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Cancer Treatment: Psychological Support

Volume 649: debated on Thursday 22 November 2018

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

I am grateful to be granted this debate on psychological support after cancer treatment. I recognise that there will probably be fewer Members here than there have been in the last few hours, but I thank anyone who stays to hear what I have to say.

When we talk about cancer, the conversation often starts with survival. Overall, survival has doubled in the last 40 years in the UK, but we lag behind the best in Europe, and survival rates for certain cancers—such as lung, brain and pancreatic cancer—continue to be extremely low. That means there is, rightly, a drive towards earlier diagnosis and access to new and innovative treatments. However, for most patients, just living is not enough. They want to live well, and that is why we must do more to ensure that patients receive the best possible psychological support after cancer treatment.

It goes without saying that cancer can take a huge emotional toll on patients and those close to them, right from the moment of diagnosis. Less well understood are the consequences of cancer treatment, which can affect patients’ lives on a daily basis and leave them needing support for many years afterwards. No group illustrates that better than stem cell transplant patients.

Every year in the UK, around 2,000 blood cancer patients need a stem cell transplant from a donor to save their life. It is usually their last hope. One third of patients will be lucky to find a matching donor in their families, but the remaining two thirds of patients will require an unrelated donor. The search for a donor can be extremely stressful. Despite the fact that there are more than 1.4 million incredible individuals on the UK stem cell donor register, there are still patients who miss out on the life-saving transplant they need because either no donor is available or a donor cannot be found early enough.

My experience with my son was that we were very fortunate to find a donor. That donor then failed his medical, which was a traumatic experience for the family. Not only were we concerned about what the problem was for the donor, but we did not know whether the donor would return to fulfil that pledge. We will be eternally grateful that he did.

Even when a patient does find a match, this is not the end of their journey. Tellingly, the day of the stem cell transplant is commonly referred to as day zero. First, the patient must spend a number of weeks in hospital isolation to protect them from infection. This alone can be a very difficult experience, with patients often feeling very cut off from the outside world. Things such as patchy wi-fi, poor facilities and rooms without windows do not exactly help with this experience. Hopefully, the patient then begins their recovery, which brings with it entirely new physical, emotional and practical challenges. In fact, of all cancer treatments, stem cell transplant patients experience some of the most severe long-term effects, and it is for that reason that they are often described as patients for life.

To give hon. Members some idea of what it can be like for those living with the long-term effects, approximately half will suffer from graft versus host disease, which is when their new immune system attacks their own body. I can certainly say that this is not a particularly pleasant experience, and in the worst cases it can actually kill the patient as well. Patients can also experience infertility, premature menopause, sexual dysfunction, fatigue and problems with their eyes, bones, teeth, joints and muscles, and they are at higher risk of infections and secondary cancers. In addition, it is not unusual for patients to be left with a range of psychological effects, including depression and post-traumatic stress disorder. All of this can have an impact on patients’ ability to study and work, and with that can come financial issues and even a loss of their identity. It can be completely and utterly overwhelming.

With all this in mind, it is perhaps not surprising that in response to a survey of more than 300 stem cell transplant patients conducted by Anthony Nolan, the UK’s stem cell transplant charity, nearly half—47%—said that they needed emotional and psychological support, such as counselling or group therapy. It is surprising and even shocking that only half—54%—actually received it.

Let us take some individual cases. Joanna received a stem cell transplant in 2016 to treat acute myeloid leukaemia. It saved her life, but when she got home to her family, she could not get off the sofa or out of bed. It was the worst she had felt since the actual diagnosis. Her daughter was only a teenager at the time, and the caring role of mother to child had to be reversed. In Joanna’s own words:

“I think my lowest emotional time was after transplant. I questioned why I’d gone through this experience and just couldn’t see an end in those first three to four months… I wish there had been more psychological support for me and my family—even though staff tried their best, when I really needed help, it just wasn’t there.”

Joanna’s story is not unique.

Ruth, a teacher from Yorkshire, also received a stem cell transplant in 2016. In the two years since, she has experienced many ups and downs, and she is still dealing with chronic graft versus host disease. For her, this means her eyes are constantly dry, she cannot perform fine motor skills too well and her feet are in constant pain because of nerve damage. Ruth says:

“The biggest downside of my whole transplant experience has been the complete lack of support since leaving hospital. It felt like I was on my own—my GP has offered me nothing. I’m on the waiting list for a counsellor, but it’s very long… I’m surprised you’re not referred to a counsellor as soon as you’re diagnosed.”

