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21 Jun 2005 : Column 227WH—continued
Abdominal Aortic Aneurysm Screening
1.30 pm
Dr. Howard Stoate (Dartford) (Lab): Thank you, Mr. Hood, for giving me the opportunity to raise such an important subject in this Chamber.
Those hon. Members who sat in the last Parliament will remember that, as chairman of the all-party men's health group, I hosted two events dealing with screening older men for abdominal aortic aneurysms, also known as AAAs. At our first meeting, organised for the group by the Men's Health Forum, we were briefed by a vascular surgeon who has been running a highly successful screening programme in Gloucestershire for nearly 15 years. We were also briefed by representatives of a company that provides scanning services, and by a survivor of a ruptured AAA.
At the second of those meetings, in March, men of both Houses could have a scan for an AAA, to find out for themselves how quick and simple the test is. Those at most risk of an aneurysm are older men, especially those who smoke, and those with high blood pressure or who have conditions such as angina. AAAs are rare in women and younger men.
An AAA is a bubble-type swelling in the wall of the body's main blood vessel as it passes through the abdomen. Burst AAAs kill about 6,000 men a year in the UK, mostly men aged 65 or over. AAAs are usually symptomless until they burst. In most cases, people die without knowing what happened. In a few cases, people can be lucky enough to wake up some time later in an intensive care bed.
AAAs are about four times as common in men as in women, so it is not thought cost-effective to screen women for the condition. An AAA will generally cause no pain or discomfort, and those that are picked up are usually found by happenstance in the course of treatment for other conditions—unless you happen to live in Gloucestershire.
The test for an aortic aneurysm is a simple ultrasound scan, exactly the same as is used to examine pregnant women. It is also quick; 10 people an hour can be scanned by a single professional with a portable scanner. If an aneurysm is detected before it bursts, the operation to repair the aorta has a 94 per cent. success rate. If it bursts, only 20 per cent. survive. The few who survive the major emergency operation that follows a burst aneurysm will spend a long period in a hospital intensive care unit.
The national screening committee has been looking at the case for introducing screening for AAAs. It has been considering the issue for a considerable time, and last autumn it created a new working group on the matter. I am told that it could be some time before it makes a recommendation, but thousands of men throughout the country may not have that much time.
On 15 May, Bob Carson, a youthful 63-year-old, died of an AAA. Bob was a stalwart and utterly indefatigable member of Dartford Labour party, who had delivered hundreds of thousands of leaflets for the party over the years, in all weathers and all conditions. Although others might shrink at having to deliver 2,000 leaflets on an icy January evening with snow in the air, Bob approached it with characteristic gusto and enthusiasm,
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and invariably came back for more when he was done. Indeed, he would be disappointed if there was nothing left for him to do and would ask why we had not had the foresight to print more.
Individuals such as Bob Carson, who work tirelessly and without complaint year in, year out for their local parties, are the lifeblood of politics in this country. Without their efforts, political parties would simply cease to exist and the political process would grind to a halt. Ironically, Bob knew all about AAAs; he knew about my work on the issue with the all-party men's health group, as he had delivered leaflets referring to my work on the subject. However, he would not have known what killed him. Probably the only sign that anything was wrong would have been what felt like a backache and possibly dizziness in the moments before he lost consciousness.
In most cases, the few men who survive a burst aneurysm have never heard of an abdominal aortic aneurysm. They have probably heard of testicular cancer, and may have read some of the press coverage about the test for prostate cancer, but it is unlikely that they will have come across anything in the media referring to AAAs. However, although testicular cancer kills about 100 men a year, AAAs kill about 6,000 a year. Indeed, some argue that the number is much higher, because many deaths caused by burst AAAs are recorded as the result of heart attacks or other conditions. Moreover, although the prostate-specific antigen, or PSA, test for prostate cancer is widely considered to be unreliable—studies show that it produces false positive and false negative results—the 14 years of screening in Gloucestershire, as reported in the British Medical Journal and The Lancet, has shown that screening for AAAs not only works but is extremely cost-effective. Testicular and prostate cancers are terrible conditions that together kill many thousands, but when compared to the scale of the problem and the effectiveness of the test, I am at a loss to explain the low profile of abdominal aortic aneurysms in the media, and even among health professionals.
