HC Deb 02 March 1971 vol 812 cc1666-76

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Fortescue.]

5.47 a.m.

Mr. Julian Ridsdale (Harwich)

I am sorry that the Government have not reversed the decision of the Labour Administration to phase out the mobile X-ray service. A report by the Medical Director of the South-West Metropolitan Regional Hospital Board for 1968 described mass radiography as part of a revolutionary development in medicine the implications of which are not yet recognised. He stated: We are at the beginning of a new era, the era of pre-symptomatic diagnosis, in which treatment will begin before the patient feels ill, and if the disease is infectious before the patient becomes a danger to others. Periodic health examinations are being increasingly practised by private physicians and by industrial medical officers. Such examinations depend largely on the possibility of pre-symptomatic diagnosis. Up to recently in nearly all cases the symptoms have selected the sick person from the healthy majority and eventually led him to the clinic. But examinations of a wider kind have been made with the evolution of mass techniques. Mass radiography was the first of these mass examination techniques. It was hoped that this would be the forerunner of other techniques in which early diagnosis could forestall illness or improve chances of recovery. This routine chest radiography has served the individual and the community by fighting against three causes of ill health: tuberculosis, heart disease, and lung cancer.

While the service is to be run down, it is to be included in hospital diagnostic X-ray departments. But is it realised that these departments are already overworked and in many cases have to limit the open access of practitioners in holiday times? Essentially the question is whether we shall get an efficient screening by changing to the system which the Ministry suggests or by continuing with the present arrangements.

I ask the Minister why he is so certain that industry will be served so well in the future. I have seen very considerable medical advice which suggests that the discontinuance of the mass radiography service is medically undesirable. It is all very well that the Minister's medical advisers, we are told, agree with this decision, but what consultation has taken place with practitioners on the ground and with industry? Only last night I spoke to a leader of industry employing 2,000 people. He underlined most strongly the value of the mobile X-ray system and the service which it was performing for industry. The Minister should not discount this too lightly. I believe the decision was taken without adequate assessment of medical considerations or consultations or of consultations with industry.

I feel certain that from the industrial point of view the facility of providing a mobile unit at the place of employment was a major factor in obtaining efficient screening. When firms are obliged to pay for each X-ray and lose productivity by sending their employees several miles for X-ray, it is obvious that screening will become non-existent with the risk of tuberculosis from an increasingly immigrant population, this decision seems deplorable. How can the new system be efficient?

I will now deal with some of the details concerning tuberculosis and its detection. The reason which the Minister has given for closing down the mass X-ray service is that detection of active cases of tuberculosis has fallen steadily from 8,720 cases in 1954 to 2,619 in 1967. But surely the fact that there were so many fewer cases in 1967 was in itself a case for continuing the service. There were 15,665 cases of other diseases in 1968 which were also screened. I am glad that my hon. Friend the Member for Ipswich (Mr. Money) is present to support me, particularly in regard to the observation I have just made.

Has the Minister the latest figures in regard to screening? May I ask for a detailed breakdown of the figures, particularly with reference to country and city areas? The evidence that I have leads me to believe that the disease is far from eradicated in big cities. Is it not a fact that in Greater London in 1967 there were 2,450 notifications, almost 50 cases a week, and the disease persists because a pool of unrecognised cases which can be detected only by chest X-ray examination continues to exist? Is it not a fact that in 1967, as a result of the radiography of 108,000 people in South-West London, 165 cases of active pulmonary tuberculosis were discovered and that 10 years ago the corresponding figures were 183 cases for 93,000 people?

If these figures are correct, and I have no reason to believe that they are not, they give no cause for phasing out of mobile X-ray units, especially in the big cities. I should like to have further evidence from the Minister. I believe that the view that tuberculosis has almost disappeared from the city is prematurely optimistic. Is the Minister satisfied that the incidence among immigrants is small? Would he say what is happening in rural and city areas and what is the policy towards schools?

