Cancer Treatments

John Baron Excerpts

Tuesday 19th June 2012 Westminster Hall

[Mr John Baron (Basildon and Billericay) (Con)]

I congratulate my hon. Friend the Member for Southport (John Pugh) on securing this important debate. The all-party group on cancer, of which I am chairman, has consistently called for us to see the NHS reforms as an opportunity to improve outcomes for cancer patients, and I welcome the chance to highlight that once again.

Perhaps I should start by briefly taking us back to 2009, when the all-party group produced its report on reducing health inequalities. After a long evidence session, with oral as well as written submissions, we discovered that those patients in this country who reached the one-year point stood as much chance of reaching the five-year point as patients in any other country in Europe, but we fell down badly in getting patients to the one-year point. That tended to suggest that the NHS is as good as anybody else at treating patients—once detected—but poor at detecting cancers in the early stages in particular. Other hon. Members have made that point in this debate.

How do we encourage earlier diagnosis? There are few magic keys to solutions in life, but perhaps earlier cancer diagnosis is one of them. The 2009 report concluded that the best way of doing that was to focus on outcomes—to get the NHS actually to look at one and five-year survival rates, because late diagnosis makes for poor outcomes. Getting the local and national NHS to focus on one and five-year rates would encourage the local NHS in particular to drive forward initiatives and earlier diagnosis. We were grateful when the Government accepted the logic of that argument and included one and five-year outcome measures in the NHS outcomes framework. The NHS reforms essentially boiled down to two strands—two initiatives. One was the change in the commissioning structure; the second was the focus on outcomes. For me and for many in the all-party group, the focus on outcomes was by far the most important bit of the NHS reforms.

We welcome the Government’s response so far. The all-party group was pleased that, at the beginning of 2011, the Government released their strategy for cancer, which clearly highlighted the importance that they attached to the issue. They came up with a figure—an ambition—to save an extra 5,000 lives a year from cancer by 2014-15. We should remember that that would take us up to only the European average, not the best in Europe, but it is still a laudable ambition that we very much welcome.

We have had a constructive dialogue with the Government, experts and patients. I want to touch briefly—I am conscious that other hon. Members wish to speak—on some of the key recommendations from the all-party group that flowed from the 2009 report. We welcome the Government’s response to that report. Many others have made the same argument, but we played a small part in moving the Government in the right direction.

However, we are still ambitious with regard to some of our recommendations. For me, the first is key. There seems to be an anomaly in the different outcomes frameworks. We have the commissioning outcomes framework, which has the five-year survival rate as an outcome measure. We have the NHS outcomes framework, which has the one and five-year measures. The COF is the framework by which the clinical commissioning groups will be held to account for their performance, and we are arguing for the one-year measure to be included in the COF, just as the one and five-year measure is included in the national outcomes framework. In other words, we want standardisation.

Our concern is that if we have different outcomes frameworks focusing on slightly different things, or certainly not the same things, a disjointed message can be given. It is important that both the local and the national NHS focus on the same things. I raised that question—the Minister will forgive me for raising it in this debate—in Health questions last week. I was slightly worried about the response. The Minister will correct me if I am wrong, but he cited concerns with the quality of the data available for the one-year measure within the COF. If the one-year data are good enough for the NHS outcomes framework, why are they not good enough for the COF, particularly given that the NHS Commissioning Board will shortly provide geographic boundary data for the clinical commissioning groups? It should not be beyond the wit of man to transfer what we have in the NHS outcomes framework across to the COF once those data from the NHS Commissioning Board are available. I am led to believe that there should be no problem at all with how the data are cut. What does the Minister have to say about that?

To pick up the point made earlier by the hon. Member for Ealing, Southall (Mr Sharma), I also want to question the Minister about why we are not expanding the number of cancers in the outcomes framework. I have a little more sympathy with the Minister on the quality of the data on this one. Whereas I cannot understand why the one-year figures, which are in the NHS outcomes framework, are not included in the COF, I have some sympathy because of the quality of the data for expanding the three cancers that are already there. Those three cancers are obviously common cancers. They account for some 40% of all new cancer diagnoses—we are talking about breast, lung and colorectal cancers. The Minister accepts that there can be a disparity in survival rates between the common cancers and the rarer cancers. Our recommendation would in some respects help to close that gap with the more common cancers. Will the Minister address the point that was made earlier and the point that the all-party group has been pushing hard on for some time?