As well as those patients who have received transplant, the charity Macmillan has provided me with some other brief personal stories. Let us take Frances, who finished treatment for Hodgkin’s lymphoma five years ago. She says:

“Emotionally, in the first year after treatment I think I was shell-shocked because you’re trying to catch up with everything that has happened to your body. You feel like you’re a failure and you’ve failed to bounce back in the way you think you should have done.”

Ciara, who finished treatment in 2016, says:

“The fear of cancer never leaves you but I’m trying now to think, if it comes back, it comes back. I can’t live under that shadow. But it is so difficult to mentally recover.”

Finally, Chris, who finished his treatment for head and neck cancer in 2016 stated:

“People say to me, ‘I bet you wake up every morning feeling glad to be alive.’ You know, it can’t be further from the truth.”

The stories from Joanna, Ruth, Frances, Ciara and Chris affect all cancer patients—they cover everybody.

So what do we need to do? First, psychological support is for everyone, not just those with diagnosed mental health conditions. Secondly, the families of patients should also be offered psychological support, and thirdly, it seems that patients and their families are not getting the psychological support they need. Let me address those points in turn.

First, psychological support is for everyone, not just those with diagnosed mental health conditions such as depression or post-traumatic stress disorder. That includes patients who are feeling anxious, worried or frightened, and those who are having trouble adjusting to their “new normal”. The fear of cancer returning can be particularly difficult to manage. For example, some blood cancers relapse, which can be a common occurrence. Even if someone is doing physically well, that sense of dread never goes away for them or their family members.

Because of patients’ varied needs, psychological support can take many forms. Clinical psychologists and others working in improving access to psychological therapies services are able to help those with the most complex needs. Clinical nurse specialists, who we know are hugely valued by patients, can enhance overall wellbeing by providing general emotional support based on skilled communication and effective provision of information. The third sector, meanwhile, provides a wide range of services, including helplines, online forums and peer support. There is no silver bullet, however, and many different actors have a role to play.

Secondly, patients’ families should be offered psychological support because they too feel the consequences of cancer treatment. If someone is acting as their loved one’s carer, that can affect their relationship and ability to go about their daily life. They might have suddenly become the family’s main breadwinner, which could be a source of enormous stress. Family members will often feel as if they have to put a brave face on things and somehow do not deserve help because they are not the ones who are ill. In reality, however, patients regularly say that they worry more about their family than themselves and that in turn can affect their recovery. I know from personal experience that the CLIC Sargent nurse who came to us on a weekly basis to give my son chemotherapy was somebody to talk to who understood, and that side of the process was just as important to us as the medicine being given.

Thirdly, patients and those close to them are not getting the psychological support they need. According to the most recent results from the national cancer patient experience survey, only two thirds of patients felt that they were able to discuss their fears or worries, and I hope the Minister will respond to that.

In many cases, this comes down to workforce—either not enough specialists are available who properly understand the consequences of cancer treatment, or the demands on staff time are so great that it is impossible to provide patients with adequate psychological support.

In response to a 2017 survey of GPs and nurses, 31% of respondents said that workforce pressures mean patients are not being supported to regain a good quality of life after treatment. In other cases, the right support existed but patients are not being appropriately signposted. I have heard of many patients having to be proactive and find help for themselves. Patients should certainly be empowered to take control of their own care, but I think we all agree that this should be a choice and not a necessity. They should not be let down by poor communication and co-ordination, but in many cases they are.

The Minister may refer to the recovery package in her response. It consists of four main interventions: a holistic needs assessment and care plan; a treatment summary; a cancer care review; and access to a health and wellbeing event. This can certainly help to identify patients’ psychological needs and I welcome the fact that NHS England has committed to rolling out the recovery package nationally by 2020. However, does the Minister agree that identifying patients’ needs is only one piece of the puzzle and that more needs to be done to ensure they actually receive the right psychological support?

My hon. Friend is making an extremely moving speech. Does he agree that getting the right psychological support from the start also helps the medical treatment? For many cancer patients and their families—as he said, it is very painful for them to watch the treatment—getting psychological support helps them to be able to face going through the treatment, which can be so devastating, as I know he knows.