In addition to the work done for the detection of tuberculosis, screening is also carried out for the detection of heart diseases and lung cancer. Consideration must be given to the useful work done for many people suffering from these diseases. What further figures has the Minister about this? I have been particularly impressed by the statement made by the Borough of Hammersmith in rejecting the reasons for the running down of the mass X-ray units. Its facts and figures emphasise the necessity to keep the mobile X-ray service on the ground that unselective chest radiography still finds two-thirds of the total number of significant TB cases. It emphasises that a disturbing feature is the proportion of infectious cases—24.2 per cent.—which is the highest for many years. It states that an analysis of pulmonary tuberculosis cases show that the largest numbers are found in the examinations of factory and office workers in open sessions for the general public. This certainly suggests that the Minister's instructions have been premature.

Is this being done because of the cost of the service? Does the Minister fear an increase in capital costs? We have no figures about capital cost although it was mentioned in a circular at the time of the Labour Administration. What is the cost of saving money and capital? Could a charge be made to cover the cost per person? Certainly the industrialist of whom I spoke earlier would be only too glad to pay a small sum for this service, for the efficiency of industry.

Hammersmith estimates the cost of finding one active case is £203. If 100,000 people were charged 4s., less than the price of 20 cigarettes, this cost could be met. The Minister is being penny wise and pound foolish. What is the cost of treatment? Surely it is much better to deal with people at an earlier date than to have to deal with them later when the symptoms are found because they go to a clinic?

I have found strong feelings about the phasing-out of this service. If it were not for the lateness of the hour I know that many more hon. Member would be supporting me now. Even this number is good for the time. I know of over 50 M.P.s who would support me, including doctors, who also feel strongly about this, particularly those who have benefited from the service.

It is all very well for the Minister to say that the service will still be available in the hospitals. Surely there is a shortage of doctors in the hospitals. This will overload the services even more. I am certain that prevention is better than cure. That is common sense. It is up to the Minister to produce far more evidence than he has so far to justify the decision to phase out this excellent and efficient mobile X-ray service which has given such service to the community. I ask him to explain to the House and the country that he is not being penny wise and pound foolish and that he realises the value of putting prevention before cure.

5.59 a.m.

Mr. Eric Deakins (Walthamstow, West)

The hon. Member for Harwich (Mr. Ridsdale) talked of support in the House. I can assure him that he was very much under-estimating his support on this important subject. He has put his case most graciously.

If this decision was taken on cost grounds, then it was deplorable. If, on the other hand, it has been taken on health grounds, then the House needs rather more information than has been made available so far. It is regrettable that we do not have an industrial health service, which would meet the point of the industrialist mentioned earlier by the hon. Member. I hope that the Govern- ment will look at this carefully, with a view to reconsidering the decision which we think they have already taken.

6.0 a.m.

The Under-Secretary of State for Health and Social Security (Mr. Michael Alison)

I am grateful to my hon. Friend for the clear and cogent way in which he has portrayed his anxieties over the Government's policy on the future of the Mass Miniature Radiography Service.

It would be helpful if I were to comment on some of the misconceptions which seem to have obtained some currency. The decision to reduce the service was not based primarily on financial considerations, nor was it taken hastily or taken without the most expert medical advice. Indeed, it has long been the view of our medical advisers that general population screening for tuberculosis was no longer achieving a result comparable with the considerable effort involved.

Another view I should like to dispel is that the Mass Miniature Radiography Service will be withdrawn abruptly and completely. The rundown will be slow and deliberate, and a substantial part of the service will be retained for some time.

I realise, nevertheless, that many people are puzzled why a service that seems to have played such a significant part in preventive medicine should be reduced at all, and I am very conscious of the concern that has been expressed by so many responsible bodies, among them trade unions and trade councils. Many feel that people should be urged to make more use of the service, but I could not support such action.