The Minister appreciates that we hon. Members in the all-party group have had a constructive dialogue, which continues, but this debate is too good an opportunity to miss, so I should like to raise some relevant issues in a more public forum. The all-party group has tended to focus on proxy measures. When we had primary care trusts, the one and five-year figures were statistically robust, because the population sizes allowed them to be so. However, we have started tinkering with the commissioning structure—first, general practitioners and fundholders and then clinical commissioning groups—and the population sizes are somewhat smaller. Therefore one and five-year figures, on their own, are not as statistically robust as we should like. That is why we in the all-party group suggested that staging and emergency admissions could be used as proxy measures to complement, rather than replace, the one and five-year figures, for the benefit of the local NHS.

Hon. Members should not forget that this is all about trying to introduce measures that allow the local NHS to focus on outcomes and introduce, through its own initiative, initiatives such as screening, which was mentioned earlier—there are many others—to try to drive forward earlier diagnosis.

In respect of proxy measures, I understand that the public health outcomes framework, published at the beginning of the year, has already identified the importance of staging data. Certainly, that is so with regard to cancers diagnosed at stages one and two. I am not alone in the all-party group in thinking that it is important that those data are shared across the outcomes framework to ensure a coherent approach throughout the NHS. I am interested in what the Minister says about that. Once again, I accept that we have to be reasonable. This is about quality of data. I hope that the Minister accepts that coherence is needed in respect of the frameworks for public health outcomes, NHS outcomes or commissioning outcomes.

If the big picture of what the NHS should focus on in respect of cancer is coherent—whether top-down or bottom-up—we stand a greater chance of achieving our goals. At the moment, there is a risk that we do not have such coherence. I know that the process is at an early stage, but I am interested in hearing the Minister’s response.

Picking up a point that was raised earlier, all hon. Members accept that improving patient experience is important, which is why the all-party group thinks that we need to do more to push on an open door. We recommended that the national cancer patient experience survey should be conducted annually. Although there is a question about feasibility, there is much merit in that suggestion. The survey should also be included in domain 4 of the NHS outcomes framework and the COF, just to ensure that the message, which is that we regard it as important, is clear. Patients can have the best treatment in the world, but unless their experience is good, particularly at a traumatic time when they have cancer, negative experiences can often act as a dampener and can affect recovery rates as well. It is important to recognise that.

I thank my hon. Friend the Member for Southport for securing the debate. The Minister knows that the all-party group is keen on a constructive dialogue—it is ongoing—and I thank him for the meetings that we have had and for the constructive way that he has liaised with us. I apologise to him for making an early exit, because I have to attend a meeting of the Select Committee on Foreign Affairs. However, he should not think that I am not interested in his response: I shall scan Hansard carefully tomorrow morning.

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[Liz Kendall (Leicester West) (Lab)]

I thank all hon. Members who have taken part in this important debate. I congratulate the hon. Member for Southport (John Pugh), hard-working as always, on focusing on the issue.

Several hon. Members talked about the context of the debate and the improvements made over recent years. Several mentioned the research—published, I think, in the British Journal of Cancer—that showed that, over the past 20 or so years, the NHS in England and Wales has achieved the biggest drop in overall cancer deaths among 10 leading countries worldwide. There have also been significant improvements with individual cancers. For example, death rates for breast cancer have fallen by 40% since 1989, virtually closing the gap with other countries such as France. Furthermore, the NHS has done so despite having a smaller budget, which led the British Journal of Cancer to conclude that the NHS had achieved more with proportionately less than in other major developed countries.

It is clear, however, that far more can and must be done to bring cancer outcomes for all cancers and all patients up to the very best standards achieved in other countries. Hon. Members have rightly said that our overall survival rates are still not as good as those in countries such as Canada, Australia, Sweden and Norway and that, although survival rates are good for breast and skin cancer, for example, they are low for lung and pancreatic cancer. I am also particularly concerned about differences in outcomes for people from different minority ethnic groups or from different social and economic backgrounds. As the shadow Minister with responsibility for older people, I am concerned about the worse outcomes for older people in the UK compared with those in other countries, even after we have taken social and economic factors into account—I shall say a bit more about that in a moment.

Hon. Members welcomed the focus in the NHS outcomes framework on one and five-year survival rates but rightly questioned why the three cancers mentioned account for 40% of new cancer diagnoses and asked about the other cancers that could be included. Although survival rates are absolutely vital, other issues need to be addressed to improve the patient experience and the quality of care—in particular, for those who will not survive cancer, at the end of life.

