§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Walter Harrison.]
§ 11.52 p.m.
§ Mrs. Joyce Butler (Wood Green)In the present organisation of the National Health Service, emphasis is placed primarily on diagnosis and treatment in medical care, while less attention is paid to prevention, after-care and rehabilitation. Although primary prevention is the ideal to be aimed at, it is limited by lack of finance and knowledge of preventive procedure. Only quite recently the Office of Health Economics has reminded us how little we know about the effects of nutrition upon health.
Last week the Minister of Transport reminded us that the medical assessments of the dangers of exhaust fumes are by no means known. Therefore, with so many uncertainties in the sphere of preventive medicine, early diagnosis has rather special merit, in that it makes treatment available earlier on the time-scale of the disease developing.
We are familar with mass radiography units, which are universally used throughout the country and widely accepted. These give early warning of possible lung disease such as, tuberculosis. Similarly, we have in recent years seen a great development in clinics for cervical cytology. These clinics, which have been established in various parts of the country, are interesting in that they have grown very rapidly.
There are still variations between one region and another, and it may be possible for the Parliamentary Secretary, in replying to this debate, to say a word about these regional variations. The interesting thing is that the Minister of Health has sent a circular to local authorities reminding them of the importance of establishing these clinics. The clinics established for cervical cytology have in many cases gone on to take tests for the prevention of breast cancer, and in some cases diabetes and other diseases. This is one aspect of early warning which is taking place.
The other aspect is in the sphere of education and research, where the findings with regard to the dangers of tobacco smoking in relation to lung cancer are 734 well known. Less well-known, but equally important, is the work which has been done on bladder cancer in the rubber industry and asbestosis and lung cancer in industries associated with asbestos. I mention these because they are all fields of early diagnosis, and in a sense preventive medicine, which have had a tremendously important effect on the greatest scourge of health at the present, the spectre of cancer, and a fact which I think should be more widely known than it is is that largely because of early detection and early treatment 30,000 cases of cancer are cured every year.
It is not only tuberculosis and cancer which can be prevented by early warning devices of this kind. Other diseases can be detected, and a very interesting experiment was begun in Rotherham in 1962 when attempts were first made to introduce diabetes diagnosis at the same time as the mass X-rays took place. Every year since then the service has been available for short periods, and further techniques have been added each year.
In the autumn of 1966, in nine days 5,763 people took an average of five tests from the 11 that were available. Of those attending, women predominated in the ratio of 2 to 1, but the failure rate was twice as high for men as for women. The individual tests were for anaemia, chest X-ray, diabetes, vision, glaucoma, hearing, artery, heart, and lung function, cervical cytology, breast cancer, and mental health. More than 1,000 failed at least one test, and one man in four and one woman in seven, were found to have hidden illnesses.
The list of cases found makes very interesting reading, because there were 300 cases of suspected diabetes, 18 men needed urgent attention for hypertension, five had active tuberculosis, two women had cervical cancer, 128 had diseases of the chest, and 50 women were referred for further breast checks. Of the 1,825 people who took a mental health test, 486 had some degree of mental trouble, one in 16 women, and one in 15 men.
A further interesting point is that the cost of this service is about 10s. per test, which is very reasonable. The medical officer of health for Rotherham stresses the importance of adequate mechanism for follow-up, and he also stresses the 735 importance of co-operation between the three sections of the service, that is, the local medical officer of health department, the hospital service, and the general practitioner. He calls it "making a slight dent in the problem of early diagnosis and preventive medicine", but the public response indicates that it is very much more than a slight dent. It seems to be something of a new wind blowing through the Health Service. The public response has been quite amazing.
I have spoken to the hon. Member for Rotherham (Mr. O'Malley) and to other hon. Members who were at Rotherham when these clinics were held. They were quite staggered to see the queues of people who went there. They did so quite informally and this is one of the great things about the Rotherham scheme. People do not have to make appointments to attend. It is all very informal. Their fears are brought into the open, and they are able to have something done about them; they are able to have something done about their hidden fears.
One of the problems about cervical cytology has been in persuading the public to accept the procedures when they have been available, but there was no problem in persuading members of the public to accept mass screening in the Rotherham experiment. There has been action elsewhere, and in Epsom an experimental scheme was run for ten days in September last year, with about five thousand attendances, fewer than a thousand of those being from men, pro-ably because the idea had got around that the tests were for women only. Some women waited for six hours to take a test.
There has been screening for breast cancer, diabetes, cervical smears and other diseases in some clinics, and at Epsom, eleven months' planning was involved. The cost for the five thousand was about £1,500.
Salford has been running multi-clinics for ten years, and last year, 3,753 patients attended over a six weeks period for tests which included vision, hearing, diabetes, anaemia, chest, and cervical smears, and the cost amounted only to 3s. in the £ rate. In Bedford, and Chester-le-Street, consideration is being 736 given to similar multi-clinics, and in Darlington there has been a screening clinic and they are considering there what further steps can be taken.
There has been a great surge of interest in the Press and among members of the public since details of the Rotherham scheme were published, and it interested people so much that more and more they are asking, "Why cannot we have something similar in our area?"
