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Column 1073Mackinlay, Andrew
Morris, Rt Hon A. (Wy'nshawe)
Pike, Peter L.
Roche, Mrs. Barbara
Tellers for the Noes :
Mr. Bob Cryer and
Mr. Dennis Skinner.
Question accordingly agreed to.
Order for Second Reading read.
Question , That the Bill be now read a Second time, put forthwith pursuant to Standing Order No. 54 (Consolidated Fund Bills), and agreed to.
Bill accordingly read a Second time.
Question , That the Bill be now read the Third time, put and agreed to.
Bill accordingly read the Third time, and passed.
Motion made, and Question proposed, pursuant to Standing Order No. 54 (Consolidated Fund Bills), That this House do now adjourn.-- [Mr. Arbuthnot.]
Mrs. Gwyneth Dunwoody (Crewe and Nantwich) : Some weeks ago I received a letter from one of my constituents who had been diagnosed as suffering from breast cancer. She said that, once the diagnosis was finally established, she had received both the best of treatment and the best of support services from the national health service. However, she wanted to make a very important point. She detailed the length of time that her diagnosis had taken and pointed out that she had had considerable difficulty in getting some sort of treatment at an early stage as a result of problems of diagnosis and referral. My constituent said that it seemed to her that Members of Parliament were concerned about matters that she regarded as not life-threatening, but when it came to something like the death of a woman from cancer--something which is, unfortunately, not altogether unusual--it was difficult to get Members of Parliament to take an interest in the difficulties that women face every day in trying to receive help. I thought that that must be wrong, so I sought the help of the Secretary of State for Health.
I told the Secretary of State the problem. I sent her the letter from my constituent. For reasons of confidentiality, I did not choose to raise the matter on the Floor of the House. I received a reply which is becoming almost standard from the Government. It was the equivalent of, "Don't call me, I'll call you." It said that the treatment of that particular patient was the responsibility of a particular trust and that was all there was to it. I received no explanation of the Government's views. I received simply a bald statement of what had happened in the case of that patient, and the Secretary of State's referral back to the health trust involved. My constituent was extremely distressed by the letter because, as she pointed out to me, her letter was not a complaint about a particular NHS trust. She had undertaken that task. She had dealt with the NHS trust and had received a reply of sorts. She either accepted or did not accept what it said. The point that she made over and over again to the Department of Health and to Members of Parliament was that what was important was early treatment, diagnosis and referral of cancer. She had received neither an adequate response nor any idea of what the Government intended to do about any of those problems.
Column 1075Therefore, I went to the Table Office and tabled a series of questions. I discovered that the Joint Council for Clinical Oncology had drawn up a series of sensible guidelines because it was so worried about the whole question of treatment. I asked
"the Secretary of State for Health (1) how many hospitals comply with the target of radical radiotherapy involving complex treatment planning within two weeks laid down in the guidelines . . . (2) how many hospitals comply with the target of urgent palliative radiotherapy within 48 hours laid down in the guidelines . . . (3) how many hospitals comply with the target of urgent radiotherapy or chemotherapy within 24 hours laid down in the guidelines . . . (4) how many hospitals comply with the target of intensive chemotherapy within one week laid down in the guidelines".
I received from the Under-Secretary of State for Health, the hon. Member for Bolton, West (Mr. Sackville) the reply that
"This information is not held centrally."--[ Official Report , 7 March 1994 ; Vol. 239, c. 83 .]
That is outrageous. What is happening to the Government ? Are they deliberately seeking to fragment the prevention and treatment of cancer by splitting up the market into individual small pieces ? Are they seeking to hide the information that we need about the delays faced by those in need of cancer treatment ? Are they prepared at least to comment on the targets that have been set for treatment waiting times ? Or are they prepared to say, as it appears from the reply that I received, "This is really not a matter for Her Majesty's Government because the information is not held centrally" ?
