Question for Short Debate
My Lords, my reason for bringing this debate today is to improve awareness of the increase in cases of cancer of the head and neck, and to consider what actions should be taken to deal with these very unpleasant and often fatal conditions. Tongue cancer and mouth cancer are the most common in the group of cancers of many sites within the head and neck area. My particular interest is oral cancer, which, as a former dentist, I look on as cancer of the mouth, but the definition includes head, neck and throat cancers, and the title of the debate is to widen the subject.
Oral cancer is the 15th most common cancer in the UK. Assessment is important but progress towards earlier diagnosis, urgent follow-up and specialist treatment is the real essential. Great work is being done in study, research and treatment, in London by the Eastman Dental Institute, King’s College London Dental Institute and the Royal Marsden, and others in different parts of the country. I would like to record my thanks to these organisations, and to the Oracle Cancer Trust, a charity that does much to help patients and increase awareness, for the data it provided me for this debate.
To quote from a review article published in Oral Diseases in 2010:
“Worldwide, oral cancer has one of the lowest survival rates and poor prognosis remains unaffected despite recent therapeutic advances. Reducing diagnostic delay to achieve earlier detection is a cornerstone to improve survival. Thus, intervention strategies to minimise diagnostic delays resulting from patient factors and to identify groups at risk in different geographical areas seem to be necessary. The identification of a ‘scheduling delay’ in oral cancer justifies the introduction of additional educational interventions aimed at the whole health care team at dental and medical practices”.
In the UK, between 1989 and 2006 there was a 51% increase in oral, tonsil and base of tongue cancers in men, from seven per 100,000 of the population to 11 per 100,000. Unfortunately, almost half of the oral cancers are diagnosed at stages 3 or 4, which are the advanced stages. Delay in diagnosis is now considered to be either patient delay or professional delay. Diagnostic delay is measured by the number of days elapsed since the patient notices the first signs and/or symptoms until a definitive diagnosis is reached. Studies suggest that 30% of patients delay seeking help for more than three months following the discovery of symptoms of oral cancer. There is a great need to improve public awareness not only of the condition but of the need to seek assessment as soon as possible, thus increasing the possibility of effective treatment. Early diagnosis can decrease morbidity and may improve overall long-term survival. In cases of laryngeal cancer, diagnostic delay has a remarkably worsening effect on survival.
What is the cause of oral cancer? Most cases of carcinoma are linked to lifestyle factors and should therefore be preventable. Most important is the excessive use of tobacco and alcohol, and in some groups, betel quid juice is relevant. Diet is significant, and another reason in favour of fresh fruit and vegetables. The recommended five portions a day should include red, yellow and green fruits. In a minority of cases, particularly among younger patients where known risk factors are absent, human papilloma virus, HPV infection, is now thought to be a likely cause. HPV infection has also been considered as a cause of oropharyngeal cancer. It is hoped that the recent HPV vaccination programme in teenage girls may have a longer beneficial impact on the incidence of this cancer. People with poor dental health, such as sharp broken teeth, dental sepsis or trauma from ill-fitting dentures, are at a slightly increased risk. An ulcer—a lesion that breaks the surface lining of the mouth—that fails to heal within two weeks with the appropriate therapy and correction of any possible causative factors, and for which no other diagnosis can be established, should be suspected of being a malignant ulcer. Hardening or enlargement of the lymph nodes in the neck are another warning sign, and attention must be sought by the patient.
There are many potentially malignant conditions, but I do not have time to list them today. It is for clinicians to be aware of these and to diagnose them. The public need simply to be aware that any noticeable change in the mouth should not go unheeded. Dental professionals need to keep abreast of the latest developments, and they can do this through lifelong learning, as they remain the major diagnosticians. However, it is essential that family doctors should be aware of oral anatomy so that they know the difference between normal and abnormal. When carried out competently, screening of oral mucosa should not take more than three minutes, and training should mean that these procedures are effective. Dentists should give advice to patients to enable them to recognise the signs and symptoms at an early stage and thus to seek early treatment. This would help, but it needs to go wider than that; pharmacists and dental hygienists need to do this as well.