That is very important. What we tend to do throughout the whole process is address the disease itself and its physical aspects, but we do not address the psychological damage and problems that can occur. My hon. Friend is absolutely right that we need to do that.

Before I close, I would just like to take a moment to talk about the specific needs of children, teenagers and young adults who have had cancer. They experience many of the same physical and psychological problems as adults, but they also face some unique challenges, such as the impact on their growth and development, education and future prospects. Earlier this year I was very pleased to be part of the inquiry into patient experience by the all-party parliamentary group on children, teenagers and young adults with cancer. I would like to put on record my thanks to my hon. Friend the Member for Bristol West (Thangam Debbonaire), who set up the group and chairs it. She is doing sterling work and I thank her for that.

When parents and young people were surveyed, 73% felt that not enough was being done to ensure access to post-treatment support. Some 26% of parents and young people identified mental and emotional help as the biggest improvement needed. As Kate Collins, chief executive of Teenage Cancer Trust, summarised:

“Young people have told us that actually the experience of being spat out at the end of treatment can be as traumatic as diagnosis, because all of a sudden you’ve been radically changed, you’ve been through this remarkable transformation experience in lots of ways, you’ve faced problems that lots of adults have not had to face…you may be clear of cancer but often young people are living with long-term effects, be they psychological or physical.”

The all-party group therefore recommended that the Department of Health and Social Care makes mental health support for children, young people and parents a key part of diagnosis, treatment, follow-up and recovery. Furthermore, NHS England should engage with children and young people with cancer to ensure that the recovery package meets that specific need. The all-party group also recommended that the Department of Health and Social Care and the Department for Education should re-examine their proposals in the mental health Green Paper and take account of the impact of a long-term physical condition on young people’s mental health.

When the Under-Secretary of State for Health and Social Care, the hon. Member for Winchester (Steve Brine) gave evidence to the all-party group, he said:

“For the 80% of children who survive, they’ve got it all ahead of them, so we have to make sure that we tool them up to live their lives.”

Can the Minster tell us what she and the Department are doing to give children, teenagers and young adults the tools they need to deal with the psychological consequences of their treatment?

CLIC Sargent’s 2017 report, “Hidden Costs”, found that 79% of young people felt that cancer had a serious impact on their emotional wellbeing, 70% experienced depression, 83% experienced loneliness, 90% experienced anxiety and 42% experienced panic attacks during their treatment. For parents, the figures are similar: more than half of parents—63%—said that they experienced depression, more than one third experienced panic attacks, and 84% experienced loneliness.

It goes without saying that surviving cancer is brilliant news. However, I urge the Minister and everyone here today to remember that although survival rates are improving, people are living with the effects, including the long-term effects, that cancer has dealt them. We must do more to ensure that patients such as Joanna, Ruth, Frances, Ciara and Chris not only live, but live well. That means taking action to improve the provision of gold-standard psychological support. Finally, I thank Anthony Nolan, CLIC Sargent, Macmillan and the Teenage Cancer Trust for their help.

I am sure that I speak for everyone here in congratulating the hon. Member for Alyn and Deeside (Mark Tami) not just on securing such an important debate, but on the bravery he showed in his speech by sharing with the House his family’s experience. It is very important that we bring the voices of the people we all seek to serve in this place into the Chamber, as well as the experiences that were shared from CLIC Sargent and Macmillan, so I thank him for that. I know that he is doing extremely good work through a number of organisations in the House to ensure that cancer patients are getting the very best treatment and support. He has also given a huge amount of support to setting up the all-party group on children, teenagers, and young adults with cancer. Although the hon. Member for Bristol West (Thangam Debbonaire) has left the Chamber, I praise her work on the really good report that she and the hon. Gentleman produced. I read it last night and thoroughly recommend it to other Members.

I am standing in for the Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Winchester (Steve Brine), who has ministerial responsibility for cancer. He is very sorry that he cannot be here this evening and he was very pleased to be able to contribute to the APPG’s report. He asked me to remind the House that he has agreed to respond to everything—all the recommendations—in the report, so the hon. Member for Alyn and Deeside will get a full written response from him.