Mr. Nicholas Winterton (Macclesfield) : Does the hon. Lady agree that, in respect of the health service, the Government should be accountable at the end of the day to the House ? If the Government have delegated responsibility to the National Health Service Management Executive, as they clearly have, surely it would not be too difficult for my hon. Friend the Minister to obtain a reply from the executive in response to the valid and important questions posed by the hon. Lady. If the Management Executive does not provide such information, it fails entirely to do the job for which it was set up, and the House clearly cannot represent the best interests of the people of Britain.
Mrs. Dunwoody : The hon. Gentleman, who was a most distinguished Chairman of the Health Select Committee, not only understands the subject well but is committed to improving health care in the national health service. I am afraid that he sets out exactly what the Government ought to do. The alternative is the type of comment that we saw in the Health Service Journal of 16 September 1993, which read :
"People with cancer are having to wait eight weeks or more for treatment in some cancer centres, a report from the Joint Council for Clinical Oncology reveals. In new guidelines the council suggests urgent radiotherapy or chemotherapy should usually begin within 24 hours of seeing a specialist."
It is worth examining those guidelines carefully, because they highlight exactly what is wrong. The report is headed "Reducing delays in cancer treatment". The joint council deliberately highlighted the problems it saw, because it believed that
"Delay in treating cancer is unacceptable. Its natural history is to spread locally and metastasise distantly. Whilst the reduction in cure rate caused by delay is difficult to quantify, the known biology of cancer and the published differences in cure rate . . . makes it evident that delay adversely affects cure."
That was said by people dealing with the problems of cancer patients every day.
Column 1076In case the Government find it difficult to understand, the council has also laid out what sort of delays can get in the way of starting treatment. It says that sometimes there are delays in recognising symptoms of cancer. It says that, therefore, it is tremendously important that there should be better public education and more rapid referrals to specialist units. It says that there can be delays in progress through primary care to hospital. It says that the efficiency of administrative arrangements, including waiting times for out-patient appointments and investigations, must be reviewed regularly. Continuing medical education to ensure appropriate and timely referrals must be encouraged and, where necessary, improved. It says that delays in hospital before specialist referral to an oncology unit also contribute to the problems.
Already, within the NHS trust which particularly concerns me, we see clear signs that referrals to radiotherapy departments are taking longer and longer. I am convinced that the split into provider services and the purchaser theory, which is so relevant to, and redolent of, incompetence, is having a direct effect on the provision of treatment. Those waiting times are not even chronicled by the Department of Health and they are not available to individual Members of Parliament. Once upon a time, we would simply have tabled questions and asked how long people normally had to wait before they got an appointment. Such information is now hidden. We are told that it is a matter for the individual trust.
In 1992, the Royal College of Radiologists received a number of reports about delays in starting treatment that had been advised at the initial oncology consultation. Its faculty of clinical oncology carried out a survey of oncology centres in the United Kingdom and received 29 replies, in which 14 centres reported waiting times for radiotherapy of four weeks or longer. In several of those, the delay was of seven or eight weeks. Those delays were after a clinical oncologist had seen the patient and advised radiotherapy, so it was not that people did not know what treatment was required--the patient had been seen and referred by a specialist.
The report states :
"Whilst there are recognised emergencies in cancer therapy" it mentions spinal cord compression--
"the majority of cancer patients do not need to begin their definitive treatment within hours. The clinical situation, including severity of symptoms and the anxiety of the patient, should properly determine the arrangements made. In some patients a fast track' to treatment will be needed with waiting times shorter than the targets"
which the joint council set out. I shall place those targets on the record because I want some publicity on the matter. I want some action.
The joint council recommends waiting time targets from the date of the first consultation to the start of radiotherapy or chemotherapy. For urgent radiotherapy or chemotherapy, good practice is within 24 hours, and the maximum acceptable is 48 hours. For palliative radiotherapy, according to the severity of the symptoms, good practice is defined as 48 hours, and the maximum acceptable period is two weeks. For radical radiotherapy involving complex treatment planning, good practice is defined as two weeks, and the maximum acceptable period is four weeks. For intensive chemotherapy, good practice is defined as one week, and the maximum acceptable waiting time is three weeks. Those targets arose because the joint council had been told that people were waiting anything up to eight weeks.
