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ARMED FORCES DISCIPLINE BILL [LORDS] [MONEY]
Queen's recommendation having been signified--
Motion made, and Question put forthwith, pursuant to Standing Order No. 52(1)(a),
- That, for the purposes of any Act resulting from the Armed Forces Discipline Bill [Lords], it is expedient to authorise the payment out of money provided by Parliament of--
(a) any expenditure incurred in consequence of the establishment by the Act of summary appeal courts; and
(b) any additional expenditure on the armed forces which is attributable to the Act.--[Mr. McNulty.]
DELEGATED LEGISLATION
Motion made, and Question put forthwith, pursuant to Standing Order No. 118(6) (Standing Committees on Delegated Legislation),
London Government
- That the draft Greater London Authority (Disqualification) Order 2000, which was laid before this House on 3rd February, be approved.--[Mr. McNulty.]
EUROPEAN COMMUNITY DOCUMENTS
Motion made, and Question put forthwith, pursuant to Standing Order No. 119(9) (European Standing Committees),
The 1999 Review of Telecommunications Legislation and Radio Spectrum Policy
- That this House takes note of European Union Documents Nos. 12838/99, the Commission's Fifth Report on the implementation of the telecommunications regulatory package, 12839/99, Commission Communication: Towards a new framework for electronic communications infrastructure and associated services: the 1999 Communications Review, 14320/98, Commission Green Paper on radio spectrum policy in the context of European Community policies such as telecommunications, broadcasting, transport and research and development, and 12840/99, Commission Communication, The next steps in radio spectrum policy--Results of the public consultation on the Green Paper; welcomes these Communications; and supports the Government's proposed response to them.--[Mr. McNulty.]
BUSINESS OF THE HOUSE
- That the Sessional Orders [25th October 1999] relating to Thursday sittings and Meetings of standing committees and the Sessional Order [24th May 1999] relating to sittings in Westminster Hall shall apply to times of sitting on Tuesday 22nd February as if that day were a Thursday.--[Mr. McNulty.]
Primary Care (Cancer)
Motion made, and Question proposed, That this House do now adjourn.--[Mr. McNulty.]
7.22 pm
Mr. David Taylor (North-West Leicestershire): I am grateful for the opportunity to draw to the attention of the Minister and other hon. Members the role of primary care in the treatment of cancer. I shall discuss present practice, current shortfalls and some potential improvements.
Cancer places a heavy burden of disease on the community. One in three people in the United Kingdom will contract cancer in his or her lifetime and one in four will die from it--compared with 5 per cent. of all deaths at the beginning of the last century. The factors driving the increase in cancer-related deaths include both better control of infectious illnesses and ageing of the population, because two thirds of all cancers occur in the over-60s.
The good news is that, as medical techniques and health services continue to improve, age-specific cancer mortality rates will fall. Even now, about a million British people diagnosed in previous years with cancer have effectively been cured of the condition or are living with it. Those numbers will rise, and that brings into sharp focus the role of primary care in the treatment of cancer, which I shall argue needs to be given a higher profile and greater resources.
As noted by Dr. Nick Summerton in his recent book on primary cancer care, the general practitioner's most fundamental role for many patients is being able to act appropriately when they attend with a symptom that concerns them. In a recent review of complaints about general practitioners received by the Medical Defence Union, failure or delay in diagnosis accounted for 28 per cent. of the notifications in 1998. The most frequent clinical condition associated with diagnostic failure or delay was missed malignancy.
Primary care clinicians are often in a very difficult position in relation to diagnosis of cancer, which frequently presents with common symptoms such as non-specific abdominal pain or a persistent cough. Of course, only a tiny number of people displaying such symptoms who are seen by a GP will prove to have cancer.
Dr. Summerton noted an acute dilemma for general practitioners. While on the one hand they are always aware of the importance of avoiding over-referral or over-investigation of their patients, on the other they continually strive not to miss important conditions in patients. That invidious position is complicated by the human trait of patients of delaying initial consultation with their doctor about potentially significant symptoms. Thus, GPs have to be trained and skilled in identifying, within a largely unselected population, which symptomatic patients are more likely to have malignant disease. A different approach to diagnosis may be needed in dealing with community-based patients, who are often less familiar with medical terminology than those who attend clinics.
The Government's initiative of a maximum two-week wait for cancer patients is a most welcome move to relieve patients' anxieties. It is both an opportunity and a challenge for general practitioners. It is an opportunity, in
that family doctors can assume important new and overdue responsibilities for developing higher quality oncology services. Oncological research and development is driven by agencies, organisations and interests that are not always fully aware of the primary care and community dimension.The capped waiting time is a challenge as the average GP sees just two patients a day with symptoms of cancer--fortunately, most do not have it--and might only diagnose lung cancer, the most common form of the disease, just once a year.