A study published in 2010 in the British Dental Journal showed that oral cancer is an important health issue in Scotland. Some of the young appreciate that alcohol and tobacco are causative factors, but the findings suggest that even among people who have the disease, understanding of the link between alcohol, tobacco and oral cancer is still limited. A number of people could recall the related television campaign and supported the view that it had played an important part in their own diagnosis and treatment. The West of Scotland Cancer Awareness Project, funded by Cancer Research UK, led many patients to make an initial appointment with a health professional to have symptoms investigated. I understand that this is the body which financed the television programme. This is a most important message, and a number of patients with oral cancer reported that it was the programme that had saved them. I hope that the Minister will pass that message on to the Department of Health.
Intra-oral cancer is particularly lethal, whereas cancer of the lip is less so. In my early practising days, many of my patients presented with a white patch on their lower lip. This is called leukoplakia and is considered pre-cancerous. In those days it was common to see men walking around with a fag hanging on their lip. Holding a cigarette or pipe almost constantly in place on that spot was one of the main causes of the symptom. Leukoplakia still occurs but for different reasons, as lifestyle habits have changed. The important thing to realise is that any white or red patch in the mouth should not be ignored. It requires proper assessment and treatment without delay.
I cannot say too often that early diagnosis is essential for the successful treatment of any cancer. Years ago, when we had free dental examinations, people went more regularly to the dentist, and early lesions were discovered, mostly by dentists. Dentists are usually still the first to see a mouth cancer, but it is essential that GPs are aware of the need to do routine checks, particularly if the patient has not had a dental check-up for some time.
Above all, the public need to be aware of the warning that comes with any change in their mouth, or any ulcer that does not heal. They should present immediately for assessment and possible treatment. If the practitioner—doctor, dentist or nurse—believes that there is cause for concern and the condition does not improve with treatment within two weeks, the patient should be referred for a biopsy, which is the only definitive diagnostic tool. If cancer is suspected, the referral must be marked “urgent”, in accordance with NICE criteria, to reduce the pre-treatment interval. The number of patients who attribute their successful treatment to the fact that they saw a Department of Health warning or information is high.
I will make a few brief points to close. There needs to be a referral change. In your Lordships’ House I have for some years pressed for mouth examinations to become routine when any patient attends an accident and emergency department or polyclinic—about which we seem to hear less now—and that in the interests of treating numbers and managing to finance this, unqualified staff could be trained in the first instance to carry out a quick check. If there is any cause for doubt about the mouth condition being normal, they would refer the patient up the line to either a specialist nurse or a dental hygienist who would then decide whether they should be referred further so that appropriate treatment could be provided, urgently if indicated. The previous Labour Government agreed that this would be a worthwhile thing to do and confirmed that semi-skilled health workers could carry out these brief mouth checks. It would not require qualified dentists or doctors at the preliminary stage. I still think that this would be very valuable and I press the Minister to give it serious thought.
My Lords, I thank the noble Baroness, Lady Gardner of Parkes, for securing the debate. It is timely and allows all areas around the treatment of head and neck cancers to be discussed. I will examine areas around diagnosis, prevention, treatment and the pivotal role that cancer networks have played in achieving improved head and neck cancer services.
The noble Baroness is well known for her championing of the role of the dentist. In the area of cancers of the head and neck they can be key players in diagnosis, spotting signs and symptoms before the patient and their GP. However, there are issues around this that need resolving in the area of the training and continuing professional development of dentists and GPs.
The evidence on the incidence of head and neck cancers and their occurrence in younger age groups is mixed. The prime causes of most of these cancers are smoking, alcohol and a poor diet—back to the five a day and three different-coloured fruits—as well as the human papilloma virus. That suggests that the age range of those affected might be wide.
There is a clear public health role in prevention. If Public Health England and public health departments in local authorities carry out the roles envisaged for them in the Health and Social Care Act, the incidence of these cancers should reduce. However, care must be taken to ensure that the NHS, Public Health England and local authorities co-ordinate their approaches and campaigns. At least three-quarters of oral cancers could be prevented by the elimination of tobacco smoking and a reduction in alcohol consumption. The scheme to make cigarette purchase less easy is to be welcomed and I urge the Government to follow the advice and not the tobacco lobby in adopting plain packaging for cigarette packs at the earliest opportunity.
Can the Minister tell the Committee what plans the Government have to address the issue of underage drinking in the home? Despite the scenes of rowdy young people in town centres, most alcohol is actually drunk at home by young and old alike.