Column 1077I began to inquire into not only obvious cancer figures but cancers generally. Of course one is concerned about cancers that particularly affect females. The numbers of registered deaths from breast cancer in the UK were : in 1990, 114 men and 15,179 women ; in 1991, 90 men and 15,403 women ; in 1992, 98 men and 15,221 women. The figures on deaths from other cancers show that the changes have not been remarkable. Despite changes in treatment and advances in medical care, the number of people dying has not altered a great deal. Even in my region, where there are considerable problems with industrial and lung cancers, one only has to consider the figures on prostate cancer to see what is happening to men.
The information given in a written answer in Hansard , at column 43 on 7 February 1994 shows that in 1988, 7,458 men died of cancer of the prostate and in 1992, 8,735 men died of that disease. In my region of Mersey, the number of deaths from cancer of the trachea, bronchus and lung in 1992 was 1,198 for men and 700 for women. In what other situation could one imagine a House of Commons treating those consistent figures as a matter of little concern ? What other disease or set of circumstances that killed that number of the population would be treated with that sort of superficial response ? It would be difficult to find any other set of circumstances where the House of Commons would accept deaths in those numbers without taking urgent and immediate action.
It is clear that problems arise not only with breast cancer and breast cancer screening. A variety of screening methods can pick up cases of prostatic cancer much earlier. Does the Department intend to take any steps to develop a screening programme ? There should be more fast tracking of patients with suspected cancers. The waiting list initiative which, whatever the Minister says, has distorted clinical priorities, could well interfere with the fast access that patients should have to screening facilities. There is no reason why general practitioners should not have much better access to screening facilities, such as ultrasound and CT scans. As far one can see, however, none of that is happening.
The House faces a Government who have adopted an accepting attitude. They seem to say, "Here is a major disease ; we have done a certain amount, we have cervical screening and a certain amount of publicity. Of course, it is true that we do not spend anything like the amount on cancer education that we spend on glossy reports for NHS trusts or individual publicity campaigns for the Department of Health, but that should not matter to us because, after all, the people of Britain will not be particularly put out if more and more of them are faced with this problem in the coming years and nothing is done to assist them."
We should be concerned, and not just that my constituent has to write to me asking, "Why cannot I get a Minister to take seriously what I am saying ?" We should ask ourselves why other constituents who have not written to hon. Members, but who are fighting fear and illness and, in many cases, major problems caused by poverty and illness, have not been given the voice they need on the Floor of the House. The Department of Health has not shown anything like the vigour and the campaigning in the treatment of cancer that has been shown in highlighting other diseases.
Column 1078Why does the Secretary of State for Health, who appears to refuse absolutely to push hard for the banning of tobacco products, not do something to monitor the rate of response of doctors to the needs of those who are suffering from carcinoma ? At what point will we receive accurate information ? We do not want the answer, "Write individually to each health care trust and if you are lucky you can put all the bits together. If you go to the Library, someone else might do it for you." We want accurate information on how long people have to wait before they are referred for their first appointment, what sort of treatment they receive and how long they have to wait for it after their first appointment with a consultant and what sort of general support services are available.
I was impressed when I telephoned the service of the British Association of Cancer United Patients--a service which is run mainly by the nurses of St. Bartholomew's hospital to help people who may have been diagnosed, or think they may have been diagnosed, as suffering from cancers. The response was helpful, civilised and informative. It gave exactly the type of support that one would need if one was very frightened.
The word "cancer" terrifies people, especially women. They are terrified if they think that they might have something that needs treatment. Many of them are still not confident enough to come forward at an early stage because they are terrified. If an unnecessary barrier is put in their way, such as the need to wait for an appointment or the failure of the system to refer them to a specialist early enough, they will give up or, in some cases, decide that they ought to try to obtain some other treatment.
If one were a private patient, one would not have to wait for a suitable appointment in a radiotherapy department or with a consultant oncologist. The response would be rapid. Indeed, one might be offered a series of appointments. What does one do if one cannot, or will not, go to a private doctor ? What does one do if one lacks the money or the back-up to go outside the national health service and demand some immediate care pattern ? One worries oneself into a state of collapse before there is any sign of suitable treatment, whatever it is and whenever it happens.
