§ Mr. Timothy Raison: (Aylesbury)I am grateful for the opportunity to raise the question of breast scanner provision for my constituents in and around Princes Risborough. I am also grateful to my hon. Friend the Minister for being here to reply to my remarks. There is no need for me to stress to my hon. Friend the importance of breast screening in the prevention and treatment of cancer, as I know that she and the Government are strongly committed to it. However, I should like to draw attention to the unfortunate circumstances that have arisen in my constituency, causing considerable local concern. Indeed, there is a strong sense of resentment over what seems an unfairness.
Briefly, the history is this. About four years ago, an appeal was launched in and around Aylesbury for a mobile breast screening or mammography unit, with the backing of Aylesbury Vale health authority and under the leadership of a consultant surgeon at Stoke Mandeville hospital—which, contrary to popular belief, is not just a spinal injuries unit, but the district and general hospital for the Aylesbury area. Stoke Mandeville is on the edge of Aylesbury.
There was a generous response to the appeal, and rightly so. Generosity was certainly shown by those living in the Princes Risborough area. The consultant surgeon who led the appeal told the people of Princes Risborough that they would be entitled to use the service: that is an important part of the story.
My constituents supported the appeal enthusiastically. Although it is not possible to say exactly how much was raised by the people of Princes Risborough, I have seen an estimate of about £3,000. Anyway, the usual energetic functions were launched. A bus was donated by, I believe, Luton airport; the money was raised, the unit was duly set up, based at Stoke Mandeville hospital, and the women of Princes Risborough were able to use it. For the most part, they had to go to Stoke Mandeville, rather than the mobile unit coming to Princes Risborough. But the distance between Princes Risborough and Stoke Mandeville is only five or six miles, and did not present any insuperable difficulties.
However, what was not fully understood, and perhaps was not sufficiently stressed by those who ran the operation, was that it was set up not in perpetuity, but only for a two-year trail period. At the end of that period, Aylesbury Vale health authority would make up its mind whether is should become permanent. Accordingly, after two years, the authority reviewed the operation and, very properly, decided to make permanent provision for screening women between the ages of 45 and 64. I give the authority credit for deciding to get on with that important process. However, it made another decision which had an adverse effect on my constituents — that the service would be available only to those living within the district of Aylesbury Vale health authority.
Princes Risborough is in a rather awkward position. It is an extemely pleasant and agreeable town which is doing very well, but it is in a kind of no man's land, lying roughly between Wycombe and Aylesbury and managing to fall between the two in various administrative ways. The district council is Wycombe, but the parliamentary constituency is Aylesbury. Princes Risborough patients 656 receive acute services from the Stoke Mandeville hospital in Aylesbury. Many people in Princes Risborough think of Stoke Mandeville as their hospital. However, for administrative purposes it lies within the territory of the Wycombe district hospital.
Stoke Mandeville provides both acute and other services, but preventive medicine is the responsibility of the Wycombe district council, the health authority for Princes Risborough. However, the mammography service was provided by the Aylesbury Vale health council. That is confusing, but what is much more important is that the Wycombe health authority does not yet provide a breast screening service. Therefore, the women of Princes Risborough no longer receive the breast screening service that they enjoyed during the two-year experiment by the Aylesbury Vale health authority, when they were able to go to Stoke Mandeville. They resent this, because they contributed generously towards the setting up of the service. It came as a considerable shock to them when they were told that they were no longer eligible for the service.
What are they to do about it? They could go private and pay £40 for breast screening; but £40 is quite a lot of money to pay for preventive screening of this kind, and not all my constituents would find it easy to fork out £40. If they are considered to be at risk, they can receive emergency treatment at Stoke Mandeville. It will not turn them away; doctors can refer patients to Stoke Mandeville for examination. Some individuals, of course, kick up such a fuss that they are taken on board, but that is not the right way to deal with the problem.
No screening service under the NHS is available to those women now. When the appeal was launched, they did not understand that it was to run for a two-year trial period. The consultant surgeon who led the appeal, unwittingly, I am sure, misled them. I do not make too much of that, because the consultant surgeon, who is well respected, was comparatively new to the district at the time and did not appreciate the administrative niceties. When he treated Princes Risborough patients he assumed that it was normal and that there was no demarcation.
Princes Risborough is now trapped in an administrative no man's land between Aylesbury and Wycombe. As the service has been withdrawn, a strong campaign has, not surprisingly, been mounted by a number of women in Princes Risborough. The Risborough and district community association, led by Mrs. Baker, has been particularly active in this cause.
Both the Ayles bury and the Wycombe health authorities have thought hard about what to do about it. Both I and other people have pressed them to take action, and the very conscientious Aylesbury general manager, Mr. Titley, has given close attention to the matter. Wycombe has also thought hard about it. Mr. Titley met the ladies of Princes Risborough to find out whether it would be possible to meet their request.