Two projects in this country show that a national screening programme for AAAs would work. I have already mentioned Gloucestershire, where a screening programme has been running since 1990. The second project is the multicentre aneurysm screening study—MASS. Reported in The Lancet, it studied nearly 68,000 men aged 65 to 74 years. MASS gives the only internationally accepted scientific information on both the benefit and the cost of screening for AAA. The study showed a reduction in AAA deaths of 53 per cent. in those who attended screening. The figures also highlighted the difference between elective surgery, which is an operation to repair an aneurysm before it bursts, and emergency surgery, after the aneurysm has burst. A month after elective surgery, 6 per cent. of patients had died; a month after emergency surgery, 37 per cent. had died. Most whose aneurysms burst do not even make it as far as surgery.
The team behind the study concluded that there was clear evidence of a benefit from screening for abdominal aortic aneurysm. The MASS team has estimated that screening should save 2,500 lives a year. They have also considered the cost-effectiveness of screening and have calculated that the cost per life year saved would be
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£8,000 by year 10 after screening and under £1,000 by year 30. In comparison, the NHS acceptable figure for cost-effectiveness is given at £36,000 per life year saved.
The team at the Gloucestershire Royal hospital has been running the screening programme since 1990 and it, too, is convinced of the merits of screening. Each year, they work with 85 GP practices and screen more than 3,000 men as they turn 65. A nurse co-ordinates a team of sonographers—the professionals who carry out the ultrasound scans—who run three or four sessions at practices each week. The process is quick, and they can check 10 men an hour. After the purchase of a computer and portable ultrasound machine, running costs are only £43,000 a year.
Jonathan Earnshaw, a vascular consultant in Gloucester, told the all-party group on men's health that 95 per cent. of men screened would be clear for life—they would not need to be checked again. A single screening test is sufficient to clear those men for life. Those with a slightly enlarged aorta are recalled annually. In more serious cases, they see a consultant every six months. About one in 100 will have an aneurysm that needs an operation to repair it.
The Gloucestershire team reported in the British Medical Journal that our family doctor system puts us in an ideal position to start screening nationally. Such a programme, they say, could save several thousand lives at a reasonable cost. Their figures suggest that a UK-wide programme could be operated for about £6 million a year.
The scanning session that the Men's Health Forum and the diagnosis company InHealth organised for the all-party group on men's health showed hon. Members how simple the ultrasound scan is. I am pleased to say that none of those who attended for screening showed enlarged aortas, although with reports that one in 10 men over 65 could have some degree of enlargement, we expected to send at least one or two hon. Members to visit their GP.
The Gloucestershire screening programme works within the NHS. In Dorset, the InHealth company has recently started to provide a scanning service for the strategic health authority. Although not yet a full screening programme, it checks people for vascular problems. It uses a mobile unit to visit five locations a day, taking scanners to places that are convenient for people. That model of delivery is in line with other Government initiatives that have expanded NHS provision and ensured that scanning and diagnostic capacity is improved. The InHealth group estimates that a national programme would cost between £7.5 million and £10 million. I understand that the Gloucester team's costings and those from InHealth are based on different assumptions, but they still give us an idea of the costs involved. The Gloucestershire experience shows that a full screening programme becomes viable when screening men at 65. Below that age, there are not enough cases to make general screening worth while.
Mr. Earnshaw told the all-party group on men's health that about 15 per cent. of men invited for screening did not turn up and that that group included a higher-than-average proportion of men with aneurysms. The experience of the Men's Health Forum in working with the hardest-to-reach men—who are often also the men with the highest intake of alcohol, the
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heaviest smokers and those who have a poor diet and take little exercise—suggests that in the longer term it may be necessary to consider how to screen men outside conventional health care settings. That could involve taking services to workplaces, including building sites and ports, to pubs and to sports venues. Services already provided in those settings have reached men who, as a GP, I rarely see. Those men can also be missed by the new walk-in centres aimed at commuters. Interestingly, the scanners are usually portable and can easily be transported, cost-effectively, to any venue chosen.
