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Earlier Cancer Diagnosis: NHS Finances

Volume 615: debated on Tuesday 18 October 2016

I beg to move,

That this House has considered earlier cancer diagnosis and NHS finances.

I thank Mr Speaker for allowing this debate and you, Mr Nuttall, for presiding over it. I also take this opportunity to welcome the Minister to his new post. He has been in it a while now, but this might be his first Westminster Hall debate. We look forward to working with him—he comes highly recommended—and I thank him for accepting the invitation, on behalf of the Secretary of State for Health, who was unable to make the appointment, to speak at our Britain Against Cancer conference in December.

Early diagnosis has been a key theme of the all-party group on cancer for some time. We call it the “magic key” to cancer. If we can drive forward on our rates of early diagnosis, the stage at which we first detect cancer, we can improve survival rates significantly.

I should perhaps briefly explain to the Minister that there is a little history to this involvement. Back in 2009, the all-party group published the report of an inquiry it had conducted into cancer inequalities. We found that patients in the NHS at the one-year point since their cancers were detected stand as much chance of surviving to the five-year point as they would in any other healthcare system. Where we let ourselves down, however, is getting patients to the one-year point. That suggests that the NHS is as good as any other healthcare provider in treating cancers once detected, but poor at detecting them in the first place.

In this country, our survival rates have been ticking up, with the rate of improvement broadly similar to that in other countries, but our survival rates still stand well below those of many other countries. For example, in this country the overall one-year survival rate is about 70% or 71%, but in Sweden it is 82%. That might not sound like a big difference, but overlay that differential with regard to the population of the UK as a whole and it tells us that tens of thousands of lives a year are needlessly being lost because we are diagnosing too late.

We need to focus on early diagnosis, and the Minister is in a unique position to be able to make a real difference to a large number of people if we can get it right. Yes, cancer survival rates are improving, but they are improving around the world and we are still well behind international averages. We welcome the improvements, but we have still not yet seen that kick-up that will allow us to catch up with those international averages.

Our 2009 report came up with, in essence, one recommendation. Reports can always come up with myriad recommendations, but we believe in short reports and, having consulted with the wider cancer community, the good and the great of the cancer world, the charities, patients and so forth, we came up with one recommendation: to ensure that we focus the local NHS, the clinical commissioning groups— primary care trusts then, CCGs now—on their one-year survival rates.

The logic is simple: the earlier we diagnose, the better our one-year survival rates. They are therefore a good measure of how successful we are in diagnosing early. Late diagnosis makes for poor one-year figures, so we get the CCGs to focus on the one-year figure and, if there is a line of accountability there, they will be encouraged to focus on how to improve earlier diagnosis and introduce initiatives promoting earlier diagnosis.

Has my hon. Friend seen the results of the Barts Health NHS Foundation Trust’s 2013 study at Whipps Cross hospital? It showed the effectiveness of complementary therapies in improving symptom control following diagnosis. The three-year study revealed that 90% of people noticed that side-effects of chemotherapy and radiotherapy decreased following such treatment, and patients said that their pain, sleep and emotional health improved. Should we make greater use of those supportive therapies as part of the scheme of things?

We certainly have to be inclusive with regards to how we look at treatment generally. As my hon. Friend knows, the all-party group and, indeed, the wider cancer community are looking at such things. He comes to our meetings, and we listen carefully. Questions certainly need to be answered on that front, so he is pushing at an open door. We have an open mind, and we are listening.

Together with the wider cancer community—at the end of the day it has been a team approach—we have been successful in ensuring that CCGs are now held accountable. The one-year survival rates have been included in the delivery dashboard of the assurance framework, and that is very good news. Figures have only been published for the past one or two years, so we are still seeing what is happening with regards to improvements and how CCGs are performing, but at least we have made a start and there is an element of accountability.

I must of course declare that I am a dentist and so have considerable professional interest in the subject, although it is rare that I am in the surgery. I am also chair of the all-party group on skin, and one might think that diagnosing skin cancer is fairly obvious, in particular given that skin problems are a major concern of GPs. However, one of the things we soon discovered was that undergraduate tuition time on skin conditions is extremely short—often a week or two weeks, which are frequently used by undergraduates, as I understand it, as an opportunity to go away, rather than to attend. If the education of GPs and doctors was better and reinforced by continuing professional development, we might get better results on skin cancer.

I thank my hon. Friend for that intervention.

We have been successful in getting the one-year figures into the DNA of the NHS, but there is no point having the tools in the toolkit if we do not use them, and one thing we are looking carefully at is the lines of accountability. We acknowledge that we are pushing at an open door—the Government have kindly accepted the need for the one-year figures—but there is still a very long way to travel. The latest Ofsted-style ratings have maintained the focus on survival rates, and yet those ratings still found that eight out of 10 CCGs must improve. That shows the scale of the challenge and the extent to which we need to raise our game.

