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Cervical Cancer Screening

Volume 485: debated on Wednesday 17 December 2008

Motion made, and Question proposed, That this House do now adjourn.—(Helen Jones.)

Thank you, Mr. Deputy Speaker, and I am grateful to Mr. Speaker for giving me permission to hold this debate on the Floor of the House of Commons.

I shall begin by praising the success over the past few decades of the cervical cancer screening programme, and all those who have worked in it. They have saved many lives but, despite that success, cervical cancer still kills 1,100 women every year. Another 2,800 women are diagnosed with it each year, but I want to speak specifically about the screening of young women under the age of 25.

I bring this matter to the House because a young constituent of mine called Claire Walker tragically died on 18 September, a few days after her 23rd birthday. Claire was diagnosed with cervical cancer at the age of 21, and she died leaving a two-year-old son, a husband, a brother, a sister, a mam and dad, and a grandma. Claire worked at the Washington child benefit centre, where I once worked, as did her mother. I remember when I was the trade union branch secretary 30 years ago that, along with many others, I negotiated for on-site screening for the 2,000 women who worked there. That was one of the first such initiatives anywhere in the UK.

Despite having this devastating illness, as well as a young family to care for and all the pressures that that brings, Claire Walker found the courage and determination to help others, even in her dying days. She found the strength that she needed through Jo’s Trust, a charity that helps support cervical cancer sufferers, and she also took part in television programmes and appeared in women’s magazines and in newspapers—always with the aim of warning others of the danger, and to provide help and support.

On the day of her funeral, her dad Bob said, “She will always be the real angel of the North.” She was a remarkable woman, whose family and friends are determined that her death should not be in vain. They have campaigned courageously and vigorously about the need for cervical screening of women under 25. They have had the support of many in the local community in Washington, and a petition was organised by the Sunderland Echo to ensure that other families do not have to go through what they have faced. Claire would have had that screening had she been born a few years earlier, or 80 miles up the road and over the border in Scotland.

Many women under 25 are still diagnosed with cervical cancer each year. The latest figures that I could get from the Office for National Statistics only go up to 2005, but they show that the number of women so diagnosed totalled 42 in 2001 and 2002, 63 in 2003, 48 in 2004 and 43 in 2005. They were all young women diagnosed under the age of 25, and many health professionals believe that the figures could be much higher.

In 2004, the routine screening age in England was raised from 20 to 25. Scotland and Wales did not raise the age. The reason given at the time was the report issued by Drs. Sasieni and Cuzick and colleagues, which the Department of Health considered. However, many feel that the data sample used in the report was relatively small—about 3,700—given that 4.3 million women a year are eligible for screening. There are differences of view within the medical profession and I shall give a couple of examples.

A report recently published in the Journal of Family Planning and Reproductive Health Care stated:

“Women aged 20-24 years should no longer be given the message that screening causes more harm than good and should not be actively discouraged from screening”.

In the same journal, Professor Fiander, in an article entitled “Cervical screening in young women aged 20-24 years”, wrote:

“The paper by Sasieni and colleagues demonstrated less protection for younger women from a normal cervical smear than for older women and paved the way for an increase in the age of first invitation for cervical screening in England. Sasieni’s study did not include microinvasive cancers, for which fertility-sparing options for treatment may be feasible—an advantage of early screen-detected tumours. If we accept that protection from current cervical screening is poor in young women then perhaps the response to this should not have been to start screening later but to find a better method of screening young women.”

Another article dealing with lowering the age concluded:

“Delaying the age for screening eligibility carries a risk of CIN becoming more extensive, and therefore more difficult to excise, as well as a risk of progression. The NHSCSP should reconsider its decision and encourage young women to be screened, not excluding those aged 20-24 years. Facilities for taking the test should be made more convenient. Women should be informed that low-grade CIN is potentially reversible and may safely be monitored. Cervical screening also provides an opportunity for education on healthy lifestyles and safer sex while treatment should be reserved for high-grade CIN.”

There are differences of opinion and the view expressed in the report considered by the Department is not universally shared by the English medical profession, by the chief medical officers in Scotland and Wales, or in a host of other European countries. That view has not been taken in Australia and many other parts of the world. Many people feel that the report did not look at interval analysis and that it was not designed to test the theory it used and the conclusions it reached.

