Cancer Targets

Philippa Whitford Excerpts

Tuesday 1st May 2018 Westminster Hall

[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.

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[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.

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

Thank you very much, Mr Streeter, and it is a pleasure to see you in the Chair. As always, it was a pleasure to hear the debate.

I, too, congratulate my hon. Friend the Member for Basildon and Billericay (Mr Baron) on securing yet another debate on cancer in this place. I do not know how he does it; he must have a special line to Mr Speaker.

My hon. Friend and I worked very closely together in my previous iterations on the Back Benches. I am hugely appreciative of all his work as chair of the all-party parliamentary group on cancer. I did not know until today that he is coming towards the end of his tenure, but my goodness—he has certainly done his bit. He will be a hard act to follow, and I do not know who will succeed him. Who knows? Maybe that next person is with us today, Mr Streeter; you never know.

We have had some excellent contributions today. I do not know why the hon. Member for Scunthorpe (Nic Dakin) is looking at me that way; he is welcome to intervene on me.

May I just say that the hon. Member for Central Ayrshire (Dr Whitford) made a speech that was, as always, very sensible, balanced and packed with experience, which most of us can only hope to get near to. It is very welcome and very important in these debates that she speaks about her long time working in the breast unit in Edinburgh—

[Dr Whitford]

In Ayrshire.

[Steve Brine]

In Ayrshire—sorry. The hon. Lady is one of my successors as the chair of the all-party parliamentary group on breast cancer and she was so right in what she said about prevention; she was right in a lot of things she said, but she was so right about prevention. As we meet here in Westminster Hall, a certain well-known TV chef is giving evidence to the Health Committee upstairs; I am sure that can be seen on all good news channels this evening. One of the things the Committee is considering as part of its inquiry is child obesity, and one of the first things that I did in this job was to publish the tobacco control plan. I am passionate about that and I am also passionate about our alcohol challenge.

Plenty of people in this country—the majority—have a very healthy relationship with alcohol, but there are some people for whom that is not the case. As the hon. Lady knows, alcohol is also a big cancer risk factor. She was spot on in saying that this debate is not just about a cancer plan; it is about a health plan. I see the obesity challenge, the smoking challenge and the alcohol challenge as a holy trinity, if you like, in the task of tackling cancer.

[Dr Whitford]

I would just like to mark the fact that Scotland starts its minimum unit pricing on alcohol today. That will not be a panacea, but we hope that it will at least help to make the dirt-cheap white ciders no longer dirt cheap and keep them away from our teenagers.

The obesity strategy introduced by the previous Prime Minister appeared to be quite comprehensive, yet the final version published by the current Government—or the Government before; it is always hard to keep track—was only about a third of the original strategy. Is a much more ambitious plan likely to be issued and will it include attempts to tackle things such as advertising, which make our living space so obesogenic?

[Steve Brine]

Nice try. We always said that addressing child obesity was chapter 1 and therefore the start of a conversation. There are a lot of things within that plan that we are still to do, or in the middle of doing. For instance, Public Health England will shortly publish the initial results of the sugar tax on soft drinks—the industry levy—and we said that we would watch that tax very closely, to see whether we needed to continue the conversation. The hon. Lady will also know that there have been lots of discussions in this Chamber and in the main Chamber about advertising, “buy one, get one free”, labelling and reformulation. As she knows, I am very interested in said agenda and I watch these things like the proverbial hawk. So I thank her for raising that issue.

I always enjoy listening to the hon. Member for Scunthorpe; he speaks so well and I see him at so many different events in this House. He mentioned the cancer dashboard and blood—or non-solid—cancers. He knows that I agree with him; it is something that I am looking at very closely with officials and with NHS England. I also pay tribute to the work that he does on pancreatic cancer. I met one of the pancreatic cancer charities with my right hon. Friend the Secretary of State for Health last week—or was it the week before last? Time flies.

The hon. Gentleman talked about the survival figures for pancreatic cancer, and they are terrible in comparison with those for other cancers. However, sometimes we have to recognise that there is an enormous challenge with pancreatic cancer, in that it is very hard to diagnose because often it is not symptomatic until its latter stages. That is one of the reasons why I was very interested in the 16-day referral to surgery pathway that he talked about and the challenge that he identified within his cancer alliance. My officials will have heard what he said, and I will take it away and consider it, because it is a really important point.

The hon. Member for Ellesmere Port and Neston (Justin Madders), who is the shadow Minister, asked about the cancer strategy and the next update to it. It is not a “three year on” update, but the next update will be in the autumn of this year. I was glad to hear his welcome for the first ever cancer workforce plan, which Health Education England published in December. It sets out how we will expand the workforce numbers. Just last week, I was with Harpal Kumar of Cancer Research UK before he steps down, and we were talking about the critical importance of that plan. I, too, would have liked to have seen it sooner, but we are committed to training 746 more cancer consultants and 1,890 more diagnostic and therapeutic radiographers by 2021.

I was at the Royal College of Radiographers annual dinner last week in London, and its members did not miss an opportunity to make the case to me about the workforce. The cancer workforce plan is a really positive innovation, and I look forward to working with HEE and my colleagues as we take it forward.

I said in this place this morning that cancer is a huge priority for this Government, and I think that everyone in here knows it is a priority for me. Yes, survival rates have never been higher. Our latest figures showed an estimated 7,000 more people surviving cancer after successful NHS treatment than three years earlier, and our aim is to save 30,000 more lives by 2020. However, we know that there is a huge amount still to do, and that is why we accepted the 96 recommendations in the cancer strategy and have backed that up with the £600 million of additional funding up to 2021.

Two years into the implementation of the strategy, we are making progress, as I said in the Backbench Business debate that my hon. Friend the Member for Basildon and Billericay secured in February. I hear what he says about standards and targets, and in some part I agree, but they are only part of the story. The alliances are not targets; they are about pathways and best practice—not just learning best practice but implementing it. The NHS is very good at sharing best practice, but perhaps not always brilliant at implementing it. The example given by the hon. Member for Scunthorpe about the pancreatic pathway—

[Dr Whitford]

rose—

[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.