Cervical Cancer Smear Tests

Steve Brine Excerpts

Monday 28th January 2019 Westminster Hall

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

It is a pleasure to serve under your chairmanship, Sir Roger—I shall refer to you again in a moment. I feel somewhat outnumbered, along with the hon. Member for City of Chester (Christian Matheson) and my hon. Friend the Member for Henley (John Howell), but I am rather used to that, having chaired the all-party parliamentary group on breast cancer for five years with the shadow Minister, the hon. Member for Washington and Sunderland West (Mrs Hodgson). We were often referred to as “Steve and the girls”.

I completely endorse the point by the hon. Member for Lanark and Hamilton East (Angela Crawley) that this is not a women’s issue. Natasha, whom I will come to in a moment, had four children—two of each. It is very much a boys’ issue for them, as it is across the board. [Interruption.] We may have heard the B-word only once during the debate, but I could have sworn I just heard something from outside. I must be imagining things.

It has been a privilege to be part of this debate. It is only right that I start by expressing my sincerest condolences to the family and friends of Natasha Sale, who tragically passed away in December. I know I speak on behalf of all Members present when I say that our thoughts are with her family and friends. Anybody who has lost a loved one to cancer knows the pain and anguish that the family are experiencing due to Natasha’s loss. As somebody who has fought and lost more than I have won, I am one of those people. In some of the coverage of Natasha’s death, I saw a quote from Amanda Scott, her best friend, who said:

“God only takes the best”.

I thought that was a lovely quote. We have heard that many times before, but I was interested in how that was reported.

As the Minister responsible for public health and cancer, cancer prevention and early diagnosis are vital priorities for me. I am delighted to see Natasha’s army here today. I saw the pictures on the bus on social media this morning, with some interesting hand signals—I must ask them about that. It is very good to see them all here. I hope they know, as Members know, that I will continue wholeheartedly to support the efforts of the NHS and Public Health England, which I hold to account, and of all our excellent cancer charities, which work as part of team cancer to prevent cancer and reduce the number of families who have to go through what Natasha’s family is going through.

There have been so many interesting speeches. Luckily, for once I have time to touch on a number of them, if not all of them. I was very interested in the point made by the hon. Member for Darlington (Jenny Chapman) about the data showing that take-up is better in the north-east than almost anywhere else. I was interested in what she had to say about the reasons behind that. The NHS as a system too infrequently talks to Members of Parliament, who know their areas better than most. I will ask Sir Mike Richards to contact her, perhaps along with the hon. Member for City of Chester, who is obviously still waiting for an introduction. I am very happy to facilitate that. Her other point was about access, which many Members mentioned. I will ensure that her very good point about disabled women is fed into Sir Mike Richards’s review, and I encourage her to raise that with him when she sees him.

[Ian Austin in the Chair]

I will come to the hon. Member for Warrington North (Helen Jones), who introduced the debate on behalf of the Petitions Committee, because many of the points she raised will come up in my speech. I was pleased that my hon. Friend the Member for Henley talked about the “Be Clear on Cancer” campaign and the new Public Health England campaign that will be rolled out next month. He mentioned the role of GPs in those campaigns. “Be Clear on Cancer” is a public-facing campaign, but elements of it relate to GP education, which I will come to. He often makes very good points in our debates, and I thank him for raising that topic. The hon. Member for Rotherham (Sarah Champion) also mentioned GP understanding, which I will touch on.

The hon. Member for Livingston (Hannah Bardell) made a very personal speech. She said she is awaiting results, and I think I speak for everyone when I say we wish her well. We will be thinking of her, and our fingers are crossed for her. She made a point about the trans community, which I had not heard mentioned in this context. NHS England has published clear guidance for trans men—people who have changed from female to male. Trans men who still have a cervix and have not had a hysterectomy remain entitled to screening. If a trans man is still registered with their GP as a female, they will continue to receive invitations for screening. If they are registered as a male, they remain eligible for screening but will not automatically be invited. The guidance makes clear that trans men need to request screening from their GP. I thank her for raising that point, which is another that I want to feed into Sir Mike’s screening review.

The hon. Member for Kingston upon Hull West and Hessle (Emma Hardy) made a brilliant speech, as always. She should be on the stage. The rather unconventional advice surgery she talked about may not catch on, but I enjoyed hearing about it. We constituency MPs all dread somebody saying, “I’m sure I know you from somewhere.” She talked about education, particularly in schools. Public Health England has a range of materials aimed at providing teenagers and their parents with information about things such as the HPV vaccination programme. She will know that the Department for Education is also working on new relationships and sex education guidance. Its consultation closed in November. That guidance, which will include input from Health Education England, will be published in the first half of this year.

