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Mr. Congdon: I have followed the hon. Gentleman's argument quite carefully. Has his research identified any correlation between the take-up of screening and mortality rates in a particular area? He cited the figure for South-West Surrey, but North-West Surrey has a very high mortality figure of 122. Has his research identified any such correlation?
Mr. McLeish: No, but that is a fair point. We conducted a distribution analysis, which was a fairly cold and clinical look at statistics sourced from the Department of Health and processed through the House of Commons Library. In a sense, it was a factual account of a snapshot for 1993.
I now turn to the Government's target as stated in "The Health of the Nation" White Paper, which relates to those who are eligible for screening. Our research examined mortality rates in each district health authority, measured any changes between 1990 and 1993 and projected those changes towards 2000. It is quite significant that, according to the current rate of change, more than 60 per cent. of district health authorities would not meet the target. It is not a case of whether our figure is right or wrong; the magnitude of our findings--60 per cent. of health authorities--is important. We must debate whether the Government are on target to meet their objectives at regional and local level. I hope that the Minister will respond to that specific point later in the debate.
The Government point out in "The Health of the Nation" that there do not appear to be significant variations in the English and Welsh averages. Our research contradicts that finding, although the Government have access to different technology and to technicians and scientists who provide other information. We believe that "The Health of the Nation" document is flawed to the extent that it
concentrates mainly on national targets and whether we are moving towards them. The Government should look at district health authority level, and perhaps at local level, to see whether real progress is being made. Under its remit, the Select Committee was to consider ways in which the quality and availability of breast cancer services in the United Kingdom could be improved, which suggests that there may not be equal service provision throughout the length and breadth of the nation.
On regional or local health service inequality, Conservative Members stress, quite correctly, that many factors--quality of life, housing and genetics--influence health. Health service teams, whether Conservative or Labour, cannot control such factors. However, there must be general areas within the health service where we can intervene more effectively--especially in relation to breast cancer. Deaths can be prevented and programmes and service distribution can be improved.
There are inequalities in health service provision throughout the nation and there are factors that we cannot change easily. However, we can make some obvious changes and it is the responsibility of Government to look more closely at what is occurring in health and to intervene more positively. That is a key issue to consider when discussing variations in health provision and whether the health service could be more interventionist and lever change much more effectively.
The Select Committee produced an excellent report; it heard a wide range of evidence and pinpointed the changes that should be made. The hon. Member for Broxbourne has already outlined some of those changes and I expect that she is hoping that the Government will respond to them positively. The Committee recommended that the upper age limit be extended to 69 for the call and recall screening programmes. Evidence to the Select Committee suggested that that would prove very worth while. The national screening programme has outlined the cash implications of the recommendation and we are not talking about substantial sums of money. However, we are talking about possibly fewer women dying and more women receiving early diagnosis and enjoying an improved quality of life.
That is a very powerful reason why we should look closely at how a small amount of money may be used to improve the length and quality of life and spare families the agony of premature death. As the hon. Lady said, the Government have responded positively and they are taking forward several pilot projects.
The Select Committee also raised the key issue of intervals between screening. Some people were shocked by the detailed figures that showed the number of cancers that grew in three years. The national health screening programme was slightly dismayed by those figures, but it is understandable in a new programme. The three-year interval was based on experience and scientific evidence, and it must now be examined more closely.
The Government claim that they need hard evidence to support any change and the Select Committee has said that there is no point spending money until that evidence is forthcoming. I hope that the Government will demonstrate some urgency and enthusiasm in pursuing that evidence, as it comes down to saving lives and improving the quality of life of many women.
Another key issue is the question of future treatment within the three-tier structure. Unlike some of the other suggestions that are more about effective clinical
management of the service, this area will require resources. The hon. Lady put it in a nutshell when she said that we do not want to develop national standards that encourage every hospital in the country to establish breast cancer units that, despite appearances, would be unable to do the job because of the quality of staff. The Minister should consider allocating resources in that area: the idea of a properly resourced primary health care service, breast cancer units and specialist centres makes sense to anyone who is seriously interested in tackling the problem.
Reference has been made to the double view or double shot. The information suggests that if two views of each breast were taken at every screening--not just the first, which the Government are quite happy to implement-- a potential condition could be assessed much more effectively. I sincerely hope that the Government will consider that issue, along with research and development, training and quality assurance, which I shall mention briefly in a moment.
The Select Committee also made an important recommendation with regard to the Cancer Relief Macmillan Fund, which is an excellent organisation that performs a great deal of work throughout the country. Labour Members may be a little suspicious and sceptical of the patients charter, but it does recommend standards of care. If a diagnosis is complete and if life can be extended, quality of life and quality of care are inextricably linked. The Department of Health dismissed the issue by claiming that some care criteria appear in the patients charter and what is not there is not necessary anyway. I hope that the Minister will not adopt a similar attitude, as it does not address the seriousness with which the Cancer Relief Macmillan Fund has pursued the charter. I urge the Government to rethink the situation.
