HC Deb 14 December 1995 vol 268 cc1112-55

[Relevant documents: The Third Report from the Health Committee of Session 1994-95 on Breast Cancer Services (House of Commons Paper No. 324), the Government Reply thereto (Cm. 3007), and the Department of Health and Office of Population Censuses and Surveys Departmental Report 1995: The Government's Expenditure Plans 1995-96 to 1997-98, (Cm. 2812).]

Motion made, and Question proposed,

That a sum not exceeding £13,948,653,000 be granted to Her Majesty out of the Consolidated Fund, on account, for or towards defraying the charges for the year ending on 31st March 1997 for expenditure by the Department of Health on or in relation to hospital, community health, mental health, family health and family health service administration services, National Health Service trusts, and on related services.—[Mr. Horam]

4.4 pm

Mrs. Marion Roe (Broxbourne)

I am very grateful to the Select Committee on Liaison for recommending that the House debates this estimate in so far as it relates to the very important topic of breast cancer services. I shall, of course, concentrate on the report published recently by the Select Committee on Health, which I have the honour to chair. The recommendations of the report were unanimous.

I should like to thank all my colleagues on the Committee for the very hard work that they put into the report, and for the very good spirit in which it was discussed. I should also particularly like to thank our specialist advisers, Professor Michael Baum of the Royal Marsden hospital and Professor Roger Blamey of Nottingham City hospital.

I shall begin by outlining the main conclusions and recommendations of the report, and the main points of the Government's response. There are a few questions that I should like to pursue with the Minister, which I hope he will be able to address in his speech.

Although the United Kingdom does not have a particularly high incidence of breast cancer—the disease is more prevalent in the United States of America, New Zealand, Canada and several other European countries, including France, Italy and Denmark—we have almost the highest recorded breast cancer mortality in the world. Breast cancer claims the lives of more than 13,000 women every year in England and Wales alone—more than any other cancer, and more than any disease other than heart attacks and strokes. None of our witnesses was able to offer any explanation of why breast cancer mortality should be so high in this country.

The Government's target, set out in 1990, is

to reduce the number of breast cancer deaths among women invited for screening by at least 25 per cent. by the year 2000. It is clear from the very wording of that target that the national health service breast screening programme is at the centre of the Government's plans to reduce breast cancer mortality. No reduction in breast cancer mortality from the programme is expected to be observed until around 1997, as there is a "lead time", which means that the full benefits of the programme will not be observed until those women who have benefited from the early detection of their breast cancer begin to enjoy additional life years. None the less, we were impressed by the fact that the programme has met or exceeded all its interim quality indicators so far, largely as a result of its excellent quality assurance programme, and especially the efforts of its national co-ordinator.

One of the great strengths of the quality assurance programme is that it operates not only in individual screening units but at district and regional health authority level. RHAs are responsible for purchasing quality assurance services and for the operation of the quality assurance reference centres in each region.

In 1992, the chief executive of the NHS management executive told the Public Accounts Committee that the standards laid down centrally for the programme were "non-negotiable", and said:

If there are purchasers that want to try to step out of line"— that is, to try to purchase a service that does not meet national specifications—

they must be brought back into line by the regions. That is the role of the region and we have made that extremely clear". The national co-ordinator of the NHS breast screening programme also told us that she occasionally had problems with district health authorities which were trying to purchase services that did not meet national standards. That is why the quality assurance programme is so important to the screening programme. It ensures not only that the service provided matches the service for which it is contracted, but that the service for which it is contracted meets the national requirements in the first place. We recommend that the QAP should be preserved in something like its present form after the dissolution of the regional health authorities next April. That could be achieved either by central funding of the programme or by bottom slicing from district health authority allocations.

In their response, the Government said that they had issued guidance to the effect that

it is vital that quality assurance systems should continue to be funded and operated in the future to the same high standards as at present. The Government have also said, however, that they will move from the present system, under which RHAs are responsible for purchasing quality assurance, to a system of lead district purchasing, which will be funded through the common services levy.

I recognise the steps that the Department is taking to ensure that the QAP continues to operate at all three levels, but I should be grateful if my hon. Friend the Minister were able to assure us that the programme will not become simply a means for purchasers to check on provider units. We must continue to ensure that the service purchased meets the national standard.

The Select Committee on Health recommended, on the strength of the best evidence now available, that the upper age limit for inclusion in the call and recall system for screening should be extended from 65 years to 69, and that the Department of Health must ensure that women over that age are aware of their right to a three-yearly mammogram on request.

