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Mr. McLeish: The subject of our exercise was to look at the base year that the Government selected--1990-- take it through to the most recent year--1993--and project the annual current rate forward to 2000. I suspect that, in many respects, that was not the most scientific of exercises, but it extrapolated the trends and showed that up to 60 of the district health authorities did not meet the target. The Minister rightly criticises our figures, but can he provide for me either in a letter or now some analysis carried out by the Government to find out whether the DHAs are on target, even though they are using a national target in local areas?
Mr. Horam: I will look into the additional point made by the hon. Gentleman, but it is our firm view that we are on target.
Of course, we would like to be able to prevent breast cancer occurring at all, but so far, despite enormous levels of research both here and abroad, we do not know how to do so. The trial currently under way in the NHS to evaluate the effectiveness of tamoxifen in preventing breast cancer in women at particularly high risk may help. However, we must be cautious. The beneficial effects of tamoxifen must be weighed carefully against its side effects. It may be years before we know whether it is a real option for preventing breast cancer.
Substantial work is also in hand to identify the gene defects which cause breast cancer in a minority of women, but that work will not stop the problem. Even if we reach the point at which we can identify that a woman is likely to develop cancer because of her genetic make-up, we do not know, despite research, what we can do to stop the cancer developing. Even the most radical option-- surgical removal of the breast--does not offer a concrete guarantee, as there is still a remote possibility that the disease could spread before preventive surgery is performed. That is why the Government have put so much research into establishing a national population-based screening programme. Experts agree that early detection is of enormous value in combating breast cancer and improves the chances of effective treatment.
Even recently reported critics of the programme have acknowledged that at present screening remains the best option for women and agreed that the programme should continue. However, screening is only part of the story. All women with breast cancer should have access to good advice, treatment and care, wherever they live. We know that at present there is variety in provision for breast cancer around the country and that some patients seem to have better treatment outcomes than others. The choice of treatment required in individual cases will vary depending on a number of factors, including the stage and site of the cancer and the general health of the woman. Studies of adjuvant therapy indicate that a combination of treatment options--surgery, chemotherapy, adjuvant endocrine therapy--is highly effective, but circumstances differ in individual cases. Clinicians should choose a treatment regime best suited to the individual, after discussion with the patient.
There is increasing evidence that women treated by surgeons and teams with a degree of specialisation in breast cancer have better outcomes. That point has been made in the debate. Concerns about the evidence of variations in cancer treatment options and outcomes led the chief medical officers of England and Wales to ask their expert advisory group on cancer to review how cancer services, including breast cancer, were delivered and to make recommendations for improvement. Following wide consultation, my right hon. Friends the Secretaries of State for Health and for Wales unveiled on 24 April 1995, a new strategic framework for the future development of cancer services.
The report recommends a network of specialised care with cancer services organised at three levels. Primary care is seen as the focus of care, with GPs better informed about the availability of diagnostic and treatment services to allow them to make appropriate referrals and to be informed promptly about the outcomes of tests and of any treatment.
Cancer units will be created in many local hospitals of a sufficient size to support a multi-disciplinary team with the expertise and facilities to treat the more common cancers. A lead clinician will co-ordinate cancer services and develop treatment protocols between primary care, cancer units and cancer centres to ensure a network of care of a high standard. Cancer centres situated in larger hospitals will treat the less common cancers and support cancer units by providing services, including radiotherapy, not available in smaller hospitals.
The NHS has already taken forward a great deal of work, making good progress towards the implementation of this new strategic framework. Key elements in this are, first, regional mapping of current patterns of provision of cancer services, work to designate cancer units and cancer centres, discussion to develop explicit contracts between purchaser and provider for the provision of cancer services and plans for improving the availability and quality of data.
Simultaneously, in order to support work being taken forward regionally, the NHS executive has commissioned work to prepare evidence-based guidance in a rolling programme of work starting with the more common cancers to help purchasers and providers identify cancer units and cancer centres. Recommendations will be made on the characteristics which are necessary if a centre or unit is to be effective. They will cover the specialisation required, compatible with a high quality of service; where appropriate, guidance on the clinical management of cancers; and ways of measuring the quality of care delivered, including measures of outcome. Guidance on breast cancer will be the first product of this programme of work and will be delivered in spring 1996--not too far off.
My hon. Friend the Member for Broxbourne said that we did not want consultants to hang out a notice, as she put it rather graphically, saying, "Specialist Breast Unit", even though the unit had no special expertise. I hope to assure her that the programme that I have just outlined is designed to deal with precisely that point. It should succeed in doing so. I remind the hon. Member for Fife, Central that part of the programme will examine the evolving national picture. That will answer some of his concerns.
Concern has been expressed about research funding. I agree that we will secure reductions in deaths only if our services are built on the basis of sound scientific knowledge. In Britain we have a record of excellence in research in this area. Ours may not be the largest programme in the world, but the work is of a very high quality, and we can be justly proud of it. Moreover, it is a research programme which is well supported by many interests. The medical research charities play a significant role in the national endeavour to combat cancer, based on generous donations from the community. The contribution by drug companies is also very high. Of course, the Government are also a major player, in collaboration with those other bodies. Collaboration in research extends right across the European Union.
The Medical Research Council funds important research on cancer generally, and breast cancer in particular, including work on diet and on breast tumour imaging. It is also a key player in research to evaluate the breast screening programme, which hon. Members have rightly discussed at some length. Total spending on breast cancer research was £14.2 million in 1994-95. Total spending on cancer research as a whole is now approximately £250 million. We must remind ourselves that there are no fewer than 200 forms of cancer, so there is a great deal for the money to cover. In addition, clinical research is supported by NHS research programmes and NHS excess service costs attributed to cancer research. The value of this additional expenditure is significant and will become increasingly apparent.
My hon. Friend the Member for Broxbourne suggested that we might use the United Kingdom Co-ordinating Committee on Cancer Research to channel funding from
the Department and the Medical Research Council. The danger is that we would lose flexibility. Improvements in research do not flow in an even stream. We cannot predict exactly what the volatility will be between one year and the next so some flexibility is essential in the research programme. We cannot meet my hon. Friend on that point.
My hon. Friend was also worried about indemnity for clinical trials, which remains a problem, and asked me to say how far we had gone in the review. We are making satisfactory progress. I hope that we shall be able to report at least some initial findings early in the new year. We are therefore dealing with that matter.
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