I believe that the Government are determined to wreck preventive health altogether by the way in which they have split the national health service, so one should not be astonished by their response on that subject. However, some people demand that we force the Department to give us some answers-- instead of allowing it to reply to five or six questions in the House, tabled correctly, with a reply about whether the information is "available". It does not say, "We cannot collect it." It does not say that it is too expensive. It does not even say, "We are terribly sorry ; we used to do that ; now we do not." It simply says :
"This information is not held centrally."--[ Official Report , 7 March 1994 ; Vol. 23, c. 83 .]
The lack of information has one immediate effect. It means that no one realises the extent of the emergency, no one puts pressure on the Ministers and no one does anything other than treat the matter individually at every level.
Before I give the Minister the chance to read his usual anodyne series of unrelated statistics, I shall read another letter to the House, which sums up some of the difficulties. It is about a disease which, oddly enough, is not capable of responding to early treatment. It was sent to the Speaker and I have her permission to quote from it because it is of importance to the debate.
Column 1079The gentleman who wrote the letter asked the Speaker to send his letter on to Members of Parliament, and especially the women Members of Parliament. He says :
"Right Honourable and Honourable Ladies,
I approach you in this way respectfully but unashamedly for the manner of the approach.
I wish to bring to your attention a situation that potentially affects all ladies . . .
At 4.45am just before dawn on Wednesday 22nd September 1993 my gentle, caring wife became a little known statistic.
She was one of ten that day, one of nearly 4000 women in the year, to die from ovarian cancer.
She died after a five month illness.
This cancer is lethal and this year more than twice as many women will die from it than cervical cancer.
Over 75 per cent. of these women will have gone to their doctors when the disease has spread outside the ovary--it is then already too late.
More than 72 per cent. will die within 5 years compared with 38 per cent. and 42 per cent. with cancer of the breast and cervix respectively.
If detected in its early stages, ovarian cancer, limited to the ovary itself, can be treated by surgery and over 90 per cent." thus treated
"will survive 5 years.
For those of you who think 5 years is a short time then think of my wife and I who only had 5 months to say the things we needed to say and say goodbye with as much dignity as we could.
Incidences of this horrendous disease is limited of course to women . . .
If the deaths had . . . been due to say, influenza, with its 134 deaths in a month of this years outbreak then there would be an outcry against the Health Service and dark tales of epidemics and shortage of vaccines.
It is almost inconceivable that there is not a national outcry against this cancer, sometimes called, even by the normally stoical medical profession, The Silent Killer.'
The Silent Killer is not detectable in early stages with present day medical techniques . . . It is undetectable until it is too late . . .
I would be made a leper of society if I were to go out into the outside world today and denigrated women as second class citizens. Yet this is what this disease does. Deaths"
"this particular branch of . . . cancer go unreported, unnoticed and it seems only the immediate families care how the loved one became a victim."
He goes on to say that there is one chance, and one research unit. There is no clear sign that there will be sufficient funding even to start the research work at the Royal London hospital, which could make it possible to save many more women. He finishes :
"I am not appealing on behalf of any charity. I did this simply for ladies everywhere and for the memory of my wife. I know I may have been unethical in my approach ; respectfully I apologise for that but not for the content of the letter . . . read this and" I will know that you care.
We need a series of targets ; we need action from the Department of Health ; we need to take the work that is being done and to say how many departments throughout the United Kingdom do their job properly. We should not leave it to individual Members or individual doctors. We should act on behalf of the people who need our support. No other group of people would be allowed to suffer as women are being allowed to suffer and it is an added disgrace that a female Secretary of State for Health has done nothing --nothing--to change the situation.
Mr. Ian McCartney (Makerfield) : I congratulate my hon. Friend the Member for Crewe and Nantwich (Mrs. Dunwoody), not only on being lucky in the draw, but on the way in which she decided to present to the House the issue of early treatment of cancer. Each year, 16,000
Column 1080women die of breast cancer. In this country each and every year, there are more than 110,000 cancer-related deaths because of tobacco consumption. However, I want to debate not tobacco consumption but the three areas of cancer and prevention strategies. My hon. Friend has covered some of it eloquently. There are other areas which she has highlighted.