Many people feel that responsibility for the burden of proof lies with those who advocate change, yet many of us feel that the case is not proven. I have talked to people in the profession over the past few weeks and many consultants and others accept that there was an element of over-treatment, but they say that the pendulum has swung the other way and there is a change of attitude in the medical profession. Some of the arguments about over-treatment are no longer made.

The argument has been used that early screening does more harm than good, but, with greater safeguards, why should it be different for a 24-year old or a 25 or 26-year old? As my quotes from eminent medical journals showed, that argument sends out the wrong message—that cervical cancer does not affect young women. Between 2000 and 2005, the number of women aged between 20 and 29 who turned up for routine screening went down from 77 per cent. to 71.6 per cent.

I readily accept that I am not a medical expert, but I have talked to the families and to people in the profession. I feel confident that a case needs to be answered and that an analysis needs to be performed. I have been a Member long enough to recognise that the Minister will not stand at the Dispatch Box and say, “We will alter the procedure and take the age back to 20”, but I ask for recognition that eminent figures in the medical profession have expressed genuine and serious differences of opinion about how we approach the issue, particularly within our neighbouring nations of the UK.

Obviously—this is connected in many ways—I welcome the recently announced vaccine programme, together with the catch-up initiative, but it will still leave a group of young women who are not covered by routine screening or vaccination. I respect the Minister. She is a former health service professional. She will want to be reassured that what we are doing is absolutely right and in the best interests of young women. I should like simply to put it to her that we should analyse the available data, and that view is supported by other hon. Members. Early-day motion 195, which I submitted, has support from Conservative, Liberal and Labour Members, all of whom feel that this issue seriously needs to be revisited.

When we look at the data, we see that we have a unique opportunity for the first time. Two different systems have been operating in England and Northern Ireland and in Scotland and Wales. If the argument of harm exists and if damage is done to young women, that would be presumably demonstrated by looking at the data on those young women under 25 who are routinely screened in Scotland and Wales. One way or the other, the argument can now be proved. We can analyse what the difference is, because we have had similar populations with similar genetic make-ups for the past few years—so there is an opportunity.

A point that has been made to me is that the data used in the Sasieni report show that big changes have taken place. The age at which young women become sexually active has reduced. Such differences need to be assessed. In my dealings with the Department of Health, it has always argued on the basis of medical advice. Some people have suggested that cost is an issue, but the average cost of screening is between £30 and £40. The life chances that that has given to tens of thousands of women in Britain are quite phenomenal. Apart from the obvious cost-benefit analysis—screening has saved the health service money, as well as greatly benefiting the women who have been helped—to save someone’s life is clearly a great advantage. The re-examination needs to take place urgently, on the basis of different age limits, as that will provide a proper opportunity.

Some people feel that, when the Sasieni report came out a few years ago, the Department considered that other groups were not sufficiently involved. If the Minister is prepared to look at the evidence and data, she will see that the consultation should include other organisations that have a view. I could mention many of them, but I will cite one that has advised me in the preparation of my speech: Jo’s Trust, which is a cervical cancer charity. The question that needs to be asked is what is the effective age of the first invitation in order to prevent incidence and mortality in young women in their 20s. That is the basis on which we should approach this issue.

At the weekend I spoke to Claire’s mother Lyn, and she told me of another young woman who, after reading about Claire’s story and Claire’s death, discovered that she had cervical cancer.

Motion lapsed (Standing Order No. 9(3)).

Motion made, and Question proposed, That this House do now adjourn.—(Helen Jones.)

Let me repeat that I spoke to Claire’s mother, Lyn, over the weekend, and she told me the very moving story of a young woman who, after reading about what Claire had gone through and about Claire’s death, discovered that she herself had cervical cancer, and she is now receiving treatment for it.

Even in death, Claire Walker continues to do what she did in life, and that is to help others. With that, I conclude, and I look forward to the Minister’s response.

I congratulate my hon. Friend the Member for Houghton and Washington, East (Mr. Kemp) on securing this extremely important debate. He has demonstrated the work that he did on this subject before he came to this House. The thought and research that has gone into his contribution was obvious for all to hear.

