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Bowel Cancer Screening

Volume 536: debated on Wednesday 23 November 2011

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

Thank you, Mr Deputy Speaker, for giving me the opportunity to raise this matter in the House. Bowel cancer affects men and women, and it is the second-highest killer after lung cancer. The debate is, I suggest, both timely and genuinely needed.

I have personal experience of the NHS that is probably too long to list. When I was a jockey, I was saved by a gastro-surgeon at Warwick hospital. I hoped I was riding the winner at Stratford races, but we turned over and the horse ruptured my spleen, perforated my left kidney and broke nine bones in my ribs. I can assure the House that it hurt a great deal. The surgeon saved my life on that occasion. Subsequently, it is well known that I had a meningioma in April and was recently given the all clear by Mr Neil Kitchen and the amazing staff at Queen Square hospital in north London.

My grandmother was an NHS matron and I have had bowel cancer screening. Certain family members have had this cancer, so I had the colonoscopy that was medically advised in those circumstances. I would certainly not be an MP were it not for the campaigns I waged on behalf of Savernake hospital in Wiltshire, where I was born; that hospital also saved my mum’s life.

I would like to declare an interest as a taxpayer. The NHS’s approach to individual screening is surely an issue in which we should all be interested—from the point of view of prevention of loss of life and the maintenance of good health, but also in respect of how NHS funding, which is clearly finite, is spent on preventing future problems.

I pay tribute to the Beating Bowel Cancer regime, to Cancer Research UK, to the British Society of Gastroenterology, and to Professor Wendy Atkin, her funders and the 170,000 volunteers who took part in her definitive study of flexible sigmoidoscopy, which is known as a flexi-scope. I also pay tribute to Imperial College London, University College London, the University of East Anglia and St Mark’s hospital, and to the variety of doctors, constituents, charities and members of the public who have worked so hard to combat this problem and have helped me to prepare for the debate—including the clinicians, particularly Dr Colin Rees.

As a Member of Parliament representing a constituency in the north-east, I am proud to say that the north-east leads the way in bowel cancer screening. It was the first to complete coverage of an entire region in April 2010.

Before I embark on the substance of my argument, I also make an apology on behalf of my hon. Friend the Member for Stratford-on-Avon (Nadhim Zahawi), who sponsored the Beating Bowel Cancer reception in the House last year. Much to his regret, he cannot be here tonight. He is a good friend of mine, but he is well known in the House—and, indeed, throughout the world—for having worn the Beating Bowel Cancer tie, which I am now wearing, in the Chamber after that reception. My hon. Friend, who has quite a generous build, was attempting to restrain that generous build with his suit when he accidentally touched a button on the tie, setting off a melody that lasted for nearly two minutes. Madam Deputy Speaker virtually extracted him from the Chamber. I understand that the incident was reported in 25 countries, and did more for the screening of bowel cancer worldwide than anything that anyone has said since.

I have no future as a surgeon, and I assure the House that I have removed the bottom half of my own tie so that there is no possibility of my being extracted from the Chamber for being too musical.

Let me now make some serious points about the clinical position. Traditional bowel cancer screening involves the faecal occult blood test, known as the FOB. In the last few years 11 million people in the country have been offered the test, 6 million have accepted it, 120,000 scopes have followed, and 12,000 diagnostic findings of cancer have resulted. It is clear from the statistics that lives have been saved. Previously those screened were aged between 60 and 69, but screening has now been extended to those aged between 60 and 74. It should be noted that the north-east—leading the way, as it does so often in a medical context—was the first region to extend the age group.

Tragically, take-up of that vital free NHS screening is only 54%, whereas take-up of breast cancer screening is 74% and take-up of cervical cancer screening is 79%. However, the situation is changing. Professor Wendy Atkin and her team have brought flexible sigmoidoscopy to the forefront of bowel cancer screening. The results of their 16-year study were definitive. Their randomised trial, which followed 170,432 people, established that the flexi-scope examination reduces the incidence of bowel cancer in those aged between 55 and 64 by a third. Mortality was 43% lower among that group than it was in members of the control group.