As we have heard, HPV is often linked to oropharyngeal cancers. The evidence of this cancer has doubled in 10 years. There must be a case for vaccinating all teenagers and not girls alone. Will the Minister consider looking at the evidence for this?
Most people do not know that radiotherapy cures more cancers than drugs. Cancer patients should have access to treatments that their doctors think will be best for them. It is essential that new radiotherapy techniques, such as intensity modulated radiotherapy—IMRT—are rolled out swiftly. IMRT can be really beneficial to patients with cancers of the head and neck. It focuses very much around the cancer itself and does not spread to surrounding tissue. It is a welcome announcement that £15 million is to be found for such targeted radiotherapy treatment. For this to be widely available across England there are implications for both equipment and training, but it is a good start.
Currently all aspects of cancer care are co-ordinated by cancer networks, multidisciplinary teams looking at the whole pathway through diagnosis, treatment, hospice and palliative care where required, and aftercare when the patient returns home. This is all about integration at work. They have played a key role in driving up the quality of cancer services and patient experiences for the past 12 years. I draw attention to the excellent work of cancer networks and raise some concerns about their future in the new system.
In England there are 28 cancer networks that, since 2000, have been bringing together providers and commissioners of cancer care to work together to plan and deliver high-quality, integrated cancer services for people living with and beyond cancer in their local areas. These networks drive forward local cancer strategies. They are a key source of cancer expertise, encourage service redesign and integration, and monitor the performance of providers to highlight poor outcomes. Many cancer networks have been central to the implementation of NICE’s guidance on improving outcomes on rarer cancers. Many of the cancers that we are discussing today fall into that category. More specifically, they have also been acknowledged as key players in delivering NICE’s service guidance on improving outcomes in head and neck cancers. These are not common cancers, and the networks have been used to disseminate information.
NICE recommends that networks should be charged with deciding which hospitals will diagnose, treat and care for these particular patients. So when it comes to the quality of care that people living with head and neck cancers receive, networks have been driving service improvements throughout the country. An example of integration and service improvement is the Greater Manchester Cancer Network, which has a head and neck clinical sub-group with the aim of overseeing, supporting and bringing together multidisciplinary teams working on these types of cancer to ensure that each patient gets the most appropriate treatment and the highest standards of care. There are several networks that have co-ordinated to inform local strategies for head and neck cancers and to promote integration: East Midlands, Anglia, Central South and North London to name a few. These have been absolutely pivotal. They have also been critical in driving up patient involvement. The Peninsula Cancer Network hosts head and neck cancer support groups across Torbay, Cornwall and Plymouth for people who find it difficult to eat, drink or speak after having treatment due to head and neck cancers.
It was encouraging that, last year, the former Health Secretary made a public commitment to fund and support cancer networks in 2012-13. I welcome the proposals on clinical networks recently published by the NHS Commissioning Board Special Heath Authority which officially establish cancer networks as strategically clinical networks in the new NHS.
However, the significant changes proposed for the new structure for cancer networks leave me with a worry about how networks will be supported in delivering their key services. In the sector, there are fears in three distinct areas. The first fear is of a drastic reduction in the staffing levels for cancer networks. The proposals indicate that there will be only eight permanent staff in each regional team, compared to 20 staff members currently in post per network. Research carried out by Macmillan also showed that a number of network directors reported difficulties in recruiting and retaining staff because of uncertainty around resourcing. Can the Minister assure the Committee that cancer networks will have sufficient staff to carry out their functions effectively?
The second fear is of a loss of experienced directors, which would have an impact on the effective running of cancer networks. Under the proposals, existing directors with a wealth of knowledge in the development and delivery of high-quality cancer care in their region will have to reapply for their roles. Recruiting and training senior staff, some of whom have had no previous experience in cancer, could have a negative impact on the quality of services and support that cancer networks provide. Can the Minister suggest what steps he will take to ensure that experienced directors and cancer experts are retained?