I would like to start by paying tribute to my hon. Friend’s constituent Claire Walker, and her brave battle against cervical cancer. For such a young woman to find herself in that position with a young family is devastating, and hearing of her brave work throughout what was left of her life is something that we must all take very seriously. I hope that during my speech I will address most of the issues that my hon. Friend raised.

I offer my sincere condolences to Claire’s family, her husband and her son. Of course, these sound like just words, but they are heartfelt words, because as a woman, as a mother, as a sister, and as an aunt, I know of the pressures that are on women today to look after themselves, but with the fear and dread of having bad news whenever one goes for screening. Of course, it makes it worse for the family to have this devastation at this particular time.

The NHS cervical screening programme is a great success, and it is one of the most well-regarded cancer screening programmes in the world. More than 3.5 million women are screened every year, and experts estimate that the programme saves up to 4,500 lives in England alone. However, we cannot be complacent, of course, and we are always striving to improve the programme.

Following the evaluation of a Government-funded pilot study of liquid-based cytology—LBC—the National Institute for Health and Clinical Excellence concluded in 2003 that this new technology should be rolled out across the country. I am pleased to say that the whole of England had converted to LBC by October 2008, as planned. Prior to the introduction of LBC, rates of inadequate samples were over 9 per cent. This resulted in about 300,000 women a year being screened again, just because their initial sample could not be read. As LBC was rolled out, the rate of inadequate samples has fallen every year and is now at a record low of just under 3 per cent., or fewer than 100,000 women. That means that 200,000 fewer women a year do not have to have a repeat test because their original sample could not be read, with all the anxiety that ensues for those women and the extra costs to the service. It is important to put this on the record because it is a good and welcome change.

The implementation of LBC also allowed us to modernise the programme in other ways. Prior to 2003, there was a longstanding inequality in the NHS cervical screening programme regarding the frequency of invitations for screening. Some local programmes invited all women every three years, some all women every five years, and some used a combination of the two intervals, but there was no clear evidence base. The Advisory Committee on Cervical Screening had always kept the issue under review and commissioned research to find robust evidence to show what was the optimal screening interval. The research, by Sasieni et al., was published in the British Journal of Cancer on 1 July 2003. That research recommended that women aged under 25 should not be screened, as the risk is so low that there may be more harm done than good. It recommended that women aged 25 to 49 be screened every three years, and women aged 50 to 64 every five years.

The Advisory Committee on Cervical Screening carefully considered the research at its meeting on 14 July 2003 and advised that the recommendations in the research be adopted across the NHS screening programmes, but I certainly appreciate my hon. Friend’s comments about the fact that the screening programme in Scotland is offered to women between the ages of 20 and 60. However, I would like to give him details on why it was decided to raise the screening age in England from 20 to 25.

Cervical cancer is very rare in women under 25. Claire’s case is of course tragic, but thankfully it is very rare. All screening programmes must do more good than harm. However, research presented to the Advisory Committee on Cervical Screening, coupled with 15 years of experience of screening, has shown that screening women under the age of 25 may do more harm than good. Women under 25 often underwent unnecessary investigations after results suggested that they appeared to have cervical abnormalities. They were, in fact, normal cervical changes, caused by hormonal changes that will normally resolve themselves naturally over time without the need for treatment.

Back in 2003, when the policy was changed, the 9,000 women under 25 with a high-grade smear whom we sent each year for colposcopy would all be treated, and ran the risk of complications that could lead to infertility. Treatment relating to colposcopy using large-loop excision—the most common procedure—is relatively safe, but there are risks. The short-term risks include pre-operative and post-operative bleeding and secondary infection. It is possible to perforate the uterus and/or cut through the vaginal wall, which may lead to unintentional damage to the bowel or bladder. In the longer term, cervical stenosis, or narrowing, can be a problem, and occasionally there is functional damage that leads to problems with pregnancy. I am explaining the technicalities to show the extent to which the research was looked into.

With young women, there is the possibility of repeated loop excisions. That is not uncommon, and it means that the risk of complication is greatly increased. There is significant bleeding in 5 to 10 per cent. of cases in which a cone biopsy is necessary, and cervical stenosis occurs in 2 to 3 per cent. of patients. Hysterectomy is occasionally necessary to delay excessive bleeding, and there are arguments about the rate of fertility issues.