AAAs are more common in men who take little exercise and who have high cholesterol levels. Those problems were highlighted last week, during national men's health week, which I, along with the rest of the all-party group on men's health, supported. This year's men's health week focused on the key public health issue of weight and obesity, and drew attention to the need for men to take more exercise and eat more healthily, steps that would undoubtedly reduce the incidence of AAAs.
As in previous years, national men's health week run by the Men's Health Forum helps health professionals to work more effectively with men in general and particularly with less well-off men who are more likely to suffer from a range of conditions that contribute to their low life expectancy. I remind hon. Members that the difference in life expectancy in England between the highest, in east Dorset, and the lowest, in Manchester, is more than eight years. The difference in male life expectancy in the UK between east Dorset and the lowest—Glasgow—is 11 years.
However, it is not just the deprived and socially excluded who have lifestyles that can lead to being overweight and all the conditions that are linked to that. I have said before, in this very Room, that there is no obesity time bomb; it has already gone off. Already, two thirds of men are overweight or obese. If present trends continue unchecked, three quarters of the male population will be overweight by 2010.
Excess weight causes or exacerbates numerous health problems, some of which are of the greatest severity. It is clear that the current approaches are failing too many men. Men have different attitudes and behaviour from women in relation to weight; the solution to the problem must therefore lie in "male-sensitive" policies and services. For example, men are less likely to be concerned about becoming overweight than women, are more likely to fail to notice that they have gained weight, and are more likely to deny that they have a problem once they are overweight.
Two new documents from the Men's Health Forum highlight the scale of the problem and suggest solutions. The first is entitled "Hazardous Waist? Tackling the epidemic of excess weight in men." It calls for changes in underlying attitudes, investment in primary care services and a male-sensitive national strategy. It has been given greater impetus by the consensus statement on men and weight. That document was endorsed and supported by 28 major public, charitable and commercial organisations including Royal Mail, BT, the Football Association, Sport England, Age Concern, Beating Bowel Cancer, the Stroke Association and all the major national charities acting directly to address the issue of being overweight and obesity. Those 28 organisations share a desire and a commitment to halt the rise in overweight males before it is too late.
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I hope that my hon. Friend the Minister agrees that action on men and weight will have a positive knock-on effect on the incidence of conditions such as heart disease and cancers. I also hope that she will look at the recommendations made in "Hazardous Waist? Tackling the epidemic of excess weight in men" and will take the action suggested in the consensus statement on men and weight.
The Men's Health Forum has also just published the latest in its health manuals for men, produced in the style of a car manual by Haynes, the manual publisher. This book on men and weight, called the "HGV Man Manual" is written in a way that is more male-friendly, or blokier. It will be on sale, I am told, in Halfords, but will also be distributed in some areas by charities and NHS organisations.
I am pleased that two big employers of men will be working with the Men's Health Forum. Both BT and Royal Mail have recognised how important a role weight plays in conditions such as heart disease and cancer. Action to reduce excess weight would almost certainly also reduce the risk of aneurysms.
Other professions are also known for lifestyles that could be high risk for aneurysms. In Sefton, the health promotion team has been working at Liverpool docks with lorry drivers who have a sedentary yet stressful work pattern, who have poor access to fruit and vegetables and who are often smokers. That combination of factors could lead many drivers to suffer aneurysms. Like many others, the health promotion team in Sefton took part in national men's health week this year. Its commitment to taking health improvement out into the community—one of the team won a national award for that—is an example of how more people can be helped into healthier lifestyles and reduce their chances of suffering an AAA.
Smoking is another major factor in AAAs; in fact, it is probably the single biggest risk factor. Older men are more likely than average to smoke and more likely to smoke heavily. To quit smoking is the most significant thing a person can do to avoid an aneurysm. I am pleased that we will soon have the chance to ban smoking in public places serving food. That will be a major step forward. However, I would also like to see that policy expanded to include pubs where food is not served. Those pubs are most likely to be in less well-off areas—the same areas where more people, especially older men, will be smokers.