The flexi-scope test works by detecting and removing growths on the bowel wall, known as polyps, which can become cancerous if left untreated. It can prevent cancer from developing by removing polyps before they become cancerous, and provides long-lasting protection from bowel cancer.

I congratulate my hon. Friend on securing this very important debate. Does he agree that screening for certain kinds of hereditary cancers, such as non-polypsosis colorectal cancer, should begin at a much earlier age, and should take place relatively frequently throughout the lives of those who are screened?

I do indeed. I welcome the fact that the guidelines from the National Institute for Health and Clinical Excellence have changed to allow screening to become considerably more frequent in such cases. I am sure that the Minister will comment on that.

Flexi-scope screening will undoubtedly save thousands of lives. FOB screening saved 700 to 1,000 lives a year, and flexi-scope screening will save about 3,000 lives a year. To confirm that, the Government implemented a pathfinder project in three areas. Unsurprisingly, two of those areas were in the north-east, this country’s leading medical region. The three areas were South of Tyne and Wear and Tees, along with Derby. The pathfinder findings are with the Department of Health and have not yet been published, but I can assure the House that, in broad terms, they accord with Professor Atkin’s findings. Last October, the Prime Minister announced a proposal to pilot the scheme nationally in 2012, but there are clinical and funding issues that need to be addressed.

First, when is the Department of Health going to invite bids for the follow-on pilot process, given that that was supposed to be done in 2011 and it is now 23 November?

Secondly, clinicians raise the specific concern that the flexi-scope system is only manageable if we have a sufficiency of trained nurse endoscopists, so where are we in respect of this crucial training? Even with the most amazing piece of equipment, if we do not have the people to operate and interpret it, it is useless. Under this scheme, several hundreds of thousands of endoscopies will have to be carried out, with colonoscopies to follow in about 10% of cases. Therefore, everything will depend on training.

Thirdly, how does the Department of Health plan to assess its age groups? My understanding is that the current group of 60 to 74-year-olds will have FOB testing, and those aged 55 will have a flexi-scope. That is relatively clear, but what will happen for gentlemen and ladies in the 56-to-60 age group is not at all clear. Will they be offered the flexi-scope as well, or is that to be based solely on GP referral? Trusts need guidance on what they are to do with such a large and unknown number of people, as they need to plan budgets, staffing and much more besides.

Fourthly, we need to assess what we are going to do with those who have a flexi-scope at 55 and receive the all-clear and then reach the age of 60. Will we rescreen? Anyone who has ever worked in the health industry will know that there is “health speak”, and in this case the following question would be asked: “What is the parallel screening modality for the future?” As always, “health speak” is gibberish, but the simple question here is: are we going to rescreen people who are fine at 55?

I have also gone through the screening process because of a family history of cancer. My GP and consultant at that time said the screening would have to be done again in a year’s time and then again a year later, in order to be absolutely sure. Has the hon. Gentleman considered whether there should be checks not just every now and again, but on a periodic basis?

It is ultimately up to the clinician—which it should be, frankly. The Minister must say how this policy will be implemented, but it should always be clinically driven.

Fifthly, trusts need confirmation that the pilot projects to be implemented next year will be funded from national funding.

I want to turn briefly to the financial case. The researchers behind the Atkin study suggest that the screening programme will reduce the costs associated with treating people with bowel cancer. Ministers will be aware of the Department of Health-commissioned report, as set out in the memorably named journal, Gut, in 2006, which suggested that if a screening programme based on this test was effective, it could save an average of £28 for every person screened. I urge the Minister to follow what a lot of doctors and others have recommended. We must understand why people do not take up the state’s offer to safeguard their health. If only 54% of those eligible are taking up this offer, that is a serious issue that needs to addressed.