If I could cast the hon. Gentleman’s mind back to the previous intervention, the Be Clear on Cancer campaign identified about 700 more patients with lung cancer, which led to about 300 more patients receiving life-saving surgery. That shows that publicity campaigns work. Does he agree that the Government need to encourage the NHS to have more publicity campaigns to identify the issues and save more lives?

I agree completely. Briefly, the initiatives that could be introduced to promote earlier diagnosis are greater awareness campaigns, better diagnostics at primary care level, better uptake of screening in screening programmes, and better GP awareness—although this is not only about GPs. A whole host of initiatives could be introduced at the primary care level to improve survival rates and awareness generally. So yes, I completely and utterly agree.

Given the limited time available, I will make a little progress on the central point of this debate. We are pushing at an open door, which is fine; we are keeping a watching brief as a cancer community; and, as I have said, the Ofsted-style ratings have shown, among other things, that a big improvement is required. The all-party group on cancer will hold its annual parliamentary reception next summer—the Minister no doubt will be invited to that—at which we will focus on those CCGs that have most improved their one-year survival rates. The Britain Against Cancer conference, which we believe is the largest gathering of the cancer community in this country, will take place at the end of this year and will also focus on that issue.

We are therefore not walking away from the issue of survival rates, but we are saying as part of our watching brief that we wish to bring to the Government’s attention the fact that when it comes to cancer treatment, earlier diagnosis can not only help patients—diagnosing cancers earlier makes for better survival rates—but save a lot of money. The later cancer is diagnosed, the more aggressive the treatments and the higher the cost. That cost is quite significant, and the cost savings from earlier diagnosis could be ploughed back into treatment for patients. At a time when the NHS is under financial pressure, we suggest that too little attention is being paid to those potential cost savings. Too little work has been done by the NHS and too few health economists are looking at how reducing costs to such an extent would benefit both the taxpayer and, most importantly, patients.

Given the NHS’s lack of focus on that area, we have had to go to outside sources to give us some sort of measure of the potential cost savings. A September 2014 report by Incisive Health and Cancer Research UK showed quite a disparity between the cost of treating patients with early stage, or stage 1, cancer and those with late stage, or stages 3 and 4, cancer. For example, the cost per patient per year of treating colon cancer is £3,300 at stage 1 and £12,500 at stage 4—a near fourfold increase. Treating stage 1 rectal cancer costs £4,400; that goes up to nearly £12,000 if it is treated at a late stage. Treating ovarian cancer costs just over £5,000 per patient per year at an early stage, but £15,000 at a late stage. That report focused on four cancers: colon, rectal, lung and ovarian. They amount to only around a fifth of all cancers diagnosed, but if such cost savings were replicated across all cancers, we could be talking about savings of hundreds of millions of pounds, and that is before we even consider the number of patients who would benefit from earlier diagnosis, which Incisive Health cites as something like 52,000.

I ask for a bit of patience. Let me make a little progress, and if there is time, I will take further interventions.

That report also showed variation between the highest and lowest-performing CCGs in the proportion of patients diagnosed early. That is also important. In colorectal cancer the variation was threefold, in lung cancer it was fourfold and in ovarian cancer it was fivefold. It is clear that if we could ensure that all CCGs achieved the best rate of early diagnosis—the rate achieved by the top performing CCG—significant cost savings could be made.

Those are interesting figures. Many believe them to be conservative—with a small “c”—in the sense that we often forget the costs of treatment later on down the care pathway beyond diagnosis, but we are certainly talking about hundreds of millions of pounds. One could argue that that is a drop in the ocean when we are looking at the NHS budget, but patients—cancer patients in particular—could certainly benefit from a couple of hundred million pounds. In an age when it is all too easy for politicians to talk about spending more money, we are trying to focus on potential cost savings from encouraging earlier diagnosis. As prevalence rises—Macmillan Cancer Support believes there may be another half a million cancer patients in the next five years, in addition to the around 2.5 million we have at the moment—so will costs, so the need for such savings will grow in importance.

The most recent report of the all-party parliamentary group on cancer followed an oral evidence session with the then cancer Minister and key decision makers in NHS England, as well as written evidence from more than 30 cancer-related organisations. That report concluded that where the new initiatives outlined in the cancer strategy could save costs, those initiatives required more focus and attention. It is our opinion that there needs to be greater appreciation in NHS England and the Department of Health of the savings that earlier diagnosis offers. As I have said, there are too few health economists working in the NHS, and even fewer looking at this area.