I said that a central task for GPs has traditionally been to avoid overreaction to low-risk situations, but we must treat GPs fairly. If, in future, we expect them to refer more low-risk patients to specialists in the hope of detecting a limited number of additional early cancers, the taxpayer must foot the bill. If, conversely, GPs are urged not to overload limited or expensive hospital facilities, we must not blame them too readily for the missed cancers that could be a consequence of more restricted diagnostic strategies.
To prevent hospitals being over-burdened with referrals and to reduce patient anxiety, two areas must be addressed. First, research is needed to find the evidence about which symptom clusters and findings put the patient at higher risk of having cancer and to define those cancer patients who can be safely and conveniently followed up in primary care, thereby relieving the burden on secondary care.
Mr. Andrew Reed (Loughborough): Does my hon. Friend agree that it is not only GPs who are important in that primary care group, but the whole spectrum of those who are involved in such care, particularly nurses in the community, and it is necessary to take a holistic approach and ensure that they are included in the strategies that he has mentioned?
Mr. Taylor: I thank my hon. Friend for that point, and I am coming to the importance of the whole team being involved in the support of cancer patients.
The second area that needs to be addressed is effective, evidence-based education for GPs and nurses, which is a prerequisite to allow them to implement existing knowledge in all practices. Dr. Arthur Hibble, who leads for the Royal College of General Practitioners on cancer, describes the role of primary care in the patient's cancer journey as aiming to highlight risk prevention, including issues such as diet, tobacco and occupation, and to diagnose cancer early, either in screening programmes or by recognition of disease. There must be prompt appropriate referral to recognised centres. Primary care must include continuing care of the person and their families and carers in all areas of their health. There must be recognition of recurrence, and finally palliative and terminal care at home.
Dr. Hibble flags up the issues for primary care cancer services. They must incorporate effective interpersonal communication skills, in order to diagnose and explain better to patient and carers; professional knowledge and information about cancer; high-quality interprofessional communications in every aspect of referral to specialist service and patient management; multi-professional team working; and, most important of all, a service provision of consistently high quality.
I shall take a more detailed look at that last issue because there is an immense variability of service provision in our country. As a Back Bencher, I am proud of the various cancer initiatives that the Government health team have introduced. Indeed, just weeks ago, I congratulated the Under-Secretary, my hon. Friend the Member for Pontefract and Castleford (Yvette Cooper), on the launch of the cancer services collaboratives with their nine pilot national networks, including one part based in north-west Leicestershire, which involves the local primary care group, the Measham medical unit and Glenfield hospital near Leicester.
I know, from talking to Dr. Orest Mulka and Dr. Pawan Randev at the Measham practice and from listening to patient and carer stories, that the way in which cancer sufferers throughout the country are cared for in the community is very variable, with excellent care in one area accompanying the unacceptable in another. The proportion of cancer patients being looked after at home nationwide varies from 13 per cent. to over 50 per cent.
Now, the diagnosis of cancer is, in most cases, suspected or confirmed in primary care. Most of a patient's cancer journey is spent in primary care. Yet, with recent changes in out-of-hours provision by general practitioners, most patients are looked after by doctors other than their own for most of the 24-hour period. That can lead to variable quality care, but need not if the issue of communication is adequately addressed. I shall return to this point shortly.
The primary health care team offers continuity for the patient. The average patient encounters around 25 doctors during hospital care, but usually has one GP and a named nurse in the practice. The all-important patient-doctor relationship is usually well established prior to a diagnosis of cancer.
The family is a vital part of the care team for most patients. The family can care for most patients at home, but doing so needs a high level of appropriate support from GPs, nurses and other members of the primary health care team who are only too willing to do so if they are properly resourced.
Primary care is responsible for the round-the-clock, everyday response to cancer patients' physical and psychological problems. Out-of-hours arrangements are implemented almost universally, but, with appropriate measures, they can be seamless for cancer patients dying at home. Quality improvement in primary care cancer is needed. Service improvements in primary care can, I believe, be achieved via a system of accreditation. Such a system for hospitals is a major outcome of the Calman-Hine report, and it has improved quality of care in the hospital sector.