Professor Forrest's report, on the strength of which the NHS breast screening programme was originally established, suggested an upper age limit of 64, on the ground that there was lower acceptance of screening by women of older ages. It is difficult to understand what basis was used for that assertion, as the Swedish two counties study—one of the key pieces of clinical trial evidence on which the Forrest report drew—showed that 80 per cent. of women up to the age of 74 accepted invitations for screening.

There are two good reasons, I believe, for including older women in the screening programme. First, the risk of breast cancer increases with age. Secondly, the cancer detection rate among older women is much higher than among younger women.

Conversely, we found no evidence that extending screening to women under the age of 50 would be beneficial. None of our witnesses supported that proposal. Professor Martin Vessey of the advisory committee on breast screening explained to us that, apart from the lower incidence of breast cancer in women under the age of 50, it is also difficult to screen for breast cancer in pre-menopausal women, as

the hormonal environment in the breast is different and the breast is much denser, making it more difficult to obtain accurate readable mammograms. The Committee was pleased to note the Government's response, which is to conduct clinical trials in screening older women.

The NHS breast screening programme is a model service. It has strong central co-ordination, a set of auditable national performance targets, and a quality assurance programme that has been praised by the National Audit Office. However good the screening programme, however, screening alone will not lead to a reduction in breast cancer mortality.

As we were completing our report, evidence emerged that breast cancer mortality was already beginning to fall in 1989. As I have said, such an effect could not have been generated after only two years of breast screening. It is probable that the welcome reduction in mortality is the result of improvements in the treatment of more advanced breast cancer.

There are ways in which treatment for women with both screen-detected and more advanced breast cancer could be improved. There was a wholehearted welcome for the Government's policy framework for commissioning cancer services. The Government's plan is that cancer services should be arranged into three tiers—primary care, designated cancer units and designated cancer centres.

The designated cancer unit will normally be a district hospital with a full range of support services for cancer patients. More importantly, however, it will have site-specific clinics for patients with the commoner cancers, led by a consultant specialist. Those will be clinics that deal with only one type of cancer, such as breast cancer or gastro-intestinal cancer.

In practice, that means that, where there are several hospitals in one area, purchasers and providers may agree between themselves that a unit for certain cancers or groups of cancers will be established at one hospital, and a unit for another cancer or group of cancers in another hospital. Such clinics would also treat patients with related non-malignant conditions—for example, women with non-malignant breast problems, which account for about 90 per cent. of all breast disease, would be seen in a specialist breast unit.

The cancer centre will be part of a large general hospital or a teaching hospital, and will offer the same range of services as the cancer unit. It will also offer specialist clinics for the less common forms of cancer, and a full range of support services for the local cancer units, including

those treatment regimens which are too specialised, technically demanding or capital intensive to be provided by the cancer unit. That could include radiotherapy, for example.

The most important point to make about the policy framework is that it is based on sub-specialisation. It is not acceptable that a woman with a serious life-threatening disease such as breast cancer should be treated by a general surgeon who might spend most of his or her time dealing with a muddle of other surgical conditions. In addition to a specialist breast surgeon, the specialist breast unit should have a multidisciplinary team of other specialists with specific training in the management of breast disease.

The advantages for patients in such units are manifold and great. Each unit will see enough patients to operate a dedicated clinic for new patients with breast problems each week—a one-stop shop, at which women can have all their diagnostic tests done at the same visit.

Rapid diagnosis is of the utmost importance. It allows women who have breast cancer to receive treatment at the earliest opportunity, and permits the timely reassurance of women who do not have cancer. Patients who have breast cancer will receive a high-quality package of care planned by a multidisciplinary team of specialists, rather than what the British Breast Group report, "Provision of breast services in the UK", described as

ad hoc therapy being carried out by an individual acting without interaction with other members of a team". More importantly, there is evidence that patients treated in such units have improved survival rates. A paper in The Lancet last spring showed that women treated by a consultant who sees more than 29 new cases of breast cancer each year have a 30 per cent. better survival rate than those treated by a consultant who sees fewer new patients.

The specialist unit also represents a very efficient way of treating breast cancer. Mr. Hugh Bishop, of the British Association of Surgical Oncology breast surgeons group told us:

a specialist breast unit is actually more efficient. It does fewer benign breast operations, it does fewer unnecessary investigations … and processes people more efficiently and in a more kindly way. That is the Government's vision for the future of breast cancer services in the United Kingdom, and it is a vision shared not only by the Select Committee but by organisations such as the British Breast Group, the British Association of Surgical Oncology breast surgeons group and the Cancer Relief Macmillan Fund.