I took the Teenage Cancer Trust and CoppaFeel!—a breast cancer charity with possibly the best name of any cancer charity—to see my right hon. Friend the Minister for School Standards at the end of last year. We were very keen to make the point to them that we must improve awareness in schools of health, bodies and particularly cancers, but in a balanced way that educates children about warning signs without frightening the life out of them. I think we have struck that balance, and I think Members will be pleased when they see that guidance rolled out in the first half of 2019.

[Helen Jones]

Will the Minister tell us whether that guidance includes educating young girls about the need to go for smear tests? Some of Natasha’s friends have forcefully made the point to me that if we do that, it may encourage girls to go for smear tests when they reach the age for screening.

[Steve Brine]

I cannot tell the hon. Lady that, but I will find out and write to her and other Members who in the debate. It is not my policy area—obviously I am not the Minister of State for School Standards—but it is a good point and it would seem logical that that is done in consultation with the Department of Health and Social Care and with Health Education England.

To go to the heart of where I want to start, the hon. Member for City of Chester talked about a constituent being refused a smear test. He said that it would be simple for a Minister to change the regulations and said that this was an example of the system not doing what we direct it to do. As the shadow Minster said, the system should already do that. It would not be appropriate to go into individual instances, but it is important to understand that cervical screening is a screening test and not a diagnostic test. It aims to detect abnormalities of the cervix that if left undetected may develop into cancer, so it is preventative. Cervical screening is not appropriate for women with symptoms, but if women of any age, including under-25s, have unusual symptoms or abnormal bleeding, they should consult their GP immediately and they should be treated under the NHS and initially offered a speculum examination in accordance with the National Institute for Health and Care Excellence guidance for primary care. If that is not happening and if that were one of my constituents, I would be taking that up through the procedures that the hon. Gentleman will know about as an experienced constituency MP. I think that is clear.

The hon. Gentleman also touched on the petition. To be clear, the petition is entitled:

“Lower the age for smear tests from 25 to 18 to prevent cervical cancer.”

He is right to raise the point about women requesting that. We do not often hear about “Liberating the NHS: No decision about me, without me” in the House these days, but it is still very much alive. I would encourage him to take that case up, as I would encourage any other Member who runs into that issue to do.

[Liz McInnes (Heywood and Middleton) (Lab)]

Will the Minister address the issue of self-screening kits for HPV in his remarks? I am sure he will go on to talk about them. My interest is at the other end of the spectrum, with women aged over 64, but it is pertinent to young women, aged 18 to 25, as well.

--- Later in debate ---

[Steve Brine]

Indeed. If the hon. Lady is not satisfied with what I say now, then please come back and we will make sure that she gets more information after the debate. Self-testing for HPV is an emerging area of medicine. It is not in the same place as the fecal immunochemical test for bowel cancer, but it is an emerging and exciting area of policy. I echo all the positive words that have been said about Jo’s Trust, Jo herself and Rob Music, who runs that charity.

Members will be aware that the NHS offers cervical screening to all eligible women aged 25 to 49 every three years and to those aged 50 to 64 every five years. The screening is designed to detect abnormalities of the cervix at an early stage so that women can be referred for effective treatment. It is important to remember that the purpose of population screening is to reduce mortality and morbidity from cancer and other conditions—that is why we do it—in people who appear healthy and have no symptoms, by detecting conditions at an earlier, more treatable stage. Hence prevention is better than cure.

The purpose of any screening service is to maximise the chances of healthier outcomes and, by association, minimise risk of harm to the whole population. With this in mind, the UK National Screening Committee considers the evidence on whether population level screening should be offered and makes recommendations to Ministers. It is not Ministers who make this stuff up, and nor should we. Using research evidence such as pilot programmes and economic evaluation, the NSC assesses the evidence for programmes against a set of internationally recognised criteria. It is important that these recommendations are made by experts based on the best available evidence, and not by politicians.

On this basis, in 2012 the UK NSC recommended that women should be invited for their first cervical screening at the age of 25. This recommendation was based on evidence that showed that the majority of women below this age would receive little benefit from being screened and treated, which can lead to unnecessary treatment, as we have heard from hon. Members. It is very rare that cervical cancer occurs in women under 25 —as the shadow Minister said, there are fewer than three cases per 100,000 women. That is no consolation to someone who, like Natasha, is one of those three who pays the ultimate cost. I am only setting out the facts as they are.