It was hoped that an interim solution could be found. It is clearly Wycombe's responsibility to offer preventive treatment. It was hoped that on Saturday mornings the mobile service could go to Princes Risborough and that Wycombe would pay for it but that Aylesbury would provide the service. I am afraid that that was not able to be brought about. There may have been problems about whether staff would want to work on Saturday mornings. I do not know exactly what happened. For one reason or another, it was not able to be put into effect.
657 As I understand it, Wycombe health authority is now working on plans to provide a district service. In a letter to me, it said that it is considering using Risborough for a pilot scheme. It is applying to the Oxford region for a share of the funds that are being made available from the DHSS to promote the service. I hope that something will come of that soon, but, for the moment, there is nothing in the immediate offing, and the feeling remains justifiably strong. What can my hon. Friend the Minister do about it? She is well known throughout the country for her positive approach to problems. She is not one to sit back and do nothing. I am quite confident that her positive approach will be manifested when she replies.
Certain things might be done. My hon. Friend could go back to Aylesbury and, once again, ask whether it might not, after all, be able to provide temporary cover for the people of Princes Risborough, presumably acting on an agency basis for Wycombe. There were serious discussions about it between the two authorities. They came to nothing. A debt of honour is owed to the people of Princes Risborough. It seems to be eminently reasonable for the Minister to go back and, once again, ask whether an interim solution can be found. If that is not possible, another possibility is worth thinking about; that is, to see whether for the time being one of the local private hospitals might be employed by one or other of the health authorities to provide an interim service. I have not gone into the matter in detail. I am not sure exactly whether facilities are available, but it is likely that they are. It will obviously be a matter of whether Wycombe should pay for them—presumably it would since it is the responsible authority—although it might be argued that, since, in a sense. Aylesbury has been involved in the history of the matter, it would be appropriate for Aylesbury to pay it. One way or another, it seems that there may be an interim answer by using a private hospital to provide what is not available in the National Health Service.
The other point is to urge the Wycombe authority and the Oxford region to proceed as fast as possible with the setting up of a proper breast screening unit. It is widely accepted that that is an important aspect of preventive medicine. The district general manager of the Wycombe health authority wrote to me on 28 April to say:
We must now press on as quickly as possible with the establishment of a district service which will meet the needs of the Princes Risborough population.I hope that my hon. Friend will endorse that view and do all that she can to try to make sure that it is brought about as soon as possible. The Oxford region is rather starved of money—that is not the topic of the debate—but there is a central Government commitment, and additional central Government funds are being made available. I hope that we may now see swift action to solve the serious problem that has caused much anxiety. I look forward to hearing my hon. Friend's response.
§ The Parliamentary Under-Secretary of State, Department of Health and Social Security (Mrs. Edwina Currie)I congratulate my right hon. Friend the Member for Aylesbury (Mr. Raison) on his success in the ballot today. Once again, he represented his constituents with a determination and distinction that less experienced hon. Members watch so that we might learn how it is done. He may be aware that I was in Oxford last week and had the opportunity of meeting the chairmen of the district and 658 regional health authorities. We discussed many issues, including co-operation between districts, to which the subject of the debate is pertinent.
In 1984, a public appeal was launched by a consultant surgeon, Mr. Alan Taylor, at the Stoke Mandeville hospital to raise funds for a two-year pilot project to evaluate the need for a breast cancer screening service in the Aylesbury Vale district. The appeal was supported by the district health authority, and money was donated, as my right hon. Friend rightly said, not only by the residents of Aylesbury Vale but by the residents of Princes Risborough, Tring, Thame and Chinnor. A coach was donated by the Luton airport authority. It was converted into a mobile examination and screening unit into which a mammography unit and an X-ray film processor were fitted. This is an opportune moment to put on record our considerable appreciation of the tremendous efforts that have been made to help the women of that neighbourhood.
The survey started on 21 May 1984. During the following two years of the pilot project, the mobile unit never visited Princes Risborough, but remained in the boundaries of the Aylesbury Vale district health authority. The women from Princes Risborough used the self-referral service when the coach was parked in the car park at the Stoke Mandeville hospital, which was the nearest of the coach's venues to Princes Risborough.
From an examination of the records of the women who were screened during that two-year period, it seems that between 50 and 60 women residents of Princes Risborough managed to use the service. In 1985 the unit spent more than three months on site at Stoke Mandeville, which is the longest period that it spent anywhere. Clearly, it was of some value and use to the women of Princes Risborough.
