvant setting, adjuvant or for those with metastatic cancer as part of the palliative treatment service.

[Feryal Clark]

I thank the Minister for all the information about the machines and investment into radiotherapy. Are the figures that she set out for replacing what is already out of date, or is there a plan to increase investment in radiotherapy treatment? As we have all said, radiotherapy accounts for 5% of the cancer budget. Is there a plan to increase that, or is it about replacement and keeping up what we already have?

[Maria Caulfield]

It is about replacing existing equipment, but also investing in new. Some of the equipment is 10 years old. Radiotherapy has changed a lot over those 10 years, so the replacement equipment can do more than what it replaces. As I pointed out, we are also investing in new radiotherapy equipment, with £250 million into two proton beam therapy facilities at Christie’s and at UCL—new facilities that will be able to provide state-of-the-art radiotherapy treatment. I hope I have reassured Members that we are addressing this as a top priority.

[Chris Bryant]

Will the Minister give way before she sits down? She sounds very like she is finishing.

[Maria Caulfield]

I was finishing, but I will give way one more time.

[Chris Bryant]

The Minister may not be able to answer the question today about adjuvant provision of immunotherapy for people with stage 2 melanoma, but if she could write to me, I would be very grateful.

[Maria Caulfield]

My understanding is that it is available for stage 3 melanoma, as the hon. Gentleman has highlighted, and that it is still in clinical trials for stage 2. It is available within clinical trials. We expect the data to come forward shortly and then a decision will be made. That is where we are with melanoma.

[Tim Farron]

Will the Minister give way?

[Maria Caulfield]

I will give way one more time.

[Tim Farron]

The Minister is being very kind and I really appreciate it. I have two quick points that I do not think she has mentioned. First, will she take up the request from myself and the hon. Member for Easington for a meeting with the APPG for radiotherapy? We would love to meet her.

Secondly, I do not think she referred to the tariff situation. A lot of the issue is that we need more money. We want the Minister to accept—it is not just her fault; it is the fault of every party in this place, over decades—that we are behind comparable countries and we need to strengthen radiotherapy. The reality is that there are lots of state-of-the-art machines out there, in trusts up and down the country, that are not being used because the tariff is stupid. It incentivises trusts to do second-division radiotherapy, if I can put it that way, because more visits equal more cash, rather than targeted and specific radiotherapy—stereotactic, as she mentioned, for many cancers—because the tariff rewards number of visits, not precision or effectiveness of treatment. Would she look at that? It is free.

[Maria Caulfield]

I am very happy to look at the tariff situation, but my experience is that when a clinical oncologist is referring someone for radiotherapy, that decision is not based on whether they have smaller numbers of fractions as opposed to traditional courses. I am very happy to meet the all-party parliamentary group to discuss that further. I reassure patients that clinical decisions are what decide the type and the number of fractions that a patient needs for their treatment.

Radiotherapy is a priority cancer treatment and this Government are absolutely committed to investing not just in the equipment, but in the workforce that provides it. I say a huge thank you to all the staff across the NHS, particularly in cancer services, who kept going through all the pandemic lockdowns, made sure that cancer patients got their treatment, and helped to support them and their families through what is a very difficult time.