The third fear is of cancer networks’ role being limited to early diagnosis. Although improving earlier detection of cancer is essential to preventing people dying prematurely—as we have heard today, head and neck cancers often go a long time before they are detected—cancer networks need a comprehensive remit to be able to continue delivering the functions mentioned above. They must continue to play a leading role in improving outcomes and the experiences of people living with head and neck cancers across the pathway. Can the Minister confirm that cancer networks will be able to continue delivering functions that cover the whole pathway? Cancer networks have played a leading role in delivering improved outcomes for rarer cancers, including head and neck cancers. I am pleased that the Government have recognised their value and formally established them as strategically clinical networks. However, significant steps are needed to ensure that they continue to have a comprehensive remit beyond early diagnosis. The Government should be mindful that severe reductions in resource would make it difficult for them to meet their commitment of supporting networks after 2013 and reaching their ultimate ambition of saving 5,000 lives a year. I would be grateful if the Minister could update the Committee on the Government’s plans for cancer networks and reassure us that they will have sufficient resource, human and financial, in the system.
I again thank the noble Baroness, Lady Gardner, for securing such an important debate. We must not forget that the NHS reforms offer an opportunity to refocus on delivering the best possible cancer care and outcomes for all patients, including those with head and neck cancers.
My Lords, I congratulate the noble Baroness, Lady Gardner of Parkes, on securing this important debate and thank her for her very informative and helpful introduction. As we move towards the new health system, it is vital that people with rarer cancers are fully recognised and receive the specialist care that they need so that outcomes can be improved in the less common as well as the more common cancers. I declare an interest as chief executive of Breast Cancer Campaign, which is a research charity.
As noble Lords know, the Government published their strategy for cancer in January 2011, stating their ambition to save an additional 5,000 lives from cancer every year by 2014-15, to improve the experiences of cancer patients in England and to narrow the gap in cancer outcomes between different groups in society. In turn, the All-Party Parliamentary Group on Cancer, of which I am a vice-chair, published a report in 2011, Effective Cancer Commissioning in the New NHS, which set out recommendations that would support the NHS in achieving the Government’s aims.
The all-party group has spent this year campaigning for implementation of our recommendations, focusing particularly on the new accountability structures, the NHS outcomes framework and the commissioning outcomes framework. We have raised the issue of improved outcomes in less common cancers, including the head and neck cancers that we have heard about today.
Key to improving outcomes and to achieving the Government’s ambition of saving an additional 5,000 lives from cancer each year is earlier diagnosis, as we have heard so eloquently put by the noble Baroness, Lady Gardner. The earlier a cancer is diagnosed, the greater the chance a patient has of surviving it. That is why the all-party group has long campaigned for the NHS to be measured against one-year cancer survival rates as well as five-year survival rates for all cancers and all ages—not just the common cancers.
That is because in the new health system the NHS outcomes framework will be used by the Secretary of State to hold the NHS Commissioning Board to account for its performance. As such, it sets the overall direction and priorities for the NHS. We were pleased that the Government included one-year and five-year cancer survival rates for breast, lung and colorectal cancer for people aged between 15 and 99 in the NHS outcomes framework. However, as we know, cancer is one of the biggest premature killers in this country and we do not believe that the current version of the framework goes far enough.
We know that 53% of people who die from cancer in the UK have a rarer cancer, such as head and neck. There is a significant gap in survival rates between people with a rarer cancer, such as head and neck cancers, and those with a more common cancer. For example, the five-year survival rate for brain cancer is less than 20% compared with more than 80% for breast cancer. We must take steps to ensure that survival rates for rarer cancers improve and catch up with those for the more common cancers such as breast cancer. Across the board, there is a lot more to do and we need to do more. The APPGC is calling for one-year and five-year survival rate indicators in the NHS outcomes framework to be extended to all cancer types.
We are pleased that the Government are listening to our concerns and know that, as a result, they are considering developing a composite survival rate indicator which would include rarer cancers. While we recognise the efforts being made to address the current absence of focus on rarer cancers, we believe that a composite indicator should be in addition to, rather than a replacement for, existing indicators. There is a very important reason why that should be so. It is vital that any new indicator provides additional insight into performance relating to rarer cancers. A composite indicator covering all cancers could mask poorer performance by the NHS in relation to rarer cancers through improvements in relation to the more common cancers. We should be concerned about that. Can the Minister say what progress has been made towards developing a composite indicator? Would it apply to those cancers not currently covered in the framework, such as head and neck cancer?
From Answers that I have seen to parliamentary Questions it appears that there will be a separate publication route for the composite indicator. Will the Minister be able to explain that a bit more? Could he reassure the Committee that any composite indicator will be in addition to existing indicators that are already planned and will not serve as a mask for poorer performance in the less common cancers?