Although Princes Risborough lies within the boundaries of Wycombe health authority, the residents of Princes Risborough generally look to Aylesbury Vale DHA for acute services. They are usually provided at Stoke Mandeville, which is the major district general hospital. It is now accepted that in the early days of the appeal the organisers may have given Princes Risborough residents to understand that the unit would visit their town. Perhaps, as my right hon. Friend has hinted, some of those concerned were not fully aware of the geographical boundaries or the administrative niceties of the Health Service, or of the corresponding different areas of responsibility of the two district health authorities concerned.
At the end of the two-year pilot project, an evaluation report was completed. That report was considered by the Aylesbury Vale district health authority at its meeting on 9 April 1986. On the basis of the evidence contained in the report of the pilot project, it was decided to develop a formal breast screening service for all women residents between the ages of 45 and 64 years, living within the Aylesbury Vale health district. Those women were to be identified individually and invited to attend for screening, using a letter sent by their general practitioner in April 1986. Unfortunately, some months elapsed between the decision being taken and formal notification of the new operational policy being sent to general practitioners in Aylesbury Vale, and to those on the boundaries. In fact, the letter was eventually sent on 21 November 1986. I have no indication as to why there was such a long delay.
However, the health authority agreed to fund the service from its growth money, using equipment paid for 659 out of the public appeal. The service could not be extended beyond the boundaries of the district, not only because of the increased financial resources that would be required, but because of an inability to cope with the greater work load. Before long, Aylesbury Vale health authority had received complaints and representations from many people including the Princes Risborough parish council, the Risborough community association and my right hon. Friend, stating that the service should be available for all women in the appropriate age group who were residents in Princes Risborough. Aylesbury Vale health authority has stuck to its opinion that the service cannot be extended to residents in other health authority areas.
Meanwhile, as my right hon. Friend knows, the Government had been taking steps of their own. During the approximate time period of these events, the Government had commissioned Professor Forrest from the university of Edinburgh to report to us on much the same basis as to whether a system of breast screening, based on mammography or on something else, would be appropriate for the population at large. During the late autumn of 1986 Professor Forrest and his team reported to us and the Forrest report, setting out in detail how such a programme could be organised and what it would cost, was sent to the Government. The report recommended that we should base the screening system on mammography—a system of low-energy X-rays.
My right hon. Friend the then Secretary of State announced on 25 February this year that the Government had accepted in full the proposals of the Forrest report that a breast cancer screening system should be set up throughout the United Kingdom. A draft circular setting out the proposed arrangements in England was issued on 31 March.
As I am sure my right hon. Friend the Member for Aylesbury realises, we are the first country in the world to set up a screening programme that will be available for all women in the target age groups. That is a major first for this country and for this Government. I am pleased that the Government have recognised the needs of women and recognised also the importance of preventive health for the women of this country.
The services will provide a computerised call and recall system to screen women aged between 50 and 64 by mammography every three years. Older women will be screened if they wish; they are not being excluded. There is insufficient evidence so far to show that mass screening for younger women is effective in significantly reducing mortality. More research is required and is under way. The women who were coming in through the previous system in Aylesbury and Princes Risborough were coming from the age of 45. The recommendation of the Forrest report is that with the current state of the art the service is effective only from the age of 50. However, that is a matter we are keeping under review. Although women under 50 are not to be included in the screen population, any younger women at special risk—for example, if there appears to be an inherited tendency in the family—may be offered mammography if referred by the general practitioner.
A total of £6 million is being provided in 1987–88 to set up the centres in England. Each regional health authority is being funded by approximately one third of a million pounds to set up its first centre which would cover a 660 population of about 500,000. Four of the centres, which are at Guildford, Nottingham, Manchester and King's college hospital in Camberwell, will be funded to provide training for staff for the whole programme in England. The remaining centres, which total about 100 in all, will be set up during 1988–89 and 1989–90. In other words, it is a three-year programme.
All parts should have a service by 31 March 1990 and every eligible woman in this country should have been offered screening by 31 March 1993. The programme must be developed relatively slowly because of the need to train staff and to provide back-up facilities for diagnosis, treatment, counselling and aftercare. A total of 1,000 additional staff, all of whom need to be recruited and trained, will be involved and we are well aware of the importance of the advice given to us by Professor Forrest that at all times we must aim for a high quality of service, so we must not rush the training of the staff involved.
An advisory committee is being set up to advise on the development of the service, to monitor its effectiveness and efficiency and to advise on research concerned with its provision. The appointment of Professor Martin Vessey as chairman was announced on 8 April and the other members have now been appointed. Sir Roy Griffiths, the deputy chairman of the National Health Service management board, is leading a small team to oversee the implementation of the service.