When should we start screening? I speak as an MP whose constituency borders Scotland, and we are often told that in Scotland the health care system is much better, much more expansive and so much more free. In Scotland, FOB screening takes place at 60, not 50 as it does in this country and my understanding is that they do not intend to take up the flexi-scope screening. Personally, I am yet to be persuaded of the clinical or financial basis for screening at the age of 50 given the immense task of screening from the age of 55 onwards, with all the numbers of people who will go through the system. Although there might be pressure—obviously, the Opposition Benches are packed—to move towards such screening at 50, there is no clinical or financial basis in the current system to justify such an approach.

I want to address the possible role of private or other public organisations, suitably supervised, in this process of change. We need to explore the issue of those whom the state must look after but do not take up the offer of screening. It affects both their health and our finite budget. The state must and will always be the provider of medical services in the future—no one disputes that—but it must also enable change and encourage private or public organisations to help in health care. All acknowledge that the take-up of screening is tragically low, as 46% resist the chance to screen themselves for bowel cancer and more than 20% of women resist the chance to have cervical or breast cancer screening. Everybody must accept that there is a problem with that. How can we address that?

Only the short-sighted or extremely socialist would suggest that the state always has the answer to all those problems. What if public sector organisations were to go the extra mile and care for their employees in a different way? We should bear it in mind that the state spends a fortune training its employees to carry out their designated tasks, whether they are consultants, surgeons, endoscopists or nurses. It surely makes sense to safeguard one’s assets—that is, one’s employees. Why not use the public sector as a lead by making it either mandatory or strongly advisable that all permanent core workers should have the screening that their health deserves and that we ask of the rest of the public? I would suggest that they should lead the way. That follows on from the point that is made about flu jabs and the prevention of winter problems in hospital.

We should also consider companies; I want to finish on a localism point. We always criticise employers in this House, but let us say that we had an enlightened employer. Why could they not be allowed or even encouraged to conduct screening of their workers, in whom they invest so much? There is clearly a benefit to the worker, the employer-employee relationship would improve as the employee was valued and cared for, and the state would not necessarily have to pay for the health care screening provided to its citizens. I am talking not just about bowel cancer screening, which is quite complex. Breast cancer screening, for example, is important but not necessarily that difficult.

The cost of such privately paid screening could then be borne in the form of a reclaimable tax break to the company, such as an equivalent cut in the cost of the company’s local business taxes. That would offer localism, increased health screening and better care for employees. Although there might be some data protection issues and concerns about who would pay for the follow-up care, it would unquestionably improve the take-up of screening. I refuse to accept that there is no mileage in my suggestion, which surely brings true localism and better screening to the workplace.

In the minute or so I have left, I want to address the fact that this is men’s health awareness month and individual members of the public must take responsibility for their own health. All around us, perfectly sane men are sporting moustaches as “Movember” kicks into gear. For too long, men have ignored their health. It is well known that they do not have regular check ups. The reality is—I am not surprised the House is not packed this evening—men do not like to talk about the prostate or their bowel. As one of the nurses I met in hospitals put it to me: “Men and their bits—they get so precious about them! If men had to go through what women have to go through with cervical cancer screening and pregnancy they would be a great deal more healthy and self aware.”

I praise the television celebrity Chris Evans for his campaign to show that there is no shame and in fact great benefit in having bowel cancer screening. The shame in such matters exists when people ignore the signs and even die through false manliness or ignorance.

I congratulate my hon. Friend the Member for Hexham (Guy Opperman) on securing the debate and on setting out the issues so clearly. Let me just confirm the answer that he gave to his hon. Friend the Member for West Worcestershire (Harriett Baldwin)—it is the case that the NICE guidance has been changed in the way that he said. I hope that helps her. I look forward to reading the Hansard report of his description of his tie and the removal of certain items that would have made a noise in the debate had he pressed the button.

My hon. Friend the Member for Hexham has used this opportunity very well to raise awareness of these issues further. There has been good progress in bowel cancer survival over the past 30 years, with the survival rates for men and women doubling, but it remains a devastating disease. In 2009, some 32,751 people were diagnosed with the cancer and 12,691 people died from it. In the vast majority of cases, the earlier a cancer is diagnosed, the sooner the treatment can begin and the better the outcomes are likely to be. That is why early diagnosis of cancer is central to the Government’s cancer outcome strategy and that is why it is vital that we do more to diagnose cancers earlier and improve survival rates as a result.