It is necessary for the Government to give clear and precise answers about their strategic approach in relation to the early diagnosis and treatment of cancer. Only improved diagnostic skills, with improvements in screening, will determine whether the outcome for the sufferer is a period of progress and health or one waiting for a slow, lingering death.
The profile of cancer prevention has never been higher because of the debate in relation to the banning of advertisements of tobacco products. My hon. Friend the Member for Bristol, South (Ms Primarolo) has assiduously asked the Minister questions about the
cost-effectiveness of screening and early detection.
The Minister would see an immediate return in one area without one extra penny having to be spent. Professor Smee's report on the banning of tobacco advertising shows that by that measure alone, 5, 000 lives a year would be saved. The lives of 5,000 of our fellow citizens would be saved without an extra penny being spent on the national health service. Some £95 million of immoral earnings goes to the Treasury through the tax yield from children's purchases of cigarettes ; yet only £5 million of that--5 per cent.--is reinvested in prevention programmes. That is an obscene set of priorities for a Health Minister.
I should like the Minister to turn his mind to three areas. I will give only a snapshot of the problems raised by my hon. Friend the Member for Crewe and Nantwich to illustrate the way in which the Government fund, manage, resource and plan the national health service. I shall refer to prostate cancer, bowel cancer and primary liver cancer.
The incidence of prostate cancer has risen by 19 per cent. in five years, from 9,127 a year to 10,837. Death rates are up 17 per cent. in five years, from 7,458 to 8,735. In the past five years, 40,722 men have died from prostate cancer. It is the most common cancer affecting men over 60 in the United Kingdom. It is a silent killer ; post mortem investigations prove that 10 to 30 per cent. of men between 50 and 60 and 60 per cent. of those between 70 and 80 have silent prostate cancers--undetected cancers--at the time of death. Using those figures, at least 20 male Members of Parliament currently have an undetected, silent prostate cancer. Yet with screening methods, 15 to 18 of us would be identified early enough to survive. The survival rates are good if the cancer is detected early. Some 43 per cent. of those whose cancer is detected early are alive five years after diagnosis. In 1990, the British Medical Association's "Family Health Encyclopedia" said of the outcome of this very dangerous cancer :
"When the growth is discovered at an early stage, the outlook is very good. However, if the cancer has spread outside the prostate gland and does not respond to hormone treatment, the prognosis is poor."
Despite that, the Government remain stubbornly opposed to the introduction of a screening programme.
My hon. Friend the Member for Bristol, South (Ms Primarolo) recently asked the Under-Secretary of State for health what was his policy for the screening of this cancer. He replied :
Column 1081"The key to any screening programme must be to secure a demonstrable improvement in health by increasing length of life and enhancing quality of life. There is, as yet, no evidence to suggest that this would be achieved in relation to prostate cancer. The Department of Health is pursuing research in screening through its own centrally commissioned programme and through the national health service research and development programme. A copy of the Chief Medical Officer's speech to a recent British medical Journal' conference setting out current policy implementation issues for screening in the NHS will be placed in the Library."--[ Official Report , 3 February 1994 ; Vol. 236, c. 855 .]
In 1992, the disease claimed 9,396 mens' lives ; that is four times the number of deaths from cervical cancer. There are rightly screening programmes in place for cervical cancer, yet the Government will still not introduce screening devices for men in relation to a killer disease. As I have said, the figures are alarming. Yet the prostate gland is an accessible piece of the anatomy for clinicians to reach. New scanning techniques, such as ultrasound, can detect prostate cancer. There are a number of proven treatments, such as radiology, chemotherapy, hormone therapy and, if necessary, surgery. With the use of those proven treatments, survival rates are good. It was left to Doctor Thomas Stuttaford, writing in The Times on 6 March 1992, to put the matter into perspective. He spoke for many colleagues in the medical profession in advocating the institution of a screening programme. He said :
"If the tumour is localised, early surgery gives a 65 per cent. chance of surviving for ten years. As well as saving lives, a screening programme would reduce the number of men condemned to suffer lingering ill-health, and pain, for years."