The first point we should remember is that, although the service has made an important contribution, and can continue to make a contribution, to the detection of this disease, and to the reduction of its incidence, it has not been the only factor in the immense strides that have been made to control it. Nor could this service itself ever achieve the total eradication of pulmonary tuberculosis.

In the years before the introduction of the service there had been a continuing decline in the number of deaths each year from this disease due to rising standards of living and better hygiene. This improvement was accelerated in the years after the war by the introduction of B.C.G. vaccination, by improved treatment by chemotherapy, and by continued advances in the state of public health and living conditions.

My hon. Friend asked for some figures and I will give a few to show what improvement there has been. In the years 1945–49 the average number of deaths from pulmonary tuberculosis was 19,236. By 1969 this figure had fallen to 1,092. The part played by mass miniature radiography since the inception of the National Health Service has been as follows. In 1946 the number of persons examined by this means was 571,697. This figure rose to a peak in 1956 of 3,617,550. Since 1960 the number examined each year has stayed fairly constant at a little over 3 million, until in 1968 it dropped to 2,882,730, with a further decline to 2,663,670 in 1969.

I think these are roughly the figures quoted by my hon. Friend. The number of new cases of active tuberculosis—that is to say, those requiring treatment or supervision—discovered by this service in 1954, which was the peak year, was 8,748; this has declined steadily to 2,358 in 1969. My hon. Friend has given some statistics for South-West London; those he quotes for 1967 should, I think, refer to 1968. This is a small point, I must confess. But I am unable to reconcile the earlier year he refers to with my information. However, to give a 10-year comparison, in 1958 94,300 people were examined in the area, among which 274 cases of active tuberculosis were found. No record is kept by the Office of Population Censuses and Surveys of a breakdown of cases of tuberculosis detected as between city and rural areas. However, a comparison between the Liverpool and South-Western Regions shows that in 1969 in the former 75 cases were detected out of 83,270 examined and in the latter, the more rural region, 78 out of 93,150. My hon. Friend's figures for notifications in the G.L.C. area for 1967 are correct, but these are not related to mass radiography.

What is of great significance here, however, is the proportion of cases detected for the number of people examined, and this means a great variation depending on the particular group being considered. For example, in 1969 the rate of detection for volunteers from the general public and for office and factory surveys was only one in 2,000, whereas for those referred by general practitioners the rate was six per 2,000.

Mr. Ernie Money (Ipswich)

Will my hon. Friend deal with the point raised by my hon. Friend the Member for Harwich (Mr. Ridsdale) with regard to the discovery of heart disease and lung cancer by this means?

Mr. Alison

I shall come to that point. In any event—going back to the imbalance between general and more specific services—the Department is advised that the continuance of the service for general population, office and factory surveys cannot any longer be justified on the basis of the sharp imbalance which I have described.

The case for retaining the service for general practitioners is, clearly, stronger if they have no other means of referral or if access to hospitals is difficult for their patients. Over the past years the hospital radiological services have been improved and open access by general practitioners extended so that in general throughout the country open access is available to them. Thus, for these doctors mass miniature radiography should no longer be necessary for the referral of their patients suspected of having active tuberculosis. Nevertheless, in order to avoid exacerbating the shortage of radiologists to which my hon. Friend referred, all boards have shown their desire to keep mobile or static units for the use of general practitioners where open access to hospital radiological departments is not adequate, and particular attention is paid to rural areas. In 1969 43 per cent. of all active tuberculosis cases detected were in patients referred by general practitioners. This leaves 57 per cent. "unselected", not two-thirds as quoted by my hon. Friend. But the important point is that the proportion between detection and examination for general practitioners is six times that for random surveys.

Finally, there remain groups at special risk, such as those in prison; persons known to have been in contact with a tuberculosis suspect, and where a rapid screening service is needed; or where there is known to be an unusual prevalence, such as among Asian immigrants. My hon. Friend has very rightly shown concern for schoolchildren. We do not, of course, favour the radiological examination of children unless there is some special reason such as a positive Mantoux test. However, in 1969, 16,930 random tests were made, and only three cases found. There are other safeguards for children. They are offered B.C.G. vaccination at 12 to 13 years; and it is generally considered desirable for local authority employees and other persons whose occupations bring them into contact with groups of children—for example, teachers—to have chest X-rays, and these are now provided free by hospital radiological departments. Where necessary, the Mass Miniature Radiography Service can help in this work.