We are focusing on survival rates because they are a much more effective way of addressing and assessing NHS performance, as they show how good the NHS is, compared with other countries, at diagnosing and treating people with cancer. Measures such as cancer mortality figures are not a good way of assessing the NHS’s performance as they are an indicator of both incidence and survival. They indicate more about societal changes than about what the NHS has done.

Screening is one of the most important means by which cancer—and in the case of bowel cancer, of abnormalities that may lead to cancer—can be detected earlier. Research undertaken in Nottingham and Denmark in the 1980s showed that screening men and women aged 45 to 74 for bowel cancer using the faecal occult blood test could reduce the mortality rate from bowel cancer by 16%. An independently evaluated pilot in Warwickshire and Scotland showed that this research could be replicated in an NHS setting. Based on the final evaluation report of the pilot and a formal options appraisal, the programme in England began screening men and women aged 60 to 69 in July 2006, and I am pleased to say that full roll-out was achieved last August.

Experts have estimated that by 2025, about 2,400 lives could be saved every year by the current NHS bowel cancer screening programme. However, I agree with my hon. Friend that there may be more we could do through occupational health interventions. As at 31 October this year, more than 12.2 million kits had been sent out and more than 6.9 million had been returned. We have to do more to get more returns, but from those returns 10,785 cancers were detected and 53,616 patients underwent polyp removal. As my hon. Friend said, polyps that are left untreated can develop into bowel cancer. Men and women over the age limit can request a testing kit every two years, and more than 145,000 have self-referred to the screening programme in just that way.

As some 15% of bowel cancers—4,893 in 2009—are diagnosed in men and women aged 70 to 74, the NHS bowel cancer screening programme is currently being extended to men and women aged from 70 up to their 75th birthday. As at the end of October this year, 33 of the 58 local screening centres had implemented the extension of that programme. When the extension is fully rolled out by next year, about 1 million more men and women will be screened each year.

We know that the evidence for faecal occult blood test screening starts at 50, as shown by the trials that have been mentioned. The original programme invited only people in their 60s because the risk of bowel cancer increases with age. Nearly 85% of bowel cancers arise in people over the age of 60. In the pilot, more than three times more cancers were detected in people aged over 60 than in those under 60, and people in their 60s were most likely to complete the testing kit. In addition, there was not enough endoscopy resource to begin the wider age roll-out. To underline a point that my hon. Friend made, in terms of cost, the 2004 working group report on NHS cancer screening programmes, which assessed a number of models for bowel cancer screening, found that starting at age 50 ranked fifth—bottom—in terms of cost-effectiveness.

The national endoscopy training programme has allowed us to begin extending the programme to people up to age 75. However, this extension to the current programme, the planned introduction of flexible sigmoidoscopy screening, which I will come back to in a moment, and the move to more investigations of symptomatic patients mean that a key priority is to increase endoscopy activity. We have begun from a low level, as my hon. Friend suggested, with much lower rates of endoscopy than many other comparable countries. For example, colonoscopy rates in England are eight per 1,000 population, compared with Scotland, where they are 12 per 1,000 population, and Australia, where the rate is 21 per 1,000.

The Department has undertaken further modelling work to estimate the demand for endoscopy services up to 2015-16. That analysis shows that the NHS will need to increase lower GI endoscopic capacity by 15% a year over the next five years to meet underlying growth and the commitments set out in the Government’s cancer outcomes strategy. In response to my hon. Friend’s question, that is how the issue about the work force and making sure that there is a sufficient supply of nurse endoscopists is being addressed.