AAA survivor Bernard Bush, who spoke to the all-party men's health group in November, was a prime candidate for an AAA. He smoked, suffered from stress and was overweight. On Boxing day 2003, he was at home with his family. He remembers being in his kitchen when a back ache came on. He woke up in hospital, where he spent the next several weeks, and found out how lucky he was. Although we do not like to think about such things at Christmas time, the quiet Christmas roads made a vital difference. His ambulance got him to hospital faster than it could have otherwise. He says that that small time saving was a crucial factor, as was the expertise at Addenbrooke's hospital.
Even men who are too young for screening could benefit. There would be an increase in awareness that could prompt a few more to quit smoking and perhaps
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enable men in their 50s and early 60s to recognise the symptoms if they are among the few who experience them before it is too late.
The science shows that screening men for abdominal aortic aneurysms will work. The experience in Gloucestershire and that of independent providers of screening for other conditions show how it will work. Thousands of lives could be saved each year through a straightforward procedure provided at relatively little cost. I urge the Minister to introduce a national NHS screening scheme at the earliest opportunity.
1.46 pm
The Parliamentary Under-Secretary of State for Health (Caroline Flint) : I congratulate my hon. Friend the Member for Dartford (Dr. Stoate) on raising this important issue, and welcome him back to the House of Commons. I hope that his campaign on the play park in his constituency continues. I was happy to visit his constituency during the general election campaign and know that he is fighting to keep a play park open. We believe that open spaces are important for families, both because of our fitness agenda, and because of the need to ensure that children have access to exercise.
I take this opportunity to send my condolences to Bob Carson's family and to say how much I value and recognise the support of our foot soldiers who work tirelessly for the return of Labour MPs and Labour councils for the good of society. It is a credit to Mr. Carson that my hon. Friend mentioned him today, albeit in sad circumstances.
I also pay tribute to my hon. Friend for his important work as chair of the all-party parliamentary group on men's health. It is right that we should discuss this matter just after men's health week. I look forward to supporting the launch of the "Haynes HGV Man Manual" in a few weeks. I hope that I can, in my new job as a Minister with responsibility for public health, give support and attention to an important issue.
I have already looked at some of our campaigns on smoking, and have been considering the fact that the messages that we put across about such issues need to be different for women, men, girls and boys, as our research tells us that men and women respond differently to messages. Some messages are valued more by men and others more by women. It is important to approach people differently, particularly on the health and equality agenda, not just on gender but in terms of income and deprivation, so that there is not a one-size-fits-all approach to promoting public health.
The issue of abdominal aortic aneurysms is a serious one. I could not outline better than my hon. Friend did the condition and its impact on men. I understand the stress that families go through when they lose a loved one because an aneurysm erupts. I have not yet received the advice of the UK national screening committee, but there are several officials here today who have a role in determining such issues or helping us to come to a point at which we can take decisions. I will carefully consider their advice and my hon. Friend's points, to which I have listened carefully. We hope to be in a position to take a decision based on all the evidence by the end of the year.
The UK National Screening Committee advises Ministers on all aspects of screening policy. It assesses proposed new programmes against a set of internationally
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recognised criteria, which cover the condition, the test, treatment options and the effectiveness and acceptability of the screening programme. As my hon. Friend said, the multicentre aneurysm screening study, known as MASS, demonstrated that screening men aged 65 and over to detect asymptomatic aneurysms of the abdominal aorta reduced mortality from ruptured abdominal aortic aneurysms in that population group.
The NSC is currently considering whether a screening programme for AAA based on these findings should be introduced. It will also consider the results of the endovascular aneurysm repair, or EVAR, trial, which has just been published, at its meeting on 29 June. I reassure my hon. Friend that this issue is under active consideration, and that any new evidence is being actively considered. I expect to receive advice from the national screening committee by the end of this year.