Primary care has a greater quality variability than the hospitals had, but there has still been no significant move towards a national system of accreditation for primary care. Without such a quality system, patients can feel vulnerable and powerless. They feel that they are not being heard by professionals, and have inadequate information to make decisions on their treatment. They are worried about continuity of care--especially at nights and at weekends, when access to their notes is often difficult. Patients do not always have information about
specific treatments and complications, and in the terminal stages of some cancers, their wish to die at home is not granted.The whole medical profession supports the principles of the Calman-Hine report, whereby diagnosis and treatment of cancer takes place in specialised centres. However, there is at present no specific role for primary care in the clinical management of cancer patients. One should be developed, having at its heart cancer: accredited general practices whose approach is centred on patients, listening to their experiences and respecting their wishes for care at home. It should involve the whole primary health care team--as my hon. Friend the Member for Loughborough (Mr. Reed) pointed out--including nursing staff and others, use patient-held records to improve communication and collaboration, and incorporate a practice-based cancer registry of patient information with appropriate data collection systems. Finally, the approach should have access to appropriate equipment, reference material and support groups for patients and carers.
Two practices in Leicestershire--I have already referred to one--have been performing a pilot year of accreditation for cancer management in primary care. The practices were supported by the health authority up to this year, when the obligation fell to the primary care groups. The PCGs have, however, been unable to support the practices financially. Fourteen out of the 15 practices in the North-West Leicestershire PCG wish to be involved, but the project marks time while it awaits secure funding. Protecting resources for primary care development is thus necessary.
North-West Leicestershire PCG had earmarked a small sum--£120,000--out of a budget of £90 million for all primary care development, but that was deleted as a result of the unexpectedly steep rise in the cost of generic drugs. A slightly larger sum is earmarked for next year, but it is vulnerable to any crisis in the secondary care sector, such as bed pressures or flu outbreaks. A ring-fenced budget for primary care development would address the problem, which is unique neither to cancer care nor to Leicestershire.
Primary care is evolving from a history of isolated small practices. Each primary health care team should not have to reinvent the wheel of high-quality cancer management in the community. There is a need for a national framework that teams can pick off the shelf, with the appropriate financial back-up available. The framework would encompass a system of cancer accreditation, which I have outlined, audit modules to allow quality to be improved and educational modules for all members of the team.
Such a framework would clearly also use the expertise and experience of the Royal College of General Practitioners, the Royal College of Nursing, cancer charities and the national health service. It would respond to groups campaigning on these matters such as BACUP--the British Association of Cancer United Patients--CERT and the NHS confederation. It would look to Macmillan, which has much relevant training experience.
Patients want better-quality cancer treatment, as near to home as possible when that can be provided safely. This fits with current policy on the importance of primary care and it can be delivered, but it needs protected investment in primary care, as well as the current investments in secondary care.
I pose four questions to my hon. Friend the Minister and to the profession. How can patient wishes about place of care be best fulfilled? What proportion of cancer development funding should be earmarked for primary care? How can primary care development budgets be protected from unexpected overspends in other parts of a PCG's budget? Finally, are the Government prepared to offer a firm commitment to pump-prime key aspects of primary care oncological research and development, and to support and resource general primary care oncology? I would appreciate an early response to those key questions.
High-quality, generalisable primary care oncological diagnostic research is difficult. The types of large, prospective and methodologically rigorous cohort studies needed will require significant amounts of time, funding, collaboration and organisation, which are not in any plan of which I am aware. Furthermore, such research needs to be built on a robust foundation involving broad-ranging, systematic reviews combined with qualitative and quantitative re-examinations of patients' paths to diagnosis. Unfortunately, it is proving to be a Herculean effort to convince the major cancer charities and the Department of Health of the enormous practical value of such work and the need to alter their funding strategies to accommodate it.
I am delighted that, two weeks ago, the Department announced £23 million of funding for the Living with Cancer programme, which will enable more cancer patients to be treated at home, and will provide more support for those who are caring for them. Many thousands of cancer patients and their families will benefit from the programme. I hope that it will be extended into other areas, both geographical and professional.
The missing element in high-quality cancer care is a case manager, who would ensure proper co-ordination of care, appropriate support services, including counselling, and the existence of an advocate for the patient in the event of problems. I contend that the primary health care team is well placed to undertake that role under existing commissioning arrangements, but with the new accreditation system that I have outlined.
For too long, the role of primary care in the treatment of cancer patients has been undervalued and under-resourced. Active and aggressive treatments have obtained great investment and have been successful in many ways, but primary care, given certainty of research funds, a flexible education programme and imaginative development, can do much more, especially when allied to the magnificent services offered by Macmillan.
I hope that the Minister will agree that early diagnosis and quality continuing patient care deserve a higher priority in the exciting national cancer care programme on which our Labour Government have embarked. I urge her to persuade our right hon. Friends the Secretary of State and the Chancellor to invest in developing the role of primary care in the treatment of cancer.
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