Funding for an increased number of endoscopies has been put into primary care trust baselines, and that is part of the £750 million over four years that accompanies the cancer outcomes strategy. While it is primarily for the NHS to take the necessary steps to increase endoscopy activity, we are looking at the scope for central support, for example, through service improvement work led by NHS Improvement. However, we are making a huge investment in our bowel screening programme for people in their 50s, in response to my hon. Friend’s fifth question about funding. In September 2010, we announced £60 million of funding for the introduction of a life-saving new screening method—flexible sigmoidoscopy—in the programme.

Flexible sigmoidoscopy is an alternative, and a complementary bowel screening methodology to faecal occult blood. New evidence shows that men and women aged 55 attending a one-off flexible sig screening test for bowel cancer can reduce the risk of mortality from the disease by 43%, and it can reduce the incidence of bowel cancer by 33%. Flexi sig involves a thin, bendy tube, which the doctor uses to look at the inside wall of the bowel and remove any growths—polyps—that are present. Bowel cancer usually develops very slowly from polyps, which are called adenomas. By removing them at an early stage, it is possible to prevent bowel cancer from developing.

My hon. Friend referred to the randomised controlled trials conducted by Cancer Research UK, the Medical Research Council and NHS R&D in 14 UK and six Italian centres. The study concluded that flexi sig is a safe and practical test and, when offered only once between the ages 55 and 64, it confers a substantial and long-lasting benefit. Based on the trial figures, experts estimate that we could prevent as many as 3,000 cancers every year and save thousands of lives.

In 2011, pathfinder sites tested organisational arrangements for the operation of flexi sig screening, with particular attention to the invitation and appointment process. That will enable optimal strategies to be applied in the national pilots. The pathfinder sites were in the Tees, south of Tyne and Wear, and Derbyshire local screening centres. We have formal agreements in place to develop the IT system for flexi sig—I hope that that answers my hon. Friend’s first question—and local screening centres will be invited to bid to become pilot sites early in 2012.

In response to my hon. Friend’s third and fourth questions, the bowel cancer screening advisory committee has advised that people should be invited at age 55, with two reminders, before they become eligible for the faecal occult blood test programme at 60. People from the original trial are being followed up to gain information about the most appropriate faecal occult blood test policy for people who have undergone flexi sig screening. We do not have the answer yet, but we are working to make sure that we do have a clear answer to assist physicians.

The coalition Government’s cancer strategy set out our aim to achieve 30% coverage of flexi sig screening across England by 2013-14, and 60% by 2014-15. It is envisaged that full roll-out will be achieved by 2016. We are also looking at other ways in which we can improve bowel cancer screening. Our cancer outcomes strategy sets out how NHS cancer screening programmes will look at how more accurate and easier-to-use immunochemical faecal occult blood tests—those are words that one can struggle with, and I hope Hansard will be kind to me—can be introduced into the programme, potentially to increase uptake and to provide more accurate results. A protocol has been devised to pilot such testing within the programme to assess the feasibility, practicality and cost-effectiveness of moving to this new technology.

To date our awareness activity has focused on bowel cancer, lung cancer and breast cancer, and we have spent nearly £11 million supporting 59 cancer awareness campaigns and trialling a national bowel cancer campaign. That campaign is about making sure that people do not die of embarrassment when it comes to bowel cancer, and that, if they think there is blood in their poo or if they have loose stools, they will go and see their GP and get a referral for a diagnosis. It is also about Ministers, as much as anyone else, overcoming their embarrassment about talking about it. The more we are prepared to start talking about these embarrassing subjects, the less people will die of embarrassment as a result.

We know that the pilot, the Be Clear on Cancer campaign, which we launched in January this year and ran for seven weeks in the east of England and in the south-west, made a real difference in the number of people being referred into the programme. The evaluation of the Be Clear on Cancer campaign to date has shown that people have become much more aware of the signs and symptoms of bowel cancer, people have been very supportive of such campaigns by the Government, and there has been an increase of about 50% in people over 50 with the relevant symptoms going to see their GP. This increase will lead to people being saved.

I hope this debate has reassured people that the Government take bowel cancer screening as a serious priority. We are determined to save more lives in future and I congratulate my hon. Friend on securing this important debate.

Question put and agreed to.

House adjourned.