HC 1048-III Health CommitteeWritten evidence from Breakthrough Breast Cancer (PH 114)

1. Introduction

1.1 Breakthrough Breast Cancer welcomes the opportunity to submit written evidence to the House of Commons Health Committee Public Health inquiry.

1.2 Breakthrough Breast Cancer is a pioneering charity dedicated to the prevention, treatment and ultimate eradication of breast cancer. We fight on three fronts: research, campaigning and education. Our aim is to bring together the best minds and rally the support of all those whose lives have been, or may one day be, affected by this disease. The result will save lives and change futures—by removing the fear of breast cancer for good.

1.3 Nearly 48,000 women are diagnosed with breast cancer each year in the UK, and over half a million women are now living in the UK following a diagnosis of breast cancer, making it the most common cancer diagnosed and the most prevalent. Over the last 20 years, mortality rates for people diagnosed with breast cancer in the UK have improved significantly, thanks to a combination of better breast awareness, screening and improved treatments, however there is still more to be done.

1.4 This submission reflects the views of Breakthrough, based on our experience of working with people with personal experience of, or who are concerned about, breast cancer. We regularly consult with members of our Campaigns & Advocacy Network (Breakthrough CAN) for their views on a range of breast cancer issues. Breakthrough CAN brings together over 1,500 individuals, regional groups and national organisations to take action locally on our national campaigns to secure important improvements to breast cancer research, treatments and services.

2. The Creation of Public Health England within the Department of Health

2.1 Public Health England must provide credible, strong leadership and overall strategic direction for public health to ensure national and local needs and priorities are balanced.

2.2 Public Health England should take full responsibility for sharing best practice and act as a hub for data and provide guidance for health and wellbeing boards. NHS Evidence, the National Social Marketing Centre and the National Awareness and Early Diagnosis Initiative (NAEDI) for cancer all currently fulfil part of this role, therefore Public Health England should not seek to replicate this work, but to provide links between and join up all the relevant information.

2.3 For Public Health England to fulfil its role in using data to assess needs, set priorities and forecast future requirements for local authorities, learning from the third sector and NAEDI needs to be shared on the effectiveness and cost effectiveness of different activities to improve cancer survival. Additionally, approaches to tackle other diseases need to be shared across the sector. For example, effective initiatives to tackle stroke could be applied to promoting early diagnosis of cancer.

3. The Future Role of Local Government in Public Health

3.1 Breakthrough welcomes the whole systems approach to public health, and agrees that local authorities being responsible for tackling the wider determinants of ill health in their populations should see improvements in the health of the nation. However, for this approach to be successful it is critical that the NHS, Adult Social Care and local authorities each carry responsibility and accountability for their areas of work.

3.2 It is essential that all policy areas underpin the planned “life-course” approach. There will be many factors that impact disease risk at different life stages but also in the future. For example, breast cancer prevalence is highest in the over 50s but risk factors act at all stages of life, possibly including in utero and in childhood. Therefore, although the “ageing well” group are clearly an important audience for intervening to improve breast screening attendance and encouraging breast awareness, other groups will be important for risk reduction interventions. In particular the “working well” group, whose risk of developing breast cancer will be increasing, are an important audience for behaviour change interventions around risk factors and breast awareness.

3.3 Breakthrough believes that enabling older people to contribute and participate in their community can help address a range of health challenges. It is recognised that one of the reasons why older age groups have lower breast cancer survival rates is because breast cancer tends to be diagnosed at a later stage, when there is less chance of successful treatment. Keeping people connected and active in their community could help tackle this – if opportunities are also taken to encourage breast awareness and breast screening uptake in these age groups. Research has shown that if a woman does not mention a possible breast change to a friend or member of the family, she is less likely to seek medical help. Increasing social connectedness within local authorities could help address this, thus reducing inequalities.

4. Arrangements for Public Health Involvement in the Commissioning of NHS Services

4.1 Breakthrough welcomes Public Health England taking on responsibility for funding and quality assuring the NHS Breast Screening Programme (NHSBSP). Since Public Health England will also manage the design, the piloting and rolling out of any extensions to the Programme, this should help ensure service consistency, especially regarding implementation of changes to the service.

4.2 However, more clarity is needed on how the NHSBSP and NHS Commissioning Board will work with Cancer Networks, local providers and GP consortia to make sure breast screening is fit for each local population. For example, it is important that access to breast screening in rural areas is considered especially given the ageing rural population. It is also important that current commitments/agreements and partnerships between PCTs, GPs and the NHSBSP are transferred to the new arrangements to ensure consistency of efficient working practices where needed.