Since the policy was changed in 2003, the number of excisional biopsies undertaken as a consequence of the screening programme has fallen by almost 4,000. In 2006, there were only 56 registrations, representing 2.4 per cent., of cervical cancer in women aged under 25, compared to a total across all ages of 2,321 registrations. There were no deaths from cervical cancer among those aged under 25 in 2005, according to the latest figures available to me from the Office for National Statistics; that varies slightly with what my hon. Friend said. Recent work by the National Cancer Intelligence Network, based on figures from cancer registries, shows that no increase in registrations of cervical cancer has been evident in the overall England data for that age group since the frequency policy was changed in 2003.

Screening women from the age of 25 helps reduce the number of unnecessary investigations and treatments in younger women. Treatments to the cervix can cause difficulties later in life, such as raising the risk of pre-term babies if a woman becomes pregnant. That, of course, will affect two lives, not just one.

There is internationally agreed evidence that women should be screened from age 25. A meeting in Lyons in May 2004, organised by the International Agency for Research on Cancer, part of the World Health Organisation, concluded that organised and quality controlled cervical screening can achieve an 80 per cent. reduction in the mortality of cervical cancer. Women aged 25 to 49 should be screened no more than every three years, and women aged 50 to 64 no more than every five years. The group that made these recommendation consisted of 26 experts from 14 countries.

Although some countries, including Scotland, still invite women under 25 for cervical screening, others, such as the Netherlands and Finland, do not start screening until the age of 30. The advisory committee on cervical screening constantly keeps the age range and frequency of cervical screening under review, but would formally review this policy only if there was new evidence that we should be screening from age 20. Ultimately, the NHS in England should not be paying GPs for a procedure that can potentially be harmful.

Earlier in the Minister’s contribution, when she referred to the advisory committee, she used the word “may” cause harm and she has also said “can” cause harm. I am worried that there does not appear to be a definitive view. That is why I would like the Minister to look at the evidence. “Can” and “may” can be made definitive if we examine evidence in Scotland and Wales.

I thank my hon. Friend for that intervention. I will come shortly to the important issue that he raises.

Women under 25 who are concerned about their risk of developing cervical cancer or concerned about their sexual health should contact their GP or their genito-urinary medicine clinic and go for screening. Clinicians will refer women under 25 who have symptoms of cervical cancer for other more appropriate tests, and women with suspected cancer should be seen by a specialist within two weeks.

My hon. Friend mentioned our HPV vaccination programme, which we are proud of. Cervical screening is not our only strategy for tackling this dreadful disease. The HPV vaccination programme, which protects against two strains of HPV that cause more than 70 per cent. of cases of cervical cancer, commenced in September 2008 for young girls aged 12 and 13. The national vaccination programme against HPV has been extended to offer protection to an additional 300,000 girls aged 17 and 18 from September this year. A catch-up programme will commence in September 2009 and will offer the vaccine to other older girls aged 13 to 18. The introduction of the vaccine will help reduce the number of tragic cases like that of Claire, whom we are discussing tonight.

I want to reassure my hon. Friend that the evidence has to be looked at again. Yes, everything that he has raised in the debate tonight has to be looked at again. Jo’s Trust was mentioned. If my hon. Friend feels that that is important, I would want to include any work that Jo’s Trust has done and any evidence it has produced.

I thank my hon. Friend for giving that commitment to look at the evidence that has been produced and for the commitment to involve some of the charities. That will give great satisfaction to many people who are concerned about the matter. I genuinely welcome the commitment that my hon. Friend has given from the Dispatch Box.

I thank my hon. Friend again. He has introduced this issue tonight, Claire’s family are involved and Claire had committed to continue to campaign—if we in the House and our debates mean anything, it is our duty to look at the evidence again. I thank all the charities and organisations that have been involved in bringing such detail to our attention and I recognise why the research was acted on as it was. It is always right to look again when issues are introduced as my hon. Friend has introduced this one. I give a commitment to keep a very close eye on the issue and will keep my hon. Friend informed of progress.

Question put and agreed to.

House adjourned.