As the Minister is well aware, when I raised that issue at Health questions last week, he correctly referred to some ongoing studies, including the three-year research project being undertaken by Macmillan Cancer Support in a related area. He also mentioned Public Health England, which is looking at cost-effective initiatives for colorectal cancers. Those studies are welcome, but I maintain that the approach is piecemeal. We need a root and branch approach to look more specifically at this area. We need to promote earlier diagnosis at CCG and health and wellbeing board level. We have the one-year figures. We must not allow this to become a tick-box exercise; the issue is far too important for that. There needs to be greater focus on how underperforming CCGs will be held to account for their rate of improvement.

The all-party parliamentary group on cancer will play its full part in that work. We are looking at other areas. We have achieved our goal of getting the one-year figures into the DNA of the NHS, and we certainly will not walk away. We are focused on several areas, including patient experience and rarer cancers. There cannot be a meaningful improvement in the one-year figures if rarer cancers are not included, as those account for more than half the cancers that are diagnosed. We will play our full part, which includes the annual reception and the Britain Against Cancer conference, but I would be interested to hear the Minister’s responses to the questions I have raised. What more does he believe the NHS can do to promote and focus on cost savings from earlier diagnosis? On behalf of the wider cancer community, and certainly the all-party parliamentary groups, including the cancer-specific groups represented by several hon. Members in the Chamber, may I request a meeting with the Minister to discuss this and other related cancer issues?

It is a pleasure to serve under your chairmanship, Mr Nuttall, in my second Westminster Hall debate since I became a Minister. I start by congratulating my hon. Friend the Member for Basildon and Billericay (Mr Baron) on securing this debate and raising the valid points that he did and on his stewardship of the APPG on cancer, which is highly effective and has provided a large part of the briefings that I have received since becoming a Minister. I very much hope that he will carry on that work, and I am sure that he will.

My hon. Friend mentioned several times the phrase “pushing at an open door,” and I reassure him that the door is open. We have discussed this issue twice in fairly formal circumstances, and I am keen to take him up on his offer of meeting him and colleagues to discuss it further and make progress over and above what we can do in Westminster Hall debates and oral questions. I also look forward to speaking at the event in December.

I will talk, as Ministers do, about the progress that we are making in this area across England, but my hon. Friend reminded us that we are not best in class or among the best in Europe, and he is absolutely right. He gave us the statistics for Sweden, where the one-year survival rate is 82% versus our 71%. That is a target; it is where we need to get to. As we have made progress, we have got to where the best in Europe were several years ago. We need to keep progressing in that respect.

My hon. Friend rightly talked about CCG accountability, and I will talk a little about that. I want to emphasise the power of what was done last month, when we published the four indicators for every CCG in the country. That is a massive commitment to transparency. We were quite open that many CCGs needed to improve. My hon. Friend mentioned the figure of, I think, 80%, which we agree with. It is worth analysing the data and spending a bit of time looking at that, because small differences in percentages against the indicators, one of which is one-year survival, make a big difference to how a CCG is perceived. Accountability comes from transparency, and we have made big steps in that regard, last month in particular.

I want to thank the Members who intervened in the debate. As ever, my hon. Friend the Member for Bosworth (David Tredinnick) reminded us of the role that complementary remedies can play as part of an overall solution. There is no impediment to that in the NHS—CCGs can commission what they wish to commission. He mentioned the Barts study. My view is that it needs to be clear that commissioning is science driven, repeatable and all that goes with that, but there is no impediment if CCGs wish to commission complementary therapies.

My hon. Friend the Member for Mole Valley (Sir Paul Beresford), in his capacity as chair of the all-party group on skin, told us how weak some of the training in that area may be at undergraduate level. I was not aware of that, so I will take it up and come back to him. It does not sound acceptable if the skin cancer diagnosis part of the syllabus is the bit that people leave.

If I could emphasise that a little more, we have a distinct shortage of consultant dermatologists. They are backed up by GPs with a special interest, but a large number of referrals to dermatologists are made due to fear on the part of both the patient and the doctor that they will miss a melanoma or a squamous cell carcinoma when the doctor should be able to diagnose them. Many are dealt with in the early stage with cryosurgery, which is a very effective, quick treatment that I know, having been on the wrong end of it quite often, can be undertaken by a GP who has had the right education.

I thank my hon. Friend for that and for reminding us that at the core of the debate is a point we all agree on: early diagnosis is the key, whether it is for cost-saving purposes—I will come on to some of the points my hon. Friend the Member for Basildon and Billericay made on that—or to be cost-effective. There is no question that early diagnosis saves lives and that it is the right thing to do. Whether we argue a bit about precisely how much money is saved is in a way a secondary issue; it saves lives and it is the right thing to do.