While it is vital that the NHS Commissioning Board is held to account, it will be the clinical commissioning groups which will play a key role at the local level in achieving that additional 5,000 lives saved. The commissioning outcomes framework will be used by the NHS Commissioning Board to hold CCGs to account. In August this year, the Commissioning Outcomes Framework Advisory Committee published recommendations for indicators to be included in the framework. The APPG on Cancer was shocked that only one cancer-specific indicator was included in this recommendation—that of under-75 mortality. It may be that we have not understood it properly, so I look forward to being corrected on that.
However, the APPG on Cancer believes that the omission of one-year and five-year cancer survival rate indicators at this level is a serious oversight and a missed opportunity to ensure that every CCG prioritises not only the earlier diagnosis of cancer but the commissioning of high-quality services. We cannot understand the reasons for the omission. I have been assured that, once the boundaries for CCGs have been defined, survival data will be available at the CCG level, so it should be workable. Given all this, can the Minister support the inclusion of one-year and five-year cancer survival rates in the outcomes framework for CCGs?
We are also calling for proxy indicators for cancer survival, which are particularly important for less common cancers. They are: stage of cancer at diagnosis, which we have already heard about, and cancers diagnosed as an emergency admission. We want these to be included in the commissioning outcomes framework as quickly as possible because this is about gearing up the services in real time to improve as we go forward. These measures will provide a more immediate picture of where improvements are needed in the early detection of cancer. By assessing the performance of CCGs on these through the COF, local commissioners will be encouraged to contract services that improve early diagnosis.
I support the remarks made by the noble Baroness, Lady Jolly, regarding cancer networks. I do not want to repeat the detailed points that she made, but I, too, believe strongly that cancer networks have a vital role to play in continuing to drive up standards and achieving the Government’s vision to save additional lives. I was concerned to be advised that, with the NHS Commissioning Board undertaking specialist commissioning and CCGs commissioning other aspects of patients’ care, patients with head and neck cancers could find their care pathway being commissioned by two entirely different levels of NHS commissioning. That is just one example of the role that cancer networks can play in improving quality, outcomes and the patient experience.
Can the Minister reassure us that there will be sufficient staff, including experienced directors? Will they be retained in each individual cancer network so that they can deliver their functions effectively? Can he reassure us also that the cancer-specific expertise that currently exists in networks will not be lost through this restructuring and that cancer networks will be tasked with driving improvements across the whole cancer journey? As the noble Baroness, Lady Jolly, has stressed, it is not just about early diagnosis; cancer networks have a vital role to play throughout the patient journey.
Once again, I congratulate the noble Baroness, Lady Gardner of Parkes, on securing this important debate. It is essential that we use opportunities such as this to raise awareness of the less common cancers, as she has most ably done.
My Lords, I, too, welcome this debate and thank the noble Baroness for instituting it and for the very important points that she made. I refer the Committee to my declaration of interests, which includes a number of health interests. I also echo the noble Baroness’s remarks about the role of dentists in this area. She and I have a long-standing interest in this profession, and it is important that when we consider what action needs to be taken we look at the contribution that dentists can make.
At the start of the debate, the noble Baroness said it was important to draw attention to the increase in the incidence of several head and neck cancers between 1990 and 2006. My understanding from work helpfully produced by the Library is that we have seen the incidence of oral cavity cancers increase by more than 30%, salivary gland cancers by around 37% and palate cancer by 66%, while that of thyroid cancer has doubled.
Incidence rates for all types of cancer vary significantly between those strategic health authorities and cancer networks with the lowest and highest incidence, and the geographical pattern of distribution varies from cancer to cancer. This may well reflect the distribution of different risk factors, including those that predominantly affect certain ethnic groups. We have to bear that in mind when deciding what action needs to be taken.
It is important to have accurate and up to date information available. I was interested to read the National Head and Neck Cancer Audit 2011 and the remarks made by Sir Mike Richards, the National Cancer Director. He pointed out that there have been further improvements in the completeness of the data submitted, but that more needs to be done. He urged cancer network directors, medical directors and head and neck cancer site-specific groups to reflect on this. Bearing in mind the remarks of the noble Baroness at the beginning of our debate, the more accurate information we have, the more we will be able to see the scale of the issue we face and decide what action needs to be taken. I hope that the noble Earl, Lord Howe, will be able to say something about how he thinks we might improve data collection in the future. The noble Baroness, Lady Morgan, made some important points about indicators, outcome measurements and requirements. Again, I hope that the noble Earl will be able to give some comfort to her with regard to looking at an extension of those requirements in the future.