While the Committee welcomed the Government's new initiative, we believe that it could be improved further. We believe that there must be some mechanism for ensuring that a hospital which is designated as a cancer unit or a cancer centre is providing the necessary services to the required standard. There is a real danger that every hospital with a consultant surgeon will simply hang out a sign saying "Specialist Breast Unit", and will designate itself as such, without having suitably trained specialist staff or the necessary critical mass of patients that is so vital to the good running of such a unit.

The British Breast Group recommends that a specialist breast unit should see a minimum of between 75 and 100 new cases of breast cancer each year. That serves to ensure both that the general level of expertise among the team is sustained and that the unit remains cost-effective. By issuing a set of national mandatory standards for specialist breast units, the Department could ensure that all women with breast cancer receive the highest standards of care.

During our inquiries, a definition of a specialist breast unit was produced by an ad hoc group consisting of representatives of various organisations involved in the management of breast disease, including several of the royal colleges. The Committee published the definition as an appendix to its minutes of evidence, and it can be found on page 191 of that volume. The same ad hoc group met again recently, and it has further revised the definition.

I have praised the mechanism which the NHS breast screening programme has in place to ensure that all screening and assessment units provide a high-quality level of service through its quality assurance programme. It is a Rolls-Royce among breast cancer services. Unfortunately, many women whose breast cancer is not detected by the screening programme receive a second-hand Trabant service. They might be referred to a general surgeon at a local hospital who has no special training in the management of breast cancer, does not work closely with a team of oncologists, radiologists and cytologists, sees only a few cases of breast cancer each year, and is not subject to any external mechanism of quality control.

In our report, we concluded that the QAP is one of the great strengths of the programme, as it operates at a level above individual purchasers and providers. We recommend that the remit of the national co-ordinator of the NHS breast screening programme and the regional quality assurance teams should be extended to cover the provision of services for women with symptomatic as well as screen-detected breast cancer.

Such an extension of the quality assurance programme would enable the Department of Health to ensure that all hospitals which were operating specialist breast units met the minimum mandatory standards. My noble Friend Lady Cumberlege and the chief medical officer told the Committee that they were worried that a mandatory service specification might stifle useful innovations at a local level. I fully appreciate their concern, but the mandatory requirements which the Committee proposed are the minimum requirements. There is no reason why they should prevent units from providing a higher level of service than is specified.

Perhaps I might draw an analogy with the patients charter. The charter lays down the minimum level of service that patients have the right to expect, but does nothing to prevent providing units from exceeding those standards. I am pleased that the Department of Health is working to develop service guidance for the common cancers, but I shall be grateful again if the Minister will assure the House that this will be sufficient to stop hospitals simply hanging out a sign.

Breast cancer is almost unique, in that a quality assurance system operating at national and regional level is already in place within the screening programme. The Select Committee believes that an extension of the functions of the quality assurance programme and the office of the national co-ordinator to include services for women with symptomatic breast disease could lead the way for other site-specific specialties. It is perhaps surprising that that proposal was supported by many of the doctors who gave evidence to us. They want their work to be subject to rigorous quality control.

Dr. Mike Richards of the British Breast Group told us that he would favour a national co-ordinator for all breast cancer services. Mr. Hugh Bishop of the British Association of Surgical Oncology told us that such a development was "absolutely essential". It is a pity that the Department is proving reluctant to build on the success of the screening programme in that way, but I await the Minister's response on the matter.

During our inquiry, the Committee learned that at least one regional health authority—North Thames—is extending the role of its regional quality assurance manager to encompass the provision of treatment for breast cancer patients. It told us:

Women should be offered the same standard of care from the breast service in both screening and symptomatic investigation and treatment. The Committee considered ways in which clinical research in breast cancer might be improved. Although our inquiry related primarily to breast cancer services, our recommendations on clinical research will inevitably have benefits for many researchers working in other fields. We heard from researchers and from the Department of Health that one of the obstacles to conducting good clinical research was disputes over who was to provide indemnity for the clinicians and trusts involved in that research. The present system of providing indemnity for clinicians and trusts engaged in research is ambiguous.

The Department of Health told us that NHS indemnity covered all NHS-provided health care professionals for negligent harm resulting from research undertaken as part of their NHS contract, and that the employing NHS body—for example a hospital trust—is expected to meet the entire cost of defending, and if necessary settling, a claim where negligence is alleged.