Of the chest ailments that can also be detected by mass miniature radiography that which most concerns the public is lung cancer. In 1969, 3,696 cases were detected by mass miniature radiography compared with 2,188 in 1959. The difference between this disease and tuberculosis, however, is that in the latter cases detection will very likely result in cure. In cancer it will not. A great deal of work has gone into determining the effect of early detection of lung cancer by X-ray on the prognosis for this disease, and there is, unfortunately, no evidence on which it can be said with confidence that the prognosis is thereby improved. The most effective prevention of lung cancer lies in a change in the smoking habits of the population, and it is certainly illusory for a heavy smoker to rely on frequent X-rays to detect this disease in time for it to be cured.

The value of mass miniature radiography for early detection and diagnosis of heart disease is a more complex question. Cardiac abnormalities can, of course, be detected, but my medical advice is that mass X-ray can only show one factor in a disease process and that there are simpler methods by which other signs can be identified. In 1959, 7,289 such abnormalities were detected by mass X-ray as against 8,871 in 1969.

The incidence of tuberculosis among the immigrant population from Asia is markedly higher than for the rest of the population. New immigrants are now X-rayed in their country of origin before an entry voucher is granted, except for the wives and dependants of those already here, in which case they are checked on arrival and referred to the medical officer of health of the area where they will reside, if this is necessary. A recent report on Birmingham suggests that this higher incidence has not adversely affected the decline in notifications among the British-born population among whom they live; and in those sections of the Asian age groups that have now become static, tuberculosis notifications are falling. The point I am making is that this is a comparatively small and readily identifiable group of the population and that specific direction towards them for screening for tuberculosis is practicable without retaining general population screening.

My hon. Friend has referred to the cost of the service, and has suggested that the public would be willing to pay to retain it. As I have said, financial savings have not been a determining factor in the policy for this service. I could not accept that we should charge for a service to provide general population surveys which we do not believe to be justified; or to charge for general practitioner references or surveys of special groups at special risk which are justified. In 1969–70 the service cost £1,003,000, all of which was running costs. No extra expense is caused in equipping hospital radiological departments, since the policy is to improve these independently of the policy for mass radiography. The cost of each examination averages out at 38p; the average cost of detecting a case of active tuberculosis is £425; but for general population surveys it is £671; for office and factory surveys it is £873; and for general practitioner referrals it is £125. It is true that the treatment of active pulmonary tuberculosis is likely to be cheaper in its early stages. Treatment will vary from two years on drugs without hospitalisation to hospital treatment for three to six months followed by treatment with drugs. Many of the cases detected by mass X-ray are likely to need hospitalisation; some might have regressed without treatment. Thus, I doubt whether it would be useful to attempt to draw a balance, more so since cost is not the important issue.

In conclusion, I should like to emphasise that the policy that we are now following is neither precipitate nor dramatic. There are, as my hon. Friend will be aware, two components of the service: the mobile unit and the static unit. Information provided by regional hospital boards in June, 1970, showed that there were 49 mobile and 31 static units in England at that time. Proposals submitted by boards for the future shape of the service show that by the middle of next year these units will have been reduced by 17 mobile and two static units, and that this situation is likely to be held for some time.

At the same time boards will be able to direct the savings in effort achieved in the operation of this service to other priority needs, including the radiological departments of hospitals, whose contribution to patient care is of such vital importance. I welcome the evidence that this method of mass prevention has been successful, and I do not regard as disappointing the redirection of its work in a more beneficial manner.

Question put and agreed to.

Adjourned accordingly at fourteen minutes past Six o'clock a.m.