My right hon. Friend may be aware of a parliamentary question which I answered on 23 July concerning the locations of the other 10 centres to be opened this year. The four main training centres have already been announced. The other 10 centres, adding up to one for each of the 14 regional health authorities, have now been announced and are Barnet, Epping. Liverpool, Stoke, Gateshead, Southampton, Huddersfield, Aylesbury Vale, Suffolk and Cornwall. The services at Epping, Huddersfield, Aylesbury Vale, Suffolk and Cornwall will be run from a mobile system.
Some of the regional health authorities are also planning to start further centres before March 1988, but by March 1990 there will be sufficient centres to provide a nationwide service. We have contacted the Oxford regional health authority, which tells us that it is establishing its first breast cancer screening service in line with the recommendations in the Forrest report. As I have just mentioned, it will be in Aylesbury Vale. The population to be serviced by this centre has not been finally determined. It will mainly depend on the arrangements to be made with the family practitioner committees for the operation of the computerised call and recall system, but it will be normal to cover more than one district. Indeed, we are recommended to provide centres which will cover some half a million people in order to make the system cost-effective. That implies more than one district.
In any event, Oxford regional health authority expects the population of Princes Risborough to be provided with the full computerised call and recall breast cancer screening service before March 1989. In other words, Princes Risborough, although not part of the first tranche, will certainly be part of the second tranche of the service being provided.
The problem is that for the next 18 months the residents of Princes Risborough—many of whom contributed to the appeal that launched the voluntary service at Aylesbury Vale and some of whom used it when it was 661 located at Stoke Mandeville hospital — will not have access to a service. I have listened carefully to what my right hon. Friend has said and I will take up his suggestion and draw it to the attention of the appropriate health authority chairmen. I agree with my right hon. Friend that we are not talking about an enormous expenditure, an enormous number of women or something that will go on indefinitely. The Health Service is to provide a screening service within the fairly near future.
It is important to bear in mind that only some 50 to 60 women in Princes Risborough used the service. Given that a scan is recommended at three-year intervals only, most of them would not expect to be recalled until the new service is in use. However, I recognise that if some women used the voluntary service in 1984 or 1985 their need for another scan might come up during the gap in provision.
I offer my right hon. Friend two thoughts on this matter. First, there are other systems of detection, such as self-examination. We would always strongly recommend that women undertake breast self-examination under the guidance and assistance of their general practitioners or with other groups in their community. That practice normally reveals anything that is possibly giving rise to concern. Women should certainly examine their breasts. Secondly, if there is anything wrong, nobody should wait for a letter from their general practitioner or from a computer—that applies to all screening systems. Around a quarter of a million women a year find something wrong with one or possibly both of their breasts. We pick up about 25,000 cases of breast cancer a year, but sadly there are some 15,000 deaths. The scheme is designed to reduce the death toll from breast cancer. However, nine out of 10 breast lumps are cysts that are benign. They need treatment if only because of the psychological benefit to the patient concerned. I am sure that my right hon. Friend will join me in urging any woman who discovers anything that she is not happy with to go to see her general practitioner at once and insist on being properly examined and treated.
The problem that we face here stems from a misunderstanding about the scope of the original voluntary service. I share the sense of regret felt by those 662 in the districts concerned. We must consider the following lessons. It is most important to be absolutely clear for whose benefit an appeal for funds is made. Secondly, there should be a clear, written and publicised agreement with the health authorities that will demonstrate who will run the service, who will start it, who will pay for it and, in the long term, who will replace the equipment. It is not good enough to provide a service once and then go through the hassle of raising more money when equipment requires replacing.
The enthusiasm of the appeal organisers in 1984 was tremendously commendable. However, it is clear that enthusiasm is not enough. Clear protocols are needed with regard to the service and links between the private sector, the appeal organisers and the health authorities. I say that with feeling having come across this sort of thing in my time as a district health authority chairman. I hope that these warnings will serve to avoid similar difficulties in the future when appeals are launched.
I have given the undertaking that I will write to the district health authority chairmen concerned and I am asking the regional chairman to look at the problem, take into account the issues that have been mentioned today and to report back to me. I will ensure that the points that my right hon. Friend has made are fully discussed. I will let my right hon. Friend know the outcome of those discussions.
I am sure that my right hon. Friend will join me in commending both the original organisers of the scheme and all those now concerned with it in their efforts to improve the health and the death rate of women from this appalling disease within that neighbourhood.
§ Mr. RaisonI am grateful to my hon. Friend for the tone of her response and for the information that she has given. I look forward to hearing the results. I am sure that she will get the message over strongly that we do not need an enormous operation to deal with the interim period.
§ Mrs. CurrieMy right hon. Friend and I are together on that point. I hope that, overall, there will be a major improvement in the services to women in his constituency.