I am worried that I have been a little over-generous in my support of the Select Committee report. I may be slightly more critical of it than the hon. Lady, but I am sure that she will understand why I must do that. There have been a plethora of reports on breast cancer in the past few years, and the Chairman of the Select Committee has now outlined in detail the Committee's concerns. Obviously the nation is concerned. There is clearly a problem, at least a statistical problem. We have seen the Calman report, research and development has been given priority in other reports and the Secretary of State has spoken of a policy framework for the commissioning of cancer services. We have had a number of debates and discussed a range of issues. The crucial question for those with cancer, however, is what the agenda for action will be.
Given the Government's response, the current slight degree of scepticism is understandable. When the Secretary of State for Health outlined the policy framework for the commissioning of cancer services last April, it was accompanied by an NHS executive memo. Although the Government were vague about resources and timetables in their policy statement, the NHS executive was not. Paragraph 6 of its document is worth reading. A Select Committee has produced an excellent report and the House is united in its wish to tackle an obvious problem, but the NHS executive states, in a rather cruel and clinical way:
There is nothing too specific about the different recommendations. The NHS executive simply makes the blanket statement that implementation will take some years. It continues:
We accept the latter part of that. Better delivery of services is possible in any organisation if changes are made to its resources and other arrangements. Like the hon. Member for Broxbourne, however, we feel that there is no point in having a Rolls-Royce that is being serviced in the same way as--I shall not name the car of which I am thinking in case I get into trouble with my constituents, but I am thinking of a car of lower quality than a Rolls-Royce. We can see all the problems: they have been analysed. I must ask the Minister, however, whether the Government are really committed to improving the service so that it meets the standards demanded by us and the Select Committee.
Although it is not just a question of resources, they will be needed to implement many of the recommendations that have been made--the recommendation for a three-tier structure, for instance, and the recommendations relating to quality. I hope that the Minister will mention that.
Let me raise two or three practical points. The wider brief to consider the future of the service in the next millennium involves immediate and fundamental issues relating to the national screening programme. First, there is the quality assurance programme. I could not agree more with the hon. Member for Broxbourne: that programme is vital. It is this part of the service that makes it different from any other service in Europe. The quality is there, and the service is being delivered; but fundamental concerns surround the continuation of that quality. The fragmentation of the NHS has brought more confusion to the system. The hon. Lady referred to purchasing and providing. We must be cautious and sensitive in the new, artificial market, because the quality of the screening service could be affected.
I should also like to know who will be responsible for quality assurance following the changes that will be introduced in April 1996. The proposal for a regional organisation to oversee the selection of the lead purchaser looks fine on paper, but it prompts many questions about the consistency and cohesion of the whole quality assurance programme. Those involved in the national screening programme are anxious on that score. We must ensure that we do not end up with an arrangement whereby district health authorities and others are purchasing in one environment while there is confusion and a reduction in quality in the quality assurance process.
Then there is the question of ring fencing. Funding for breast cancer at district health authority level is now part of general funding, which means that, if a district health authority gives the service a lower priority than other services, the whole process could suffer. I do not believe that "The Health of the Nation" targets and a national strategy can be left to local organisations; they should not be allowed to dictate priorities.
I agree with the hon. Lady that we should be concerned with mandatory standards. We shall be setting the minimum standards, but they are important. Enterprise and innovation are fine, but let us not use them as a smokescreen to disguise the fact that a lack of central direction and
standards of the highest order could result in problems within health authorities. I urge the Minister to consider ring fencing: that, I believe, is the only way in which we can ensure that priorities and minimum standards are the same throughout the service, and that we implement some of the Select Committee's recommendations.
Neither the country nor the House is giving enough thought to the demography of aging. If we decide to extend the screening programme to those aged up to 69-- and, indeed, if we continue to provide the same service for those aged between 50 and 64--we shall find that an increasing number of people fall into those groups. There is currently no hint of extra resources to cater for the extra demand. Every NHS executive circular, and every utterance from the Government, suggests that most of the recommendations are accepted, but there is no flexibility in relation to cash. We are told that it must be found from available resources.
That might be possible in some areas, but it is clear that, as we enter the new millennium, demography will play a much greater role throughout the health service. The Government must recognise that if screening is extended to those aged up to 69, if the intervals between screenings are reduced and if double views at every shot are to be introduced, there are bound to be resource implications.
Let me end by reiterating my concerns. I do not want the Government to reject the idea of a national strategy to tackle breast cancer. The reforms in every other part of the NHS have devolved responsibility down the line, but this is a national issue that requires national standards and firm guidance from the centre. I should like to think that the Government will not merely pay lip service to the recommendations of expert bodies and Committees of the House.
"The changes in the organisation and provision of cancer services recommended in the report will take several years to implement."
"Those planning cancer services on the basis of the recommendations should do so within available resources, taking account of the assessed needs of the local population and having regard to other health and health service priorities. A great deal can, of course, be achieved through better organisation and better use of existing resources."
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