Health and Care Bill

Debate between Philippa Whitford and John Baron

Report stage
Tuesday 23rd November 2021 Commons Chamber

[Mr Baron]

I tend to agree, and that is in part what the new clause is intended to address.

I chaired the all-party parliamentary group on cancer for nine years. We were painfully aware that the Government had once estimated that if the country matched the best survival rates in Europe, 10,000 lives a year would be saved. In 2013, the OECD confirmed that that our survival rates ranked near the bottom when compared to those of other major economies. As we have improved our rates, so have other countries, and we are not closing the gap. A more fundamental change is required.

Back in 2009, when I first became its chairman, the APPG conducted a major inquiry which showed that the main reason our survival rates lagged behind others was not that the NHS was any worse than other healthcare systems at treating cancer once it was detected, but that it was not as good at catching cancers in the crucial early stages. In other words, late diagnosis lay behind our comparatively poor survival rates. The APPG had some success in getting the one-year survival rates—rates of survival one year after diagnosis—into the NHS DNA.

A key advantage of focusing on this kind of “outcome measure” is that it gives healthcare professionals much greater freedom and flexibility to design their own solutions, which could include running wider screening programmes and better awareness campaigns, and establishing greater diagnostic capabilities at primary care. A further advantage of focusing on outcome measures is that it will better align NHS priorities with patient needs. Survival rates are what really matter to patients. However, clinical commissioning groups are too often focused on “process targets”—the 62-day wait for treatment being an example—because they are often linked to funding. The one-year survival rate measure was not.

Research produced by the House of Commons Library found that nine such process targets were applicable to cancer alone, such as the 62-day wait. Process targets have a role to play in improving the NHS, but all too often they are a blunt tool offering information without context, and they can be exclusive, especially when funding flows are attached. Also, I consider it unacceptable that, in the case of certain cancers at least, patients should have to wait for 62 days—two months, in effect—for treatment. That is simply not right. Furthermore, process targets can easily become a political football between the two Front Benches, and only short-term points are scored. All sides are guilty of this, but it rarely helps patients.

In addition, process targets are not the best way of helping those with rarer cancers, with often fall between the cracks because data on those cancer types have not been routinely collected. That is a real problem. If we want to drive up survival rates, we cannot exclude rarer cancers, if only because they account for more than half all cancer cases.

Given the advantages of outcome measures such as one-year survival rates, I have tabled my simple amendment, new clause 19. Its aim is to ensure that NHS England puts outcome measures above process targets.

[Dr Whitford]

Will the hon. Gentleman give way?

[Mr Baron]

I will not. I do apologise, but time is short.

New clause has been endorsed by the founding chief executive of Cancer Research UK, Professor Sir Alex Markham, who has commented that

“comparable health services abroad continue to outperform the NHS in terms of cancer survival. They all remain focused on cancer outcomes and the UK would be foolish not to do likewise.”

The new clause has also been endorsed by others, including the Teenage Cancer Trust. I assure those who are concerned that it will not detract from process targets; quite the opposite because, by implication, improved outcomes can only be facilitated by improved processes and inputs.

I urge the Minister to adopt the new clause. He will then have more time to assess its impact, and perhaps, following consultation, suggest amendments—if necessary —in the other place. I am confident that sufficient cross-party support could be achieved if acceptable nuances were required. If that is not possible, I intend to press the new clause to a vote, but I sincerely hope that I—we—can work with the Government and other parties to drive up survival rates in the NHS across the United Kingdom.

Cancer Targets

Debate between Philippa Whitford and John Baron

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.

--- Later in debate ---

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[Mr Baron]

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

[Dr Whitford]

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

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