Younger women often undergo natural and harmless changes in the cervix—it is part of their physiology—and screening could identify those as cervical abnormalities. In most cases the abnormalities resolve themselves without any need for intervention. The recommendation picked up by the NSC in 2012 concurred with a major review by the Advisory Committee on Cervical Screening undertaken in 2009, so the advice goes quite a long way back. The hon. Member for Warrington North asked me whether the NSC would publish its evidence on the decision to screen from the age of 25. The NSC publishes minutes of all its meetings and the full rationale behind any recommendations. However, I will ask Public Health England and the UK NSC to publish any relevant evidence used by the NSC in reaching its conclusions and on which they based their recommendations that is not already in the public domain, which I hope she will be pleased to hear.

I will talk about HPV primary screening. Every life is precious and we cannot be complacent in continuing to do all we can to prevent cancer—those who know me know that I am not complacent. Therefore, we are modernising the cervical cancer screening programme by introducing the detection of human papillomavirus as the primary test in the NHS cervical screening programme. I can confirm that this will be implemented across England by 2020. Cancer Research UK estimates that, when fully implemented, HPV primary screening could prevent an additional 600 cases of cancer every year. As we have heard, almost all cervical cancers are caused by HPV, which is a very common sexually transmitted infection which is linked to the development of the disease.

In addition to changing the primary test in the cervical screening programme itself, I want to highlight that vaccination against HPV, introduced in 2008 under the previous Government, is now routinely recommended for all girls aged 12 to 13. In England and Wales the first dose is offered in school year 8. The programme aims to prevent cervical cancer related to HPV infection and the best way to do that is to vaccinate girls and young women. We are fortunate to have achieved good uptake of the HPV vaccination in adolescent girls since 2008.

The first cohort of teenage girls to receive the HPV vaccination in year 8—those born in September 1996—will turn 23 this year and become eligible for routine screening in two years’ time. It will be of intense interest to all of us to see what impact the vaccination will have on the number of abnormalities detected through routine cervical screening and we will be monitoring this very carefully. I will be watching it like a hawk, as Members would expect. We have already seen that the vaccine has led to a reduction in HPV infection in young women and we anticipate a fall in the numbers diagnosed with cervical cancer at the age of 23 to 24 this year.

Boys have received a level of protection from the girls’ vaccination programme over the last 10 years and we have had debates in the House about that. I referred to the previous Chair, my right hon. Friend the Member for North Thanet (Sir Roger Gale), because he led a debate in the House about HPV vaccination for boys and there was a lot of debate about it. A lot of people said that the boys get herd immunity and therefore they do not need the vaccination programme. Again, I am led by the evidence and the advice that I am given, but my personal view was that I did not agree with the herd immunity argument. I was pleased that I agreed with the advice and from September 2019, all boys aged 12 and 13 will also be offered the HPV vaccination against HPV-related diseases, such as oral, throat, penile and anal cancer. I know the hon. Member for Rotherham wanted to hear about that. That will help reduce the incidence of HPV infection circulating in the population.

It is worth saying that, although HPV infection is the primary cause of cervical cancer, many other cancers, such as head and neck cancer, will be seen a long way down the line. Without wishing to be indelicate, I am told that the popularity of oral sex means that HPV vaccination will have a big impact on the incidence of oral cancers. As the dental Minister, I often hear from dentists that that is a growing problem, so I am pleased that we are able to make a positive policy response, which has been well received.

As the hon. Members for Warrington North and for Rotherham said, there are plenty of people who disagree with HPV vaccination. Whenever I speak on the subject— I can feel the tweets landing in my inbox as we speak—I open myself up to the responses of those who vehemently disagree. All I can say is that I think they are wrong and that that is what the evidence suggests. This is a free society and they are of course entitled to that opinion, but we base policy decisions on the evidence. That is where we are. What I have said about the HPV vaccination for girls, and now boys, is important, but I reiterate the message that it is still important for women who have been vaccinated to attend their cervical screening appointments when invited. It does not turn people into Wonder Woman.