I want to reflect on the points raised by all noble Lords who have taken part in the debate on the importance of improving public recognition, early diagnosis and treatment. I hope that the noble Earl will be able to say something about how this might be done, and perhaps how the work of GPs and dentists might be recognised and what we can do to encourage those professions to identify symptoms and advise their patients so as to make sure that where there is a suspicion, patients are encouraged to seek diagnosis and treatment.
Obviously, the backdrop to this debate will be the implementation of the Health and Social Care Act 2012. The noble Baroness, Lady Jolly, said that the reforms would allow for a refocus on these issues. I am not quite sure that I agree with her. Her speech was a very good description of why it would have been better if we had not had the reforms in the first place, and I think that there are a number of questions one has to ask about the architecture. We are looking for some further information about reports that the Government are going to reduce the number of cancer networks, along with their resources. The noble Baronesses, Lady Jolly and Lady Morgan, both spoke about that. It is important to note that the cancer networks have been universally regarded as a good thing that has led to a much more co-ordinated response. Given that we are now moving towards a much less integrated healthcare system, there is a real risk in reducing the effectiveness of these networks.
I would remind the noble Earl of the success of his department in relation to stroke services in London and the benefit of a strongly co-ordinated approach by reducing the number of centres for hyper-acute services. That is now being rolled out across the rest of the country. Surely we need that kind of co-ordinated leadership in relation to cancer services. I am not confident that simply leaving it to a smaller number with fewer resources working with clinical commissioning groups will do what is required. I hope that the noble Earl will be able to say something more about that.
I particularly noted the comment made by the noble Baroness, Lady Jolly, about the role of cancer networks in helping to select which hospitals should provide specialist services. I very much support that. It will be important, in thinking through the future provision of cancer services, not to forget the role of hospitals. There is a great danger in the current mantra that everything is decided through the commissioning network and the role of hospitals is simply to do what commissioners tell them to do. Obviously, chairing a foundation trust, I am somewhat biased, but I have to say that most innovation and most ideas come from those hospitals where professionals work—the reality is that mostly they are the people who know what needs to be done. That is the importance of the cancer networks. The market mantra is that commissioners decide what should be done and then the providers do what they are told, but what we need in future is much more of a partnership. That applies to all cancer services.
Does the noble Earl think that clinical senates might play a role in this? I think that we are all signed up to the idea of clinical senates, but none of us quite knows what they are going to do. It occurred to me that, given the expertise that the senates will have in their membership, they might be able to give advice to clinical commissioning groups on the effective services that need to be provided in relation to cancer services.
Let me come on to health campaigns. The noble Baroness, Lady Jolly, referred to the need for local authorities and Public Health England to work together. I echo her question about how the department will ensure that that happens in the future.
Finally, I pick up the point raised by the noble Baroness, Lady Morgan. It will clearly be important that we ensure that enough money is invested in research in these areas—identification, early diagnosis and early treatment. I wonder if the noble Earl could say a little bit more about how he thinks research should be invested in in the future. This is a very important debate and I am sure that we are all grateful to the noble Baroness for instituting it. We look forward to the noble Earl’s response.
My Lords, I begin by thanking my noble friend for tabling today’s debate and for her excellent speech. I am aware that this is a very important issue for her, for everyone who has had a diagnosis of cancer of the head and neck, and for their families and friends.
The incidence of head and neck cancer in England rose from over 8,300 to over 9,600 between 2007 and 2010, while the incidence in the under-65s rose from just over 4,800 in 2007 to over 5,600 in 2010. We know that for most cancers death rates are set to fall significantly in the coming decades. This is encouraging and highlights the impact of changes in lifestyle, particularly reductions in smoking, and improvements in the speed of diagnosis and the treatment of cancer. As noble Lords have pointed out, there are a number of risk factors that can increase the chances of developing cancer, including oral cancer. Cancer Research UK has recently estimated that over a third of all cancers are caused by smoking, unhealthy diets, alcohol and excess weight.