[Mr Edward Leigh in the Chair]

I want to focus my comments on three key areas of care in which we need to improve services: first, early diagnosis and intervention; secondly, tackling treatment variations; and thirdly, ensuring that the patient experience is at the heart of all aspects of cancer care. There is a very important issue about how we prevent cancer from happening in the first place, but I will not focus on that in this debate.

The hon. Member for Basildon and Billericay (Mr Baron) —I pay tribute to the all-party parliamentary group—hit the nail on the head when he said that the survival rates at one year are crucial, and the differences between our survival rates and those in other countries are largest around that first year. We have to ensure either that patients present to their doctors earlier or that we identify them through effective screening. We then have to ensure that GPs properly examine, diagnose and quickly refer patients to appropriate specialist and other services.

International comparisons generally indicate that England has high-quality cancer screening programmes, although there is considerable regional variation in uptake. The key to improving uptake of screening programmes and ensuring that patients present early is to improve public awareness. I am worried about who will be responsible for promoting public awareness of cancer and running cancer awareness campaigns.

In April 2013, local authorities will take over responsibility for public health. The main focus will be on strategic needs assessment for their local population and developing joint strategic health and well-being strategies, but they will also be responsible for commissioning specific public health services, and they will be free to set their own priorities.

[Mr Baron]

The hon. Lady is absolutely right in saying that cancer survival rates have been improving for 30 to 40 years, but we still lag behind the European average, although I accept that we must be careful when comparing statistics. Will she confirm that, although we heard a lot about the Opposition’s concerns about changes to the commissioning structures, we did not hear much about the other key element of the NHS reforms: the importance of focusing on outcomes, particularly in cancer, as a way to drive forward earlier diagnosis? The spotlight should be on the local NHS and areas with poor outcomes, which should introduce initiatives to drive forward earlier diagnosis, including awareness of cancer screening programmes and so on, but we did not hear a lot about that from Opposition Members.

[Liz Kendall]

I thank the hon. Gentleman for his intervention. He was lucky enough not to experience the 16 weeks of the two Public Bill Committees that considered the Health and Social Care Bill, when I regularly raised the key concerns, such as how to improve outcomes for cancer and heart disease and how services, not structures, needed to be reformed to do that. If he has a spare moment and reads the report of those debates, I am sure that he would become aware that I was very concerned about how to improve patients’ lives, their experience and the quality of care, which is always the issue for me. My concern was always about whether the reforms would do that.

I return to the point that I was making about local authorities’ role and the concern that, under the mandated public health services that local authorities will have to commission, public awareness campaigns, including those for cancer, are not included. There is a real worry among public health professionals and those working for and with cancer patients about whether public health awareness campaigns, such as the bowel cancer awareness campaign, which certainly attracted my attention, will continue.

A second issue is how to improve GPs’ skills and their awareness of cancer. Many GPs see cancer patients relatively infrequently, particularly those with rare cancers. Will the Minister explain what national or local action may be taken to ensure that skills and awareness improve?

We want to ensure that, when people are referred by a GP, they have swift access to diagnostic tests. That is about not just good outcomes, but the quality of their experience. Anyone who has had the misfortune of themselves or a family member waiting for cancer diagnostic tests knows that it is a frightening experience and that it should be done as quickly as possible. There were big improvements under the previous Government in speeding up diagnostic tests, but there is evidence that the service is going backwards. Some 78% more patients now wait more than six weeks for diagnostic tests compared with May 2010, and there are even bigger increases in the number waiting for vital tests to diagnose cancer. Some 230% more patients now wait more than six weeks for endoscopic diagnostic tests, and that includes a 242% increase in the number waiting more than six weeks for colonoscopy and a 140% increase in the number waiting more than six weeks for MRI scans. What action could and should be taken to reduce those diagnostic waits, which is vital to improve one-year survival rates?

Turning to the important issue of treatment variation, I want to put on the record the excellent briefing from the King’s Fund, “How to improve cancer survival”, which goes through the issues in detail, with the best clinical evidence and the implications for services on the ground. Treatment factors can be divided into four main groups: surgery, radiotherapy, cancer drugs and the overall co-ordination of care. On surgery, there is a lot of evidence that the outcomes for many types of cancer might be better in centralised, specialist centres, particularly for complex surgery, because their use can lead to better training for surgeons. If they have a higher case load, doctors develop greater expertise and experience. More specialist support is available, such as nursing and intensive care, as well as superior equipment. One concern that we raised when discussing the Health and Social Care Bill and reorganisation was who will lead the strategic configuration that is needed to centralise some services, such as cancer, into specialist centres.