4.3 Breakthrough agrees that the public health role of GPs can be strengthened. We have previously suggested future indicators for the Quality and Outcomes Framework (QOF), recognising the key role that primary care plays in promoting breast awareness and breast screening:

playing an active role in encouraging previous non-attenders to attend screening;

encouraging women over 70 to make their own screening appointment; and

availability and provision of advice and information relating to breast awareness.

5. Arrangements for Commissioning Public Health Services

5.1 It is essential that Public Health England, health and wellbeing boards and the NHS Commissioning Board design and commission the best possible public health services and outcomes are measured and continue to improve. A role must also be included within the commissioning process role for effective patient and public involvement (PPI).

5.2 Breakthrough recognises the need for flexibility in commissioning to ensure that funding flows are determined by decisions as to how services would be best commissioned. However, more clarity is needed on the extent to which these decisions will be subject to local approaches. For example, where services are best commissioned nationally, or where the NHS Commissioning Board chooses to pass the responsibility down to GP consortia, how will local needs be balanced within a national picture? Given there is no obligation for GP consortia to be co-terminus with local authority boundaries, it is crucial that health and wellbeing boards serve their whole local population.

5.3 Local people should have access to information on public health commissioning arrangements. However, for this transparency to be effective the information needs to be understandable and useful to the public and there needs to be a clear mechanism of action for the public to highlight any concerns on how public health money is spent.

5.4 Breakthrough is particularly pleased that local HealthWatch is included in the minimum membership of health and wellbeing boards. To achieve effective commissioning of public health services, PPI in public health must be robust and meaningful and integrated into the wider set up of the public health system to ensure that the needs and views of people in the community are taken into account. We have previously commented that in order to give patients and the public a voice in shaping NHS services, the role of PPI in commissioning should be defined in statute to give Commissioning Consortia a duty to involve patients and the public in the same way the duty was defined for PCTs. We would also argue that the role of PPI should be defined for public health and that “early implementer” health and wellbeing boards will provide an important platform to ensure that PPI mechanisms are enshrined as not just best practice, but essential practice.

6. The Future of Public Health Observatories

6.1 A robust evidence base, information and intelligence at national and local level is vital in delivering outcomes as well as running an efficient and effective public health service.

6.2 It is important that data collected by organisations such as the National Cancer Intelligence Network (NCIN) is included in data available to health and wellbeing boards and that the data is used to provide commissioners with good quality information so they are able to make informed decisions about their services.

6.3 In order to be useful in calculating breast cancer survival rates and other important statistics (eg stage at diagnosis) to measure England’s progress on improving cancer outcomes, cancer registration must be complete and accurate.

7. The Structure and Purpose of the Public Health Outcomes Framework

7.1 Breakthrough welcomes the Government’s approach to co-producing the Outcomes Framework with the public health sector and local government. Developing the detailed Public Health Outcomes Framework must involve professionals at all levels, along with patients and the public, carers and representative groups. It is essential that the Outcomes Framework is well designed, and buy-in is achieved at all levels to ensure the Framework will work for local, regional and national arrangements and that outcomes are measured and continue to improve.

7.2 Breakthrough also welcomes the Government’s aim to set out the outcomes for public health at national and local levels. However, it is important to recognise that this focus could very easily become disjointed. Local partnerships must use this framework to develop a comprehensive plan to tackle all public health challenges in their area, and not solely focus on those with direct indicators.

7.3 While Breakthrough also welcomes the flexibility for health and wellbeing boards to go beyond their minimum statutory duty we are concerned that one area is not focussed on to the detriment of others. In addition, outcomes must be coordinated across the NHS, public health and social care in order to be truly meaningful. For example, following patients from breast screening through to swift referral to a specialist breast unit to receiving prompt diagnosis and treatment, plus tailored community support, should result in a better quality of life and improved survival outcome.

7.4 More clarity is needed on how the indicators will develop with progress. It is essential that outcome indicators can evolve over time to take account of new developments but that some core indicators continue to track progress over time. Since any positive impact of changes in public health services will not be seen immediately, and any negative impacts may also not be immediately visible, setting appropriate measures to allow for the continuous monitoring of progress and long-term investment in public health is vital.

7.5 Breakthrough is concerned that action against some of the proposed indicators will not be enough to reduce the incidence of breast cancer in the UK and to decrease mortality.

7.6 For example the proposed measure D5.5 Mortality rate from cancer in persons less than 75 years of age will have negative impact on older age groups. Around one third of breast cancers are currently diagnosed in women over 70. Breast cancer survival is lower in the over 70s than in women aged 50–69. Older women tend to present later with breast cancer, and are diagnosed at a later stage, thus improvement in this area will improve survival and reduce inequalities. While recognising the complexities of measuring outcomes in older patients due to co-morbidities, Breakthrough would like to see the Outcomes Framework work to improve survival for all women diagnosed with breast cancer, and would like the indicator to reflect the picture of cancer incidence in the UK, by measuring the mortality rate for all patients, not just those under 75.