Deferred DivisionAdjournment (Christmas)That this House, at its rising on Thursday 18 December, do adjourn till Monday 12 January 2009.The House divided: Ayes 266, Noes 214.Division No. 8]AYESAbbott, Ms DianeAinger, NickAinsworth, rh Mr. BobAlexander, rh Mr. DouglasAllen, Mr. GrahamAnderson, Mr. DavidAnderson, JanetArmstrong, rh HilaryAustin, Mr. IanAustin, JohnBailey, Mr. AdrianBalls, rh EdBanks, GordonBarron, rh Mr. KevinBattle, rh JohnBayley, HughBeckett, rh MargaretBegg, Miss AnneBenn, rh HilaryBerry, RogerBetts, Mr. CliveBlackman, LizBlackman-Woods, Dr. RobertaBlears, rh HazelBlizzard, Mr. BobBlunkett, rh Mr. DavidBorrow, Mr. David S.Bradshaw, Mr. BenBrennan, KevinBrown, LynBrown, rh Mr. NicholasBrown, Mr. RussellBrowne, rh DesBryant, ChrisBuck, Ms KarenBurden, RichardBurgon, ColinBurnham, rh AndyButler, Ms DawnByers, rh Mr. StephenCairns, DavidCampbell, Mr. AlanCaton, Mr. MartinCawsey, Mr. IanChallen, ColinChapman, BenChaytor, Mr. DavidClapham, Mr. MichaelClark, Ms KatyClark, PaulClelland, Mr. DavidClwyd, rh AnnCoaker, Mr. VernonCoffey, AnnCohen, HarryConnarty, MichaelCooper, rh YvetteCorbyn, JeremyCousins, JimCrausby, Mr. DavidCreagh, MaryCruddas, JonCryer, Mrs. AnnCunningham, Mr. JimCunningham, TonyDarling, rh Mr. AlistairDavid, Mr. WayneDean, Mrs. JanetDenham, rh Mr. JohnDevine, Mr. JimDhanda, Mr. ParmjitDismore, Mr. AndrewDobbin, JimDonohoe, Mr. Brian H.Doran, Mr. FrankDowd, JimEagle, AngelaEagle, MariaEfford, CliveEllman, Mrs. LouiseEngel, NataschaEnnis, JeffFarrelly, PaulFitzpatrick, JimFlello, Mr. RobertFlint, rh CarolineFlynn, PaulFoster, Mr. Michael (Worcester)Francis, Dr. HywelGapes, MikeGardiner, BarryGerrard, Mr. NeilGibson, Dr. IanGilroy, LindaGodsiff, Mr. RogerGoggins, PaulGoodman, HelenGriffith, NiaGriffiths, NigelGrogan, Mr. JohnGwynne, AndrewHain, rh Mr. PeterHall, Mr. MikeHall, PatrickHamilton, Mr. FabianHanson, rh Mr. DavidHarman, rh Ms HarrietHarris, Mr. TomHavard, Mr. DaiHealey, rh JohnHenderson, Mr. DougHepburn, Mr. StephenHeppell, Mr. JohnHesford, StephenHewitt, rh Ms PatriciaHeyes, DavidHill, rh KeithHodgson, Mrs. SharonHoey, KateHood, Mr. JimHoon, rh Mr. GeoffreyHope, PhilHopkins, Kelvin Howarth, rh Mr. GeorgeHowells, Dr. KimHoyle, Mr. LindsayHughes, rh BeverleyHumble, Mrs. JoanIddon, Dr. BrianIllsley, Mr. EricIngram, rh Mr. AdamIrranca-Davies, HuwJames, Mrs. Siân C.Jenkins, Mr. BrianJohnson, Ms Diana R.Jones, HelenJones, Mr. KevanJones, Mr. MartynKaufman, rh Sir GeraldKeeley, BarbaraKeen, AlanKeen, AnnKelly, rh RuthKemp, Mr. FraserKennedy, rh JaneKhan, Mr. SadiqKidney, Mr. DavidKnight, rh JimKumar, Dr. AshokLadyman, Dr. StephenLepper, DavidLevitt, TomLloyd, TonyLove, Mr. AndrewLucas, IanMacShane, rh