The hon. Member for Washington and Sunderland West asked me what we are doing about education for young adults on HPV vaccination, and regional variations in uptake, a point that she has raised with me before. NHS England works in close liaison with Public Health England to deliver the HPV vaccination programme for girls, and in future for boys, and closely monitors uptake rates. It sends me regular reports. Local NHS England commissioners have access to those uptake rates in their area and, in due course, so will MPs. They work with providers, schools and healthcare professionals to improve coverage, sharing best practice where relevant. It became clear to me when looking at the information that there are variations, which is a concern. I made my concerns about regional variation in vaccination uptake clear to the NHS and have had meetings with NHS England and Public Health England on a number of occasions—twice in recent months—asking for additional action to increase uptake across England. I want them back in my office on a regular basis to report to me. That somehow seems to stimulate them.

I am pleased that the NHS long-term plan featured involving local co-ordinators to encourage uptake. That came out of those meetings along with various other commitments to improve vaccination rates, not just for HPV but across the vaccination piece. That includes requiring CCGs to ensure that all vaccination programmes are designed to support a narrowing of health inequalities. They know that I remain on their case. If the hon. Member for Washington and Sunderland West would like to continue the conversation on that with me, I should be pleased to hear it.

The review that the Secretary of State has asked Sir Mike Richards to carry out has been mentioned. Cervical cancer affects many women and their families, and screening can help to prevent many people from developing cancer each year. It is obviously important that women take up their screening appointments to help spot abnormalities. However, with uptake only at about 75%, we know that we need to make it easier to book appointments and more convenient for women to attend them—that point about access came up a number of times in the debate.

I met Mike recently and said that I have an app on my phone that tells me when my car is due for a service and lets me book a local appointment at a time that suits me. We do not embrace that kind of no-brainer technology enough in healthcare. We have to embrace modern technology to ensure that screening programmes are fit for the 21st century. The Secretary of State and I feel passionate about that, and it should offer greater ease of access. Doing that will, I am sure, improve uptake rates. That is one key reason why we are considering comprehensively how our current national screening programmes can be improved, particularly in the light of recent issues that could affect public confidence in screening and lower uptake.

Professor Sir Mike Richards will be leading a review of all three cancer screening programmes, which of course includes cervical screening. His review will report in the summer and will specifically assess the strengths and weaknesses of the individual programmes. It will also address, as I have just outlined, how the latest innovations can be utilised and integrated with research to encourage more people to be screened, and to make it easier for them to do so. That point was raised by many hon. Members, including the hon. Member for Warrington North. I met Sir Mike a couple of weeks ago to discuss the fact that his review clearly needs to set out how we can bring our screening programmes right up to date to make them fit for the people who use them. I await his recommendations with optimism. Mike ran screening programmes in the Department of Health and Social Care before the passing of the Health and Social Care Act 2012. He has great experience and credibility within the system, which is important. We have great optimism about his work.

We must do more to raise awareness not just of the importance of taking up screening, but of how to recognise the potential symptoms of cervical cancer. Breast cancer awareness campaigns have been phenomenally successful in that kind of work. In her petition, Natasha said that she wanted to make a difference to the next generation of young women by raising awareness of the symptoms. I have seen the videos online of her little girls—they are heartbreaking. Natasha certainly raised awareness of the symptoms of what is a terrible disease. I believe she has already made a difference, highlighting how vital it is for women with symptoms to contact their GP as soon as possible. Indeed, it is 10 years since Jade Goody, who also took on the fight to raise awareness, sadly died of the illness. We shall, with the permission of Jade’s family, use the anniversary to help raise awareness of the importance of screening, and of taking up appointments. In the aftermath of Jade’s sad death attendance rates rocketed. Obviously that has waned. We will, in Jade’s and Natasha’s honour, make the most of the 10-year anniversary to save other women.

[Jenny Chapman]

It is encouraging to hear what the Minister says, and his comments about the legacy of Jade Goody and others. It is a tremendous thing that they have left to us, with the campaigns we have benefited from. However, is there not, up to a point, cause for concern in that the examples being used are younger women, which could reinforce the misinformation about the need for younger women to be more concerned about cervical cancer—and therefore for older women to be less concerned? Sometimes I wonder whether the prominence given to the examples in question may create an issue for another group of women.

[Steve Brine]

The hon. Lady makes a good point, and there is always a danger with public awareness campaigns, even down to the models, actors and actresses used in the advertising campaigns, with presentation and positioning. I take the point, and Public Health England, which works on such campaigns for me, will also take the point the hon. Lady raises. I assure her it will be sent a copy of the debate.