Let me look first at smoking. The Tobacco Control Plan for England, published in March 2011, sets out three new national ambitions to reduce smoking prevalence—among adults, among 15 year-olds and in pregnancy—and sets out a comprehensive range of tobacco control actions at all levels to achieve these ambitions. The Committee will also be aware of Stoptober, a new and innovative campaign that encourages smokers all to start their quit attempt together on 1 October. As for alcohol, the Government’s alcohol strategy includes a strong package of health measures. These build on the introduction of the ring-fenced public health grant to local authorities and the new health and well-being boards, giving local areas the powers to tackle local problems.
Most people know that smoking causes lung cancer and sunburn causes skin cancer. However, far fewer people know that a poor diet, obesity, lack of physical activity and high alcohol consumption are also major risk factors for getting cancer. To deliver on improved outcomes, public health services will provide people with information about these risk factors so that they can make healthy choices.
We know that HPV is associated with around a quarter of head and neck cancers. The National Institute for Health Research Clinical Research Network is currently hosting four trials focusing on the link between HPV and head and neck cancers. The Medical Research Council is also currently supporting two studies relating to the links between HPV and head and neck cancers.
Late diagnosis is also a cause of avoidable deaths from cancer in England. Generally, as my noble friend Lady Gardner pointed out, the earlier a patient is diagnosed with cancer, the greater the chance of being successfully treated. In order to achieve earlier diagnosis, we need to encourage people to recognise the symptoms of cancer and seek advice from their doctor as soon as possible. We also need doctors—and, where appropriate, dentists—to recognise these symptoms as possibly being cancer and, where appropriate, refer people urgently for specialist care. The Government have committed over £450 million over this spending review period to improve earlier diagnosis. Through the national awareness and early diagnosis initiative jointly led by the department and Cancer Research UK, we are working to improve earlier diagnosis by raising public awareness of the symptoms of cancer and encouraging earlier presentation. We are developing a “constellation of symptoms” campaign during January to March 2013 which will highlight symptoms that might be the result of a number of cancers, including rarer cancers.
We will hold the NHS to account for improvements in outcomes through the NHS outcomes framework. As the noble Baroness, Lady Morgan, mentioned, we are working with the London School of Hygiene and Tropical Medicine to develop a composite survival rate indicator which covers all cancers to ensure that performance on rarer cancers can be monitored effectively. In addition, there is a cancer mortality indicator that is shared between the public health outcomes framework and the NHS outcomes framework, which is designed to improve prevention—to reduce incidence—as well as improve diagnosis and treatment.
The balance between composite and tumour-specific cancer survival indicators always needs to be considered. It is currently being considered. I would say to the noble Lord, Lord Hunt, on the composite indicator, that these are complex measures requiring linkage of ONS population statistics with cancer registry data and attribution to clinical commissioning groups as well as testing the robustness of the measures. It is likely to take some months to complete the work that is currently in train. The commissioning board will decide, of course, on the content of the commissioning outcomes framework. It is expected to publish a list of measures for 2013-14 in the autumn. If the composite indicators are not included in the 2013-14 framework, the board may choose a separate publication route for the data that exist to ensure that the information is available transparently to the public.
I know that there is concern on the part of Macmillan Cancer Support, among others, around proxy indicators. I understand that the NHS Commissioning Board Authority is now engaging with clinical commissioning groups and other stakeholder organisations to discuss the shape of a commissioning outcomes framework, as I mentioned, for 2013 and beyond.
We recognise that there is a role for dentists in the early detection of some head and neck cancers, including mouth or oral cancers. We are working to ensure this, and the new patient pathway currently being trialled in 70 practices provides dentists with decision support based on current best practice. Patients receive comprehensive oral health assessments at regular intervals under this pathway. Those assessments require dentists to systematically assess the soft tissue as part of the clinical examination and include a social and medical history which, through the questions on smoking and drinking, allow the dentist to assess the patient’s level of risk for oral cancer and, if appropriate, offer advice on lifestyle changes. The pathway is being piloted as part of the work to design a new dental contract. The Government are committed to introducing a new contract based on capitation and quality. Supporting dentists to systematically provide high quality care through the pathway is a key part of this. I can tell both my noble friends that the General Dental Council has recently confirmed that improving early detection of oral cancer is to be included as a recommended topic in its continuing professional development scheme. More generally, the department supports the British Dental Health Foundation which sponsors annually a mouth cancer action month; officials work closely with the foundation as well.