Mr. DenisMactaggart, FionaMallaber, JudyMann, JohnMarsden, Mr. GordonMartlew, Mr. EricMcAvoy, rh Mr. ThomasMcCabe, SteveMcCarthy, KerryMcCarthy-Fry, SarahMcFall, rh JohnMcGovern, Mr. JimMcGrady, Mr. EddieMcGuire, rh Mrs. AnneMcIsaac, ShonaMcKechin, AnnMcKenna, RosemaryMcNulty, rh Mr. TonyMeacher, rh Mr. MichaelMerron, GillianMichael, rh AlunMiliband, rh DavidMiliband, rh EdwardMiller, AndrewMoffat, AnneMoffatt, LauraMole, ChrisMoon, Mrs. MadeleineMoran, MargaretMorgan, JulieMunn, MegMurphy, Mr. DenisMurphy, rh Mr. JimMurphy, rh Mr. PaulNaysmith, Dr. DougO'Brien, Mr. MikeO'Hara, Mr. EdwardOlner, Mr. BillOsborne, SandraOwen, AlbertPalmer, Dr. NickPearson, IanPlaskitt, Mr. JamesPound, StephenPrentice, BridgetPrentice, Mr. GordonPrimarolo, rh DawnProsser, GwynPurchase, Mr. KenPurnell, rh JamesRammell, BillRaynsford, rh Mr. NickReed, Mr. AndyReed, Mr. JamieReid, rh JohnRoy, Mr. FrankRoy, LindsayRuane, ChrisRuddock, JoanRussell, ChristineRyan, rh JoanSalter, MartinSeabeck, AlisonSheerman, Mr. BarrySheridan, JimSimon, Mr. SiônSlaughter, Mr. AndySmith, rh Mr. AndrewSmith, Ms Angela C. (Sheffield, Hillsborough)Smith, Angela E. (Basildon)Smith, GeraldineSmith, JohnSnelgrove, AnneSoulsby, Sir PeterSouthworth, HelenSpellar, rh Mr. JohnStarkey, Dr. PhyllisStoate, Dr. HowardStrang, rh Dr. GavinStraw, rh Mr. JackStringer, GrahamStuart, Ms GiselaSutcliffe, Mr. GerryTami, MarkTaylor, Ms DariTaylor, DavidThomas, Mr. GarethThornberry, EmilyTimms, rh Mr. StephenTipping, PaddyTouhig, rh Mr. DonTrickett, JonTurner, Dr. DesmondTurner, Mr. NeilTwigg, DerekUssher, KittyVaz, rh KeithWalley, JoanWaltho, LyndaWard, ClaireWatts, Mr. DaveWhitehead, Dr. AlanWicks, rh MalcolmWilliams, rh Mr. AlanWilliams, Mrs. BettyWinterton, rh Ms RosieWoolas, Mr. PhilWright, Mr. AnthonyWright, DavidWright, Mr. IainWyatt, Derek NOESAfriyie, AdamAinsworth, Mr. PeterAlexander, DannyAncram, rh Mr. MichaelArbuthnot, rh Mr. JamesAtkinson, Mr. PeterBacon, Mr. RichardBaker, NormanBaldry, TonyBarker, GregoryBaron, Mr. JohnBarrett, JohnBeith, rh Sir AlanBellingham, Mr. HenryBinley, Mr. BrianBlunt, Mr. CrispinBoswell, Mr. TimBottomley, PeterBrady, Mr. GrahamBrazier, Mr. JulianBreed, Mr. ColinBrokenshire, JamesBrowne, Mr. JeremyBrowning, AngelaBurns, Mr. SimonBurrowes, Mr. DavidBurstow, Mr. PaulBurt, AlistairBurt, LorelyButterfill, Sir JohnCable, Dr. VincentCameron, rh Mr. DavidCampbell, Mr. GregoryCarmichael, Mr. AlistairCarswell, Mr. DouglasCash, Mr. WilliamChope, Mr. ChristopherClappison, Mr. JamesClark, GregClarke, rh Mr. KennethClifton-Brown, Mr. GeoffreyCurry, rh Mr. DavidDavey, Mr. EdwardDavies, Mr. DaiDavies, David T.C. (Monmouth)Davies, PhilipDjanogly, Mr. JonathanDodds, Mr. NigelDonaldson, rh Mr. Jeffrey M.Drew, Mr. DavidDuddridge, JamesDuncan, AlanDunne, Mr. PhilipEllwood, Mr. TobiasEvennett, Mr. David