A number of hon. Members, including my hon. Friend the Member for Henley, who is no longer in his place, have raised the matter of GPs. Guidance for GPs has been developed and published, specifically aimed at improving the primary care of young women who present with gynaecological symptoms. That guidance, produced by a multidisciplinary group, including professionals, patients and the voluntary sector, and endorsed by the relevant royal colleges, offers clinical practice guidelines for the assessment of young women aged 20-24 who present with abnormal vaginal bleeding. GPs are continually made aware of the symptoms of cervical cancer and the need to refer women under the age of 25 for further investigation. From today’s debate, it sounds as if we have further to go, but we knew that, of course. As part of the delivery of essential medical services under the National Health Service (General Medical Services Contract) Regulations 2004, GP practices must offer consultations and, where appropriate, they must also offer physical examinations for the purposes of identifying the need, if any, for treatment or further investigation and, if needed, referring the patient onwards as soon as possible. The hon. Member for Rotherham made an excellent point about understanding the history of trauma that some women on their lists had had. Obviously it is a subject that she has a lot of experience of in her constituency; I thank her for making that excellent point, and I will ensure it is fed into the Mike Richards review.

I have mentioned the “Be Clear on Cancer” campaign a couple of times, and said that Public Health England will work to raise awareness of this disease through that campaign, which we have run in partnership with Cancer Research UK since 2011. It has covered many different areas and is scheduled to promote the uptake of cervical screening from next month.

While we are still on the awareness point, in the 2016 Budget the Government announced that Jo’s Cervical Cancer Trust, which does so much good work in this area, as has been said, would be a beneficiary of the tampon tax. It received £650,000 in funding to kick-start a campaign to get closer to eradicating cervical cancer. I take part in many of these debates and talk about cancer, as does the shadow Minister. One third of cancers are preventable and two thirds of cancers are just bad luck. With some cancers, we are nowhere near, but this is a cancer we can get rid of. This is a “bad” that we can eradicate. That is why we are so determined to get it over the line.

Jo’s Cervical Cancer Trust ran a campaign on eradication in 2017 and 2018; it was a wide-reaching awareness programme, with a specific focus on groups where there is a higher prevalence of non-attendance of cervical screening: interestingly, that is women from black, Asian and minority ethnic communities, women from disadvantaged backgrounds—a point already made—and women in the 25-to-29 and over-50 brackets. The funding enabled the trust to provide targeted education and information to those groups and to produce a body of evidence on the barriers to screening and how to overcome them.

The trust found that some young people do not attend appointments because they are embarrassed; that finding received a lot of press coverage and came out in Prime Minister’s questions last year. Others do not think the test is important, and yet more do not think they are at risk because they lead healthy lifestyles. One in four do not attend their screening appointment, and that needs to change, so this is important work.

From talking to Rob from Jo’s Cervical Cancer Trust, I know that one thing they found on the roadshows when they were testing this work in 2017 and 2018 was the importance of talking to women’s partners and the role partners can play in reminding, or nagging—whatever word we choose to use—women about taking up their screening appointments. Last week, the trust led their annual cervical cancer awareness week, with an event here in Parliament. The aim is to help as many people as possible to know how they can reduce the risk of the disease, and to promote that among their constituents.

The #SmearForSmear campaign reinforces the message that smear tests prevent 75% of cervical cancers, so while they may not be pleasant, as we have heard, they are important. I was pleased to support them myself, as most of the Health team did, at the event in Parliament last week, and I thank all hon. Members who took part; I know Jo’s Trust found it helpful. As Natasha’s Army says—this is such an important message—we need to support all young women to “lose the fear, take the smear”.

If I may try to draw my remarks to a close, this Government—as did the previous Government, and as will the next Government—recognise that cervical cancer is a devastating disease, and we are committed to providing well-managed screening programmes based on the most up-to-date, peer-reviewed evidence. Cancer is right at the heart of the NHS long-term plan, which was published on 7 January, and I am very proud of that fact. The plan sets out a comprehensive package of measures that will transform cancer diagnosis and treatment across the country over the next 10 years, a decade in which patients can expect to see vast improvements in the prevention, diagnosis and treatment of cancer. The aim is to see 55,000 more people surviving cancer for five years in England each year from 2028. That is quite an ambition, but we will get there.

Cervical screening saves an estimated 5,000 lives a year, and the Government are committed to continuing to do all we can to prevent cancer and ensure early diagnosis, which is often rightly called cancer’s “magic key”, so that more families do not have to go through these personal tragedies, as the Sales have done. We are up for the fight. I thank everyone for taking part.