Once head and neck cancer is diagnosed, patients need to have access to appropriate and consistent treatment, delivered to a high standard, across the board. Improving Outcomes in Head and Neck Cancers, published in 2004, set out recommendations on the treatment, management and care of patients with head and neck cancers. We have made a commitment to expand radiotherapy capacity by investing around £150 million more over four years until 2014-15.
My noble friend Lady Gardner raised the issue of public awareness of oral cancer. Work is underway on the third edition of Delivering Better Oral Health, a toolkit for the dental team. This will update the section on tobacco and oral health. A patient-facing version is also in development which will seek to make the public more aware.
My noble friend Lady Jolly spoke about vaccination and asked why boys, indeed all teenagers, were not vaccinated. The Joint Committee on Vaccination and Immunisation did not recommend the vaccination of boys because high coverage of the vaccination among girls means that it is not cost-effective to vaccinate boys to prevent cervical cancer. However, as with all vaccination programmes, the JCVI keeps its recommendations under review. The HPV vaccine is offered free each year under the national programme to girls aged 12 to 13 in school year eight. That is because the HPV vaccination is best given before the onset of sexual activity. Routine immunisation started in 2008, and a phased catch-up of girls aged up to 18 years of age was also implemented. However, scientific evidence is constantly coming forward and the JCVI will no doubt take account of that as necessary.
The noble Baroness, Lady Morgan, spoke about outcome measures for rarer cancers. Of course, she is quite right that early diagnosis is important in rarer cancers as it is everywhere else; we are addressing that, as I have mentioned. It is also important to improve treatment, and the recent announcement on radiotherapy means that access will be improved for specialised radiotherapy treatments such as stereotactic radiosurgery, used predominantly for brain tumours. Proton beam therapy is also an area that we are looking at closely. We are developing two proton beam therapy facilities, in Manchester and London, to be operational by the end of 2017. This treatment improves outcomes for a number of rarer cancers, including those which affect children.
My noble friend Lady Jolly asked what plans the Government have to address the issue of underage drinking while in the home. The new “Change for Life” programme helps people check if they are drinking above the lower-risk guidelines or not, and offers tips and tools to cut down. Dame Sally Davies, the Chief Medical Officer, will be overseeing a UK-wide review of the alcohol guidelines so that people at all stages of life can make informed choices about their drinking.
The noble Lord, Lord Hunt, and my noble friend Lady Jolly spoke about clinical networks. The final number of strategic clinical networks, and therefore the number of doctors, nurses and others who will support them, will be determined locally to meet the needs of patients. The full structure for strategic clinical networks will be published shortly. The establishment of clinical networks, hosted and funded by the NHS Commissioning Board, will ensure that patients everywhere in England benefit from dedicated clinical networks for four priority conditions and patient groups: cancer, cardiovascular disease, maternity and children’s services, and mental heath, dementia and neurological conditions. These networks will receive £42 million of national funding in the next financial year. We anticipate that these strategic networks will be supported and funded through the 12 network support teams. These teams will be hosted, again, by the NHS Commissioning Board local area teams. We anticipate an arrangement that would see support teams employing their skills across different networks as needed, but one that would also involve designated subject experts such as those with expertise in cancer commissioning.
The noble Lord, Lord Hunt, asked about research, which I agree is important in reducing deaths from cancer. The National Institute for Health Research health technology assessment programme is currently commissioning a feasibility study for assessing the clinical and cost effectiveness of photodynamic therapy for the treatment of locally recurrent head and neck cancer. The National Institute for Health Research Clinical Research Network is currently hosting 33 trials, including the four I mentioned earlier, and other well designed studies into head and neck cancer.
To conclude, the Government have set out an ambition in Improving Outcomes: A Strategy for Cancer to save an additional 5,000 lives each year by 2014-15. This means halving the gap between England’s current survival rates and those at the European best—and our aspiration is to be among the best in Europe. As my noble friend Lady Gardner has made clear, it is not just about saving lives after a diagnosis, it is also about preventing the cancers to start with. The Government’s strategies for prevention are designed to tackle increasing incidence.