Fabricant, MichaelFallon, Mr. MichaelField, Mr. MarkFoster, Mr. DonFox, Dr. LiamFrancois, Mr. MarkFraser, ChristopherGarnier, Mr. EdwardGauke, Mr. DavidGeorge, AndrewGibb, Mr. NickGidley, SandraGillan, Mrs. CherylGoodman, Mr. PaulGoodwill, Mr. RobertGove, MichaelGray, Mr. JamesGrayling, ChrisGreening, JustineGreenway, Mr. JohnGrieve, Mr. DominicGummer, rh Mr. JohnHague, rh Mr. WilliamHammond, Mr. PhilipHands, Mr. GregHarper, Mr. MarkHarris, Dr. EvanHayes, Mr. JohnHeald, Mr. OliverHeath, Mr. DavidHeathcoat-Amory, rh Mr. DavidHemming, JohnHendry, CharlesHerbert, NickHoban, Mr. MarkHogg, rh Mr. DouglasHollobone, Mr. PhilipHolmes, PaulHorwood, MartinHosie, StewartHoward, rh Mr. MichaelHowarth, DavidHowarth, Mr. GeraldHowell, JohnHughes, SimonHuhne, ChrisHunt, Mr. JeremyHunter, MarkJack, rh Mr. MichaelJackson, Mr. StewartJenkin, Mr. BernardJones, Mr. DavidKawczynski, DanielKeetch, Mr. PaulKennedy, rh Mr. Charles Key, RobertKirkbride, Miss JulieKnight, rh Mr. GregKramer, SusanLaing, Mrs. EleanorLait, Mrs. JacquiLamb, NormanLancaster, Mr. MarkLansley, Mr. AndrewLaws, Mr. DavidLeech, Mr. JohnLiddell-Grainger, Mr. IanLidington, Mr. DavidLilley, rh Mr. PeterLlwyd, Mr. ElfynLoughton, TimLuff, PeterMackay, rh Mr. AndrewMackinlay, AndrewMaclean, rh DavidMacNeil, Mr. AngusMain, AnneMason, JohnMay, rh Mrs. TheresaMcIntosh, Miss AnneMcLoughlin, rh Mr. PatrickMiller, Mrs. MariaMilton, AnneMitchell, Mr. AndrewMoore, Mr. MichaelMoss, Mr. MalcolmMulholland, GregMundell, DavidMurrison, Dr. AndrewNeill, RobertNewmark, Mr. BrooksO'Brien, Mr. StephenOaten, Mr. MarkÖpik, LembitOsborne, Mr. GeorgeOttaway, RichardPaice, Mr. JamesPaterson, Mr. OwenPelling, Mr. AndrewPenrose, JohnPrice, AdamPritchard, MarkPugh, Dr. JohnRandall, Mr. JohnReid, Mr. AlanRennie, WillieRobathan, Mr. AndrewRobertson, AngusRobertson, HughRobinson, rh Mr. PeterRogerson, DanRussell, BobSanders, Mr. AdrianScott, Mr. LeeSelous, AndrewShapps, GrantShepherd, Mr. RichardSimmonds, MarkSimpson, DavidSimpson, Mr. KeithSkinner, Mr. DennisSmith, Sir RobertSpelman, Mrs. CarolineSpicer, Sir MichaelSpink, BobStanley, rh Sir JohnStreeter, Mr. GaryStuart, Mr. GrahamStunell, AndrewSwayne, Mr. DesmondSwire, Mr. HugoSyms, Mr. RobertTapsell, Sir PeterTaylor, MatthewTaylor, Dr. RichardTeather, SarahTredinnick, DavidTurner, Mr. AndrewVara, Mr. ShaileshViggers, Sir PeterVilliers, Mrs. TheresaWalker, Mr. CharlesWallace, Mr. BenWaterson, Mr. NigelWatkinson, AngelaWebb, SteveWeir, Mr. MikeWhittingdale, Mr. JohnWilletts, Mr. DavidWilliams, HywelWilliams, Mr. RogerWilliams, StephenWillott, JennyWilson, Mr. RobWilson, SammyWinterton, AnnWinterton, Sir NicholasWright, JeremyYoung, rh Sir GeorgeQuestion accordingly agreed to.