I am pleased to respond on the Government’s behalf to this debate, because it brings together two vital issues, which are crucial to the health of the nation and are at the top of the Government’s priority list. Approximately one in four people in the UK experience a mental health problem every year. In England, one in six people report experiencing a common mental health problem, such as anxiety and depression, in any given week. Cancer affects one in two of us—there will not be anyone here this evening who has not been dreadfully affected by this disease—so it is absolutely important that the Government are focusing on these priorities.

Since 2010, cancer survival rates have been improving year on year. We estimate that some 7,000 people are alive today who would not have been here just 18 years ago, but we are not at all complacent. We know that there is more to do to make sure that our results are the best in the world. That is why last month the Prime Minister announced a package of measures, which will be rolled out across the country and which aim to see three quarters of all cancers detected in the earliest stages by 2028. The plan, backed by a record level of investment in the NHS—an extra £20 billion a year by 2023—will radically overhaul screening programmes and provide new investment in state-of-the-art technology to transform the process of diagnosis and boost research and innovation.

However, what I really want to talk about in the few moments available to me is the support that we must give to people who are living with and beyond cancer. The recovery package, which is a key component of that priority, consists of a set of four interventions that are designed to help patients and clinicians to assess patients’ holistic needs and plan appropriately for their care and support. They include a holistic needs assessment and a care plan, which guide conversations about patient’s holistic needs—not just physical and psychosocial needs, but financial, social and mental health needs. An HNA should take place within 31 days of diagnosis and at the end of each acute phase of treatment, and the care plan should be updated on each occasion. Both interventions enable patients to be referred to appropriate psychological support when necessary.

That personalised follow-up and support to help people to live well with and beyond cancer is a crucial element of the cancer strategy, and helps us to create the world-class cancer services to which we aspire. NHS England will roll out recovery packages nationwide by 2020, so that the support that they provide is available to all cancer patients in England regardless of where they live. All Cancer Alliances are receiving the necessary funding this year to support full implementation of the recovery package.

As the hon. Gentleman has said, some cancers, such as chronic blood cancers, can sadly never be cured. Blood cancer patients are frequently on a regime of “watch and wait”, often over many years, to establish whether their cancer has progressed to a point at which treatment needs to begin. Understandably, that can take a huge psychological toll on not only patients but their families, which is why the recovery package takes a holistic approach and fully considers the patient’s mental health needs. The package is already being commissioned and delivered, in full or in part, by many clinical commissioning groups across England, but NHS England’s aim is to accelerate the process to ensure full implementation by 2020 so that every cancer patient is given that full package of care.

Of course we need to ensure that cancer patients, and their families and carers, can access appropriate mental health services if and when they need such support, which is why the Prime Minister has made improving access to mental health services an absolute priority for her Government. There has been a fivefold increase in the number of people accessing Talking Therapies since 2009-10, and that is excellent progress, but we are not complacent; we know that much work needs to be done. In July last year, the Government announced an additional £1.3 billion to expand the mental health workforce and allow the NHS to treat an extra 1 million patients by 2020-21. That will help to ensure that cancer patients can be referred promptly to any psychological support that they need as part of their recovery package. We know that clinical nurse specialists can provide not just clinical but crucial emotional support for cancer patients as they go through cancer treatment, and—often more important—in the follow-up after their treatment.

Does the Minister agree that we use the word “cured” far too often, as though there were a cut-off point when people are cured and therefore exactly the same as everyone else, and exactly the same as they were before? The problem with that is that it is not true: it does not take full account of the reality.

The hon. Gentleman has made a very important point. That is why the tailor-made, holistic approach to treating every person as an individual is so important: no two people will respond in the same way. No two people have the same family or community support networks around them, so it must be tailored to the individual. There must also be a recognition that some people might need a lot more help over a longer period of time than others. That is why it is so important that NHS England has committed to more people having access to clinical nurse specialists, and why last year’s cancer workforce plan produced by Health Education England committed to greater investment to make sure that everybody has access to that support. There is also a great opportunity here to signpost people to be supported by the wonderful voluntary sector organisations that the hon. Gentleman mentioned this evening.

In conclusion, I want to reaffirm the Government’s utter commitment both to improving people’s survival rates from cancer and to making sure they have tailor-made, supported arrangements, including psychological services, so that people can, not just survive cancer, but live well with cancer and continue to play their full part in society.

Question put and agreed to.

House adjourned.