My hon. Friend is aware that there is always a great deal of work to do to ensure that research proposals can be replicated across the country. We need to check that we screen the right people in the right way, that we have the services in place to deal with new cases, that we balance risks against benefits, and that the programme does more good than harm, because a second-class service just will not do. We are about to introduce a high-quality bowel cancer screening programme, which took a considerable time to arrive at. The results will be better survival rates, longer lives, and a better quality of life.
If we introduce a screening programme for AAA, the aim will be to reduce the numbers of deaths from ruptured aneurysms. As my hon. Friend said, about half the total number of deaths take place before the patient reaches hospital. Of those who do reach hospital, the mortality rate for emergency treatment is between 30 and 70 per cent. However, there would still be a risk of death with elective surgery following screening, although the mortality rate would be much lower—in the region of 4 per cent. Operations would be shorter, length of hospital stays would be reduced and less blood would be needed during surgery. At the same time, we must consider the message to the patient, which is quite difficult. My hon. Friend knows only too well the challenge of explaining uncertainties to patients in a busy GP practice.
If an aneurysm is found to have reached a certain size, the risk of rupture is such that the patient may be advised to have an elective operation. Treatment is associated with significant risk for operative death and complications. If such risks are explained thoroughly and straightforwardly, they may be acceptable to men, who are most prone to suffer ruptures. That is not an easy scenario to present to an anxious patient, but the National Screening Committee is working on proposals to recommend the best way to communicate such risks to patients who are part of the screening programme.
I should also like to thank Bernard Bush for his work with the National Screening Committee and the Men's Health Forum in this area. I have looked at the forum's website, where Bernard's experience is plainly and accessibly explained. Protocols must be established for following up detected aneurysms. Options are likely to include taking no action but remaining in the screening programme, returning at agreed intervals for further scans, or urgent referral. The options will depend on the size of the aneurysm. The national screening committee is working with vascular surgeons and other NHS colleagues to discuss how a new screening service would impact on their workload. Surgical networks need to be the right size to maximise safety and minimise adverse effects.
The resource implications for radiology and hospital services other than vascular surgery must also be studied. Overall, the service must be cost-effective. My hon. Friend made a number of pertinent points about cost, based on experience of services already being provided, and I am sure that all such evidence and information is being considered by the national screening committee.
My hon. Friend rightly mentioned public health. Stopping smoking is of particular importance in reducing death from AAA, because smoking is linked with a three to fivefold increase in the prevalence of AAA. Tackling high blood pressure, high cholesterol and obesity will help in preventing coronary heart disease, which is another risk factor. It will also help to reduce the risks of surgery. That is where the Men's Health Forum has been so helpful. I hope that my hon. Friend will reassure me that the Department works closely with the forum, which is the leading organisation in the field of men's health. The forum specialises in getting health messages across to men in a form and settings that are men-friendly. I was interested, when looking recently at some of the information on obesity, in the difference between men and women. Many women worry about being overweight when they are not, whereas many men do not worry enough about their weight. That goes back to what I said earlier about the need to understand people, where they are coming from, and how they receive different messages.
My hon. Friend may not be aware, but at least one week—maybe more—into my new job, I was asked to launch a partnership guide between the Department of Health, primary care trusts, the Football Association, the Football Foundation and others. It looked at how we could engage football and other sports in promoting public health and the options available for PCTs to work in partnership to promote good health either by getting access to space at football stadiums or other sports grounds or, more radically, by relocating certain services to some of those locations.
Listening to my hon. Friend's contribution today, I believe that there is a lot of mileage in such ideas, not exclusively with football, because football is not exclusively for men, for reaching different groups of people. I understand that there will be a number of regional roadshows to promote the partnership guide, and I am happy to give my hon. Friend some information about it, which he might find useful.
Let me conclude by making one simple point. I have a completely open mind, having arrived only recently at the Department of Health, but I want to ensure that we get the screening decision right. I expect all the necessary work to be done before I get a formal proposal, because that is important in both reaching a decision and getting on with the work if the decision is a positive one.
I am grateful to my hon. Friend, and I look forward to receiving the advice of the National Screening Committee. I hope that, while I am in this post, we will continue to have a productive relationship in discussing these important issues and how they affect men's health.
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