The Minister has so far refused by means of question and answer in the House to do anything, but could the Parliamentary Secretary tonight say that he will give a little more thought and consideration to the kind of facts which I have produced and to other information which is available? There have been special "weeks" and mass screening tests have been carried out and information has been sent to local medical officers of health asking them to consider staging something similar in their own areas wherever it might be practical to encourage them to do so. It has been done with cervical screening and, as the Parliamentary Secretary knows, there is tremendous variation between one area and another in what is done. The Medical Officer of Health of Darlington talks of future action which will emerge from the screening tests carried out in his area.
It is not only the results which are produced from the holding of these "weeks" in the bringing forward of cases and the giving of treatment which is appropriate, but there is also the possibility of developing a further measure of preventive medicine in the health service. We can learn from the varied experiences; ideas are formed, and there are lines of development for future work; and the cost of it all is comparatively small. The Kaiser Foundation Clinic in California estimates a cost of £9 per patient, and has computers linked with four experimental centres in different parts of the United States, so important do the Americans consider this type of preventive medical work. It is not desirable that the Minister should think in such terms, but it is important that all medical officers of health in different parts of this country should think in terms of something of the kind of which I have spoken tonight.
737 Therefore, I urge him to reconsider this question. I know that he is concerned about the manpower difficulties, but I am assured by the medical officers of Rotherham and other places that, when the staff are keen, they will put in the extra time and effort for a week or ten days and the follow-up and that this can be done out of limited resources. Our limited resources of general practitioners and hospitals will not permit mass preventive medicine, but short sharp courses along the lines of Rotherham's are possible.
I therefore ask him to look at this again, and, if he cannot give an answer tonight, perhaps he would put it to the Minister again to see whether some circular on these lines can be sent to medical officers of health.
§ 12.6 a.m.
§ The Parliamentary Secretary to the Ministry of Health (Mr. Julian Snow)The House is indebted to my hon. Friend the Member for Wood Green (Mrs. Joyce Butler) for raising this important matter, and if I cannot give the assurance which she would like about the circular tonight she will know that the debate will be examined by the various authorities. My right hon. Friend has devoted a great deal of attention to these check weeks and no doubt will be formulating a thorough policy which will take account of her points.
I am glad of the opportunity to explain why we are not encouraging all local authorities to follow the example of Rotherham and others. It is not because we underrate the importance of preventive medicine: that is a misconception. On the contrary, we believe that specialist weeks may be effective for health checks and we approve of the enterprise of Rotherham and other authorities.
My right hon. Friend has been advised by his Standing Medical Advisory Committee that screening of the general public should be undertaken only for conditions which can be clearly diagnosed and for which effective treatment is available. We accepted this advice and are working in this framework.
Satisfactory screening tests exist for only a limited number of conditions. A number of requirements has to be met before general screening for a particular disease can be recommended. The disease must, first, have a recognisable 738 latent or early symptomatic stage. Second, the test must be reliable and capable of being applied widely and efficiently. Rotherham's medical officer of health himself has described many of these tests as fairly blunt instruments.
Second, it is no use having tests which fail to detect people who have the condition, as they may then be lulled into a false sense of security, or an inaccurate one, since many patients will then have to undergo further full-scale examinations or may be treated unnecessarily. The efficiency of the available tests varies; some are more reliable than others. Third, we have to be satisfied that further treatment will prevent or alleviate the disease.
In the light of this situation, our advisers have considered the present screening tests for various diseases. Certain methods are fully accepted and have been in use for many years. Mass radiography for the detection of tuberculosis and other chest diseases is probably the best-known example. Even here, however, experience has shown that best results come from concentrating on certain groups known to be vulnerable rather than routine screening at regular intervals of the public as a whole.
Screening tests are widely used in the maternity and child welfare services. Mothers are screened at ante-natal and post-natal clinics for a wide range of conditions. Young babies are screened for phenylketonuria, hearing defects and other congenital abnormalities. Older children are examined by the school health services.
During the last two or three years exfoliative cytology for cervical cancer has been accepted, on the advice of the Standing Medical Advisory Committee, as a test which should be offered to all women at risk. My hon. Friend knows of the progress that has been made in this sphere, and I pay tribute to her for her work in this matter. As a result of her work and the work of others, the public consciousness has been alerted to the need to provide an overall service.
We keep in close touch with scientific developments in this field. For several years we have taken the initiative, in collaboration with the Medical Research Council, in arranging research to establish the value of screening for various 739 diseases. We are financing a large number of special studies and will continue to encourage studies wherever these seem likely to produce useful results.
When the medical requirements have been satisfied, we have also to be satisfied that the diagnostic facilities and facilities for treatment will be readily available to all those who have been offered the tests. My hon. Friend is well aware that when we first started the smear-taking service for cervical cancer it had to be restricted to certain groups of women because of the shortage of laboratory space and of technicians to examine the smears, but these shortages are now being overcome and more and more local authorities are able to offer the test to women of all ages.