However, among the Department of Health advisers and among the medical establishment, there is a group of people who discriminate ideologically against men in relation to prostate cancer. Many say that the cancer is part of the aging process and that it is not, therefore, cost-effective to screen men. They say that we should simply leave growing percentages of men, as they age, to be susceptible to the disease. Intellectually, that is an unacceptable and unsustainable argument.
If Department of Health officials are saying that they will intervene only at the point at which the individual concerned has a cancer and is unable to maintain his fitness, they are treating only to die and not to live. If that is not the Department's position on men and prostate cancer, the only option is to treat to live. To treat to live, there must be the option of screening, because without screening there is no early detection. Without early detection, it is difficult to sustain life after the operation, but with early detection, as Doctor Stuttaford has shown, there is a 65 per cent. chance of life after 10 years.
The Department and those in the medical establishment who advise the Department must come clean on the issue. Why are they discriminating against such a large proportion of the male population ? Why should men simply have to accept that in the aging process, between 55 and 70, a growing proportion of us will have prostate cancer ? As there is no screening, we shall have to accept that a growing proportion of us will die even if we have expensive and intensive treatment. That is nonsense in medical terms and in moral terms, but it is what the Government offer middle-aged men. The argument for screening is overwhelming. Let us consider the evidence in the United States and in Germany,
Column 1082where all men over the age of 45 are advised to undergo an annual screening test--a prostate-specific antigen or PSA blood test. If the Government are in the business of preventive medicine, it is inconceivable that they can hold out much longer in such discrimination against so many men. If we accept the concept and principle of screening to prevent cervical cancer among women, how can we refuse to accept the concept of prostate cancer screening for men when the death rate from prostate cancer among men is four times as high as the death rate from the deadly disease of cervical cancer among women ?
Some 22,000 of our fellow citizens die each year of cancer of the colon and rectum. Survival rates are poor even when it is detected, at 30 per cent. after five years. Yet in the specific area of colorectal cancer, which causes 17,500 deaths a year, early detection increases survival rates dramatically. With detection through early screening and the work done by consultants concerned, 80 per cent. of people survive.
The two cardinal symptoms of the disease are a change in bowel habits and rectal bleeding. As my hon. Friend the Member for Crewe and Nantwich said, because of the lack of coherence, the failure to identify the disease through screening, the lack of patient involvement in preventive health care, and the lack of significant effort being made to give general practitioners and practice nurses better training and information, a growing number of men and women are having those cancers identified too late. If treatment took place, their life expectancy would improve dramatically.
We therefore need to take a number of steps. We must improve general health education, with information for patients and patients groups and work done at GP level. We must improve education and training for doctors and nurses, particularly general practitioners and practice nurses. We need a technique to improve screening methods.
Screening does not necessarily mean blood tests, urine tests and samples on every occasion. It means introducing into the NHS a preventive strategy whereby, on a regular basis at community and primary health care level, people susceptible to those diseases are seen regularly by GPs and practice nurses, who discuss with them whether the pattern of their bowel habits has changed or there is rectal bleeding. That general approach would significantly improve the identification of the disease and thus the survival rate once treatment has been implemented.
In a written question on 27 May 1993, my hon. Friend the Member for Bristol, South asked the Secretary of State for Health :
"what plans she has to publish guidance to doctors in relation to screening for occult blood."
That important test can determine at an early stage whether someone is likely to be suffering from the consequences of bowel cancer. Yet the Under -Secretary replied :
"We have no plans to issue guidance at this time."--[ Official Report , 27 May 1993 ; Vol. 225, c. 668.]
So the Government have no plans to notify or explain to GPs that that screening method is one of the most effective ways to identify the disease at an early stage.
Where is the Government's strategy for prevention ? Where is the Minister's concern and interest ? He is not even prepared to send a letter to tell GPs that the introduction of an occult blood test would assist greatly in identifying cancer in so many of their patients. He should