I also want to acknowledge the intervention of the hon. Member for Strangford (Jim Shannon), who reminded us about the need for public health and GP awareness. In England we have had a significant increase in the number of referrals and the National Institute for Health and Care Excellence—latterly in England—has changed its guidelines for referral, which, together with the awareness issue, has increased significantly the number of people diagnosed in stages 1 and 2. We need to continue to make progress on that.

I commend the hon. Member for Basildon and Billericay (Mr Baron) for leading the debate and for the leadership he has provided on one-year survival rates through the APPG. Does the Minister accept the basic premise that value of life and value for money are not in competition? They are perfectly compatible. We can have better use of money with better outcomes because of better-timed treatments, and that also means there is better evaluation and research, which will feed into better education in a virtuous circle, to meet the point made by the hon. Member for Mole Valley (Sir Paul Beresford).

I thank the hon. Gentleman for his intervention and completely agree with the point he made. In this instance, there is no competition between saving money, saving lives and doing the right thing. In a sense, there is a secondary question as to just how much cost is saved, and the balance of cost saving versus doing more diagnostically, because in order to save lives, which is a highly cost-effective thing to do and the right thing to do, we need to do more on early diagnosis.

I have not yet got to the start of my remarks and I have a lot of pages to get through, so I will not be giving too much detail. It is worth acknowledging that cancer survival rates are increasing in the UK. In terms of improvement, between 2011 and 2015 we think something like 12,000 lives a year were saved. That exceeds the goals we set out in the cancer outcomes strategy in 2011.

Last year we saw a 91% increase in urgent GP referrals of patients with suspected cancer—that is another 822,000 patients. That shows a massive increase in NHS resources and all that goes with that, and we are beginning to see those early referrals, and the different guidelines GPs are using to refer, start to come through in the one-year survival statistics. However, as my hon. Friend the Member for Basildon and Billericay reminded us, that does not mean that we are the best in Europe. We need to continue the drive to improve.

The cancer strategy produced by the cancer taskforce is the backbone of what we are trying to achieve. The—I think it is fair to say—acclaimed strategy it produced, “Achieving World-Class Cancer Outcomes”, was published last year. It had 96 recommendations in it, and the Government accepted all 96. We are now putting in place an implementation taskforce. We believe that if we are able to make the progress we expect by 2020, a further 30,000 lives a year can be saved.

Recommendation 96 is the one we are talking about today. It essentially says that we need to do a lot more on early diagnosis because of the cost savings that will potentially arise from that. There are differing views in the Department of Health as to whether for all cancer types in all instances earlier diagnosis does save costs because of the increase in cost and effort associated with the diagnosis—the early screening and all that goes with that. That was not addressed overtly in Cancer Research UK’s “Saving lives, averting costs” report, which was mentioned by my hon. Friend. He quoted numbers of several millions of pounds, and there is no doubt that stage 4 cancer costs massively more to treat than stage 1 cancer, but whether or not there are clear cost savings in all instances and even if we dispute the detail of some of those numbers, we go back to the point made by the hon. Member for Foyle (Mark Durkan) that early diagnosis is the right thing to do. My hon. Friend also mentioned that there are not enough health economists in the NHS; the truth is there are not enough of lots of things in the NHS. Early diagnosis is certainly cost-effective in terms of lives saved, even if there may be some dispute as to whether it saves costs in all instances.

My hon. Friend mentioned the work being done by Macmillan, which I acknowledge. It is a three-year study, which we are looking forward to.

I am conscious that I am eating into the few minutes the Minister has left, but the point about cost savings links to the point made earlier about initiatives and processes for earlier diagnosis. I urge him to think carefully about this, as I know he is doing. There has been no shortage of process targets in the NHS, but the one-year survival figures focus on outcomes, and that is the true measure of whether the processes are having an effect. By using outcome measures, we are leaving a large element of discretion to CCGs to introduce the initiatives they think best fit their local populations. That does not necessarily mean big cost increases to introduce such initiatives. Better awareness campaigns and better screening uptake figures do not necessarily cost a lot of money at a local level; they just take a bit of thought.

I agree completely with my hon. Friend that it is right that we use outcome measures. I come back to the point that the Government did a big thing in publishing the statistics for every CCG in the country. That allowed headlines to be out there in the press— we all saw them—that 80% of CCGs need to improve. We used a pretty rigorous test to assess the CCGs. If we reach those levels, we will be close to being the best in Europe as we make progress.

I am coming towards the end of my time. I want to finish by re-emphasising the Government’s commitment to early diagnosis. I have not had a chance to talk about our public health measures and all that goes with them, but I thank my hon. Friend again for getting us this debate. I emphasise my commitment to work with him and the APPG to make progress in this area.

Motion lapsed (Standing Order No. 10(6)).

Sitting suspended.