7.7 In addition, while welcoming the focus to reduce the impact of alcohol related harm, it is important to note that 19% of women drink more than the weekly recommended limit of 14 units. Additionally women from higher socio-economic groups, on average drink more per week than those from lower socio-economic groups. Regularly drinking even just one unit per day can increase a woman’s risk of breast cancer—The World Cancer Research Fund (WCRF) estimates that 22% of breast cancers can be prevented by not consuming alcohol—therefore focusing efforts solely on tackling heavy drinking, especially in deprived groups may not impact on overall breast cancer risk and we would like to see this indicator amended so progress will also impact on conditions from long term regular drinking.

7.8 Since breast cancer is the most common cancer in the UK, with nearly 48,000 women diagnosed each year, it is vital that health and wellbeing boards consider the impact of initiatives to tackle alcohol consumption, and also obesity and improving physical activity in reference to reducing breast cancer incidence. Breakthrough recommends women maintain a healthy weight, try to cut down the amount of alcohol they drink and exercise regularly to reduce their risk of developing breast cancer in the future.

8. Arrangements for Funding Public Health Services

8.1 Breakthrough understands the Government’s commitment to prioritising public health funding. However, given the current economic climate, and cost reductions and efficiency gains required across the NHS coupled with savings needed across local authorities, Breakthrough is concerned that this provides considerable challenges to delivering the public health agenda. While we support the principle of investing in public health to deliver long term cost savings for health services, Breakthrough would welcome further information about the initial investment in public health and the expected return from this investment.

8.2 The Government’s commitment to earlier presentation and diagnosis of disease is particularly welcome. However, it is important that investment in this area is sustained to ensure that people continue to be aware of the signs and symptoms of various conditions and know when to visit their doctor. This is particularly important for conditions such as breast cancer as the earlier breast cancer is diagnosed, the more successful treatment is likely to be. Recent investment in raising cancer awareness, through the £10.75 million signs and symptoms national and local campaigns, focussing on breast, lung and bowel cancers, has been vital in providing impetus for local activities. If these campaigns are shown to be successful, we would like to see a further financial commitment to rolling these out across England in a sustainable manner.

8.3 Breakthrough would welcome clarity over how the central and local budgets will be rebalanced over time. It is essential that the outcomes framework and the health premium are both robust and responsive so progress can be measured fairly and to ensure the system is sustainable.

8.4 More clarity is needed around how the health premium will be developed and applied. While Breakthrough welcomes the commitment to develop the health premium formula in a transparent and evidence based way, there is a danger that focussing exclusively on reducing inequalities will not improve the health of the nation as a whole. For example, breast cancer incidence is higher in affluent populations, but survival is lower in less affluent groups. Different, and complementary, approaches will therefore be needed to reduce the burden of breast cancer in the different groups, without increasing health inequalities. Additionally all PCTs currently have one year breast cancer survival below that of consensus best practice—improvements are needed in all areas, in addition to those with high areas of deprivation.

9. Conclusion

9.1 It is essential that accountability for preventable mortality is shared between the NHS and Public Health Outcomes Frameworks. For example, there is evidence that being “breast aware” (knowing the signs and symptoms of breast cancer and the importance of early presentation) and regularly attending NHS breast screening appointments are two of the three most influential factors on breast cancer survival in the UK (the third being improved treatments).

9.2 It is particularly important to recognise that in order to prevent people from dying prematurely from breast cancer, more needs to be done to promote early diagnosis. In patients with breast cancer it has clearly been shown that delayed diagnosis is associated with poor survival. Increasing awareness of the signs and symptoms of breast cancer, the benefits of screening and the importance of early diagnosis is therefore vital for improving outcomes. In addition, whilst it is a positive sign that breast cancer mortality rates in the UK have fallen dramatically, it is important to note that incidence remains high. Ultimately, the biggest savings in breast cancer care would be realised if breast cancer could be prevented or at least if incidence were to decrease.

9.3 Excess mortality from breast cancer in the first few months to one year after diagnosis in England as compared to other European countries can give an indication of success at encouraging early diagnosis of the disease. Excess mortality in the first year after diagnosis in England is still higher than some other European countries and it is estimated that 2,000 deaths from breast cancer each year could be avoided through early diagnosis. This is equal to one sixth of the total breast cancer deaths each year in the UK. It is vital that the public health system is designed in the best possible way to give women affected by breast cancer the best chance of survival.

10. Thank you for the opportunity to comment on the consultation on the Health Select Committee Inquiry into Public Health. Breakthrough Breast Cancer is keen to support the work of the Health Select Committee in coming parliamentary sessions through written or oral evidence.

June 2011

Prepared 28th November 2011