Radiotherapy has a significant although modest overall impact on five-year mortality rates. Obviously, the optimum proportion of patients with cancer who should receive radiotherapy varies by tumour type and stage, but it is thought that overall around 50% of patients with cancer would benefit from radiotherapy. However, in 2005, the radiotherapy access rate in England was 38%. That was one reason why the former Government introduced a new strategy, “Radiotherapy: developing a world class service for England”, in 2007. Can the Minister update me on any progress on that?

I am sure that the Minister will talk about the cancer drugs fund and the Government’s aim of improving access to such drugs. He will know that concern remains that the fund has not removed variations from the system. There have been underspends in some parts of the country, and some regional cancer drug funds approve drugs that others do not. The King’s Fund raises a bigger question in its document. It says that it is more important to improve access to surgery and radiotherapy overall. It is worried that there has been almost too much attention on the cancer drugs fund and not enough on the variations in radiotherapy and surgery.

I am really concerned about older people and the variation in their care. Will the Minister say whether the Government will look into that specifically? Older people are under-treated, and their outcomes for cancer are worse as a result, even when account is taken of the different types of tumour and the presence of other diseases or co-morbidity. Older people are less likely to receive intensive treatment and more likely to be admitted as an emergency.

Crucially, major international studies show that differences in survival rates between the UK and other countries are greater for older people. We are not sure of the reasons for that based on the evidence, but the King’s Fund suggests that there may be three key issues: even later presentation; co-morbidity with older people having two, three or more other long-term chronic conditions, which may lead to cancer then being misdiagnosed or not diagnosed; and age discrimination and the feeling that, because someone is getting older, their health is perhaps not so important. I am pleased that the Minister will implement the ban on age discrimination in public services that the former Labour Government introduced. I am very keen that the Government look more into that issue as part of their work on cancer.

I wish to say something about co-ordination of care, which, as we know, is important for patients and the patient experience. During debates on the Health and Social Care Bill, we asked whether cancer networks would continue in the NHS and, if so, how they would be funded. In May last year, the Secretary of State for Health said that the Government would fund and support cancer networks in 2012 and that, after that, the NHS Commissioning Board would continue to support and strengthen them. Over a year later, however, the future of cancer networks is still unclear.

The NHS Commissioning Board has recently published early proposals for clinical networks, which include the new strategic clinical networks prescribed by the NHS Commissioning Board. The proposals also mention 14 to 15 overarching networks in England that will cover a specific geographical area and review the work of the prescribed strategic clinical networks every six months. I think, however, that people are still quite confused about how that will work, and the Government’s proposals do not refer specifically to the 28 cancer networks. I therefore ask the Minister whether all 28 current cancer networks will become prescribed strategic clinical networks, or will their number be reduced? How will they fit into the umbrella networks?

Funding is crucial. In response to a parliamentary question on 21 May this year, the Minister stated that strategic health authorities will be given £18.5 million to fund cancer networks in 2012-13, just as in the previous two years. Page 6 of the recent document from the Department of Health, “Progress Update on the Design of the NHSCB” states:

“Around £10 million of the costs of supporting Networks and Senates are expected to count against running costs.”

That seems to imply that the £10 million is to run not only cancer networks but all clinical networks and senates and that would be a cut of £8.5 million to the cancer networks. Will the Minister say whether the £10 million referred to in the document about the future functioning of the NHS Commissioning Board covers all networks, or cancer networks alone? That is a real concern for people who work in cancer networks and are already worried about the future.

I will conclude by mentioning the patient experience. Several hon. Members have rightly mentioned the need for the patient’s experience of a service to be placed at the heart of what the NHS is trying to achieve. I agree with the call from Macmillan Cancer Support and Breakthrough Breast Cancer for the NHS cancer patient experience survey to be included as part of the fourth domain of the NHS outcomes framework, which is about ensuring that people have a positive experience of care.

The cancer patient experience survey shows that the NHS does well on issues such as waiting times, pain control and patients who feel that they have been treated with dignity and respect. It does not, however, do as well as it could on issues such as patients receiving written information about their condition, financial help, clinicians who work well in a hospital and the community and whether there is enough nurse support. Those are important matters for patients.