Screening for cervical cancer is, in fact, a good example of a well-validated testing procedure which can throw up cases for early and effective treatment. It is a service to which, as my hon. Friend knows, my right hon. Friend attaches great importance. It has grown at a rapid rate. The figures for 31st December, 1966, are available and they show that the annual rate of screening in England and Wales was over 1,350,000 tests, an increase of 11 per cent. over the figure for six months previously.
Progress, therefore, continues to be good. There are, of course, variations between regions and between areas within the regions. The rate of development depends on many interlocking and local factors. We are, however, keeping a careful watch on the situation and encouraging progress in the less well-served areas. I hope my hon. Friend will accept that my right hon. Friend and I are both keenly interest in this subject, but I do not want to go into this in too much detail tonight because cervical screening is only one of the subjects germane to this debate.
Checking on people's health is, therefore, a routine in the maternity and child welfare services, in the mass miniature radiography service and in the cervical cytology service. Some local authorities also organise testing for diabetes and breast cancer or run health clinics of an advisory nature for the elderly. The special feature of Rotherham is that it organises its screening services around a week or fortnight instead 740 of throughout the year. There are advantages and disadvantages in this course.
One particular drawback of organising the screening in one intensive period is that a load is suddenly thrown on the hospital and general practitioner services. Another drawback is that it is impossible, in the period of one or two weeks each year, to make available a screening service for all people at risk. Such screening weeks have long been tried in other countries, and my hon. Friend mentioned the Kaiser scheme in America, but emphasis is now being laid on regular services for conditions where the worth is considered proved.
One of the studies which we are undertaking is research into the organisation of screeening through general practice. We are investigating whether patients in a group practice can be invited by their own doctors to attend for a number of screening examinations, at the end of which their results will be reviewed by their own doctors. This is not to play down the valuable and necessary work of local authorities, but we are not satisfied that all screening should be carried out through the public health service.
For these reasons also, research workers from our Social Science Research Unit attended the last clinic at Rotherham to carry out studies into the socioeconomic aspects. They sought to find out what kind of people came to the clinic, and whether they were or were not a typical cross-section of the population; what motivated them in choosing to attend, and what it cost them in time and effort. The unit also set out to assess some of the direct clinic costs in terms of the professional times and skills that were used. The data from this research will, we hope, supplement the report from the medical officer of health and, when analysed in conjunction with it, should enable us to make a tentative step towards an evaluation of these weeks.
We are most interested in the work that is being done at Rotherham, and the way it is organised. Medical and other officers from the Department have gone to Rotherham to see the clinics, and have been in constant touch with Dr. Donaldson, the Medical Officer of Health. In February of this year, my right hon. Friend saw my hon. Friend 741 the Member for Rotherham (Mr. O'Malley) and officers and representatives of the council to discuss the whole problem. We should like to pay tribute to the energy and enthusiasm of the organisers concerned.
Rotherham has been running health weeks for four years. At the first week, in November, 1963, two tests only were offered—chest X-ray for tuberculosis, and diabetes. In 1964, there were additional tests for anaemia, cervical cancer and hearing. By 1965, the week had been extended to a fortnight, and tests added for glaucoma, breast cancer, lung functions and vision. Last year, the clinic ran also for a fortnight and had 11 tests, the extra two being the examination of blood pressure and a questionnaire for mental illness.
During all of these weeks, the local authority has worked in very close cooperation with the local general medical practitioners and with the Sheffield Regional Hospital Board. This is of the utmost importance because of the work which will be thrown on the hospital laboratories and out-patient departments, and on the general practitioners in following up cases.
There is, perhaps, one point worth making here. Although at Rotherham 11 different tests were offered, not all of them were undergone by all who presented themselves. Indeed, I understand that the choice whether to have each test offered was left to the individual patient. That seems to me right and proper; one cannot compel people to have these tests. But it does mean that a patient who presented himself might choose in ignorance not to have a test which, in fact, he ought to have.
At the moment, we are awaiting a report from the Medical Officer of Health on the recent results. We are aware that 742 reports have appeared in the Press about this year's findings, but these were preliminary findings only. Since the Medical Officer of Health's report, which will contain his commentary on and discussion of the figures, has yet to be published I do not think that it is right to comment at this state on the results which have appeared. We have them in the Ministry, and are studying them closely in conjunction with our own research.
Let me sum up our position. We are advised, and we agree, that screening of the general public should be undertaken only for conditions which can be clearly and accurately diagnosed, and except in these circumstances screening of the general public can do harm and is, in any case, a wasteful use of resources both local and national. For this reason, I am not convinced on present evidence that this method of detecting disease should be recommended to health authorities generally. We are, however, most interested in the work that is being done by local authorities in this field and are following it closely.
In all that I have said, I emphasise most strongly that nothing should be construed as being in any way a criticism of what has been done over the last few years at Rotherham; that nothing should be construed as casting any doubt upon the validity of the results they are obtaining. All that is in our mind, as I have explained in some detail, is the doubt whether, taking account of the sudden burdens thrown on the analytical and treatment services, we are in a position with great conviction to recommend to authorities generally weeks such as have been discussed and mentioned by my hon. Friend.
§ Question put and agreed to.
§ Adjourned accordingly at nineteen minutes past Twelve o'clock.