Ultimately, it is for the employing body to decide whether to allow research to proceed or not, and a trust may decide not to allow its employees to participate in a trial if it does not wish to provide indemnity for them. Mr. Richard Gray of the clinical trials service unit at the university of Oxford told us that many trusts refused to allow their doctors to take part in trials unless they received indemnity cover from the study sponsors.

In some cases, that has led to the absurd situation in which doctors have been permitted to use conventional treatments and new treatments of unproven effectiveness in an ad hoc manner, but have not been allowed randomly to assign patients to control and study groups in a way that would allow them to gain useful information about the effectiveness of the unproven treatment. That clearly militates against the Department's efforts to encourage the practice of evidence-based medicine, of which I am sure the whole House would approve.

Good clinical research is of benefit to the whole NHS, and the Select Committee did not think it fair that the indemnity cost of that research should be provided only by those NHS bodies which participated in it. We therefore recommended that indemnity for NHS bodies and their employees participating in research which is approved by the relevant research bodies—in the case of breast cancer research, the United Kingdom Co-ordinating Committee on Cancer Research—should be provided centrally by the Department of Health. The Committee was pleased to learn from the Department that it will be considering that option in its current review of research indemnity. I hope that the Minister will be able to report the latest progress of the review to the House today.

The Committee also recommended that the Department consider ways to streamline the system of ethics committees. Ethical review is an essential part of clinical research, but representatives of the UKCCCR told us that the present unwieldy structure of that committee system puts people off entering patients into trials. For a large multi-centre trial, the approval of as many as 40 local research ethics committees might have to be obtained.

There are a few good reasons why a research proposal might be allowed to go ahead in one area and not in another. The provision of information leaflets in ethnic minority languages for patients is liable to be an essential part of a trial conducted in some parts of the country, but not others. Likewise, some hospitals may have the appropriate facilities to participate in a trial and others may not.

The fundamental ethical considerations surrounding a research proposal, however, will not vary from one region to another. Breast cancer research is changing—moving towards the examination of smaller and smaller sub-groups of patients of different tumour types. It is therefore becoming necessary to involve more and more research centres in clinical trials.

I know that the Minister shares the Committee's concern about the unwieldy system of local ethics committees, and that the chief medical officer is considering ways of streamlining the system. Perhaps the Minister might be able to give the House a little more detail about that review this afternoon.

Finally, I should like to say a few words about the United Kingdom Co-ordinating Committee on Cancer Research and, in particular, its breast cancer trials and cancer screening sub-committee.

The UKCCCR consists of the Cancer Research Campaign, the Imperial Cancer Research Fund, the Medical Research Council and several other cancer research charities. It was originally chaired by Professor Sir Patrick Forrest, who was instrumental in establishing the NHS breast screening programme. The Department of Health and the Scottish Office Home and Health Department have observer status on the committee. The UKCCCR provides a forum for the exchange of information on the policies and plans of member bodies, recommends proposals for the co-ordination of policies, and offers advice to the member bodies on any matters that might come before it. Although the breast cancer trials co-ordinating sub-committee of the UKCCCR runs some trials of its own—such as those that are being conducted to examine the treatment of ductal carcinoma in situ and the use of tamoxifen—and endorses and co-ordinates large, multi-centre trials, it does not distribute the funds for such trials. After researchers have obtained approval from the UKCCCR, they must scrape around trying to find out where they can fund the research, going to committee after committee, at the mercy of the weakest of those committees, and all before they have to go through the system of local research ethics committees, which I have just described.

The UKCCCR breast cancer trials co-ordinating sub-committee can be seen as the parent body for breast cancer research, representing most of the main sources of research funding. The Select Committee believes that it would be a step forward if the UKCCCR were to have its own budget for funding trials, so that it could act as a one-stop shop for researchers wishing to undertake a trial.

We recommend that the Department of Health and the Medical Research Council identify their budgets for breast cancer research, and distribute the money through the UKCCCR in the expectation that that will provide an incentive for other research funding bodies to do likewise.

I understand that neither the Department nor the MRC has a specific budget for breast cancer research, but I cannot see why it would not be possible for them to identify the amount which they currently spend on breast cancer research, and devolve that amount to UKCCCR. The whole Committee agrees that that would be a welcome development, which would make it easier for researchers to gather vital information about the effectiveness of new treatments at the earliest possible opportunity.

I know that colleagues from the Select Committee wish to contribute to the debate, so I shall draw my remarks to a close. In my introduction, I have attempted to focus on the main conclusions of the Committee's report, but I look forward to hearing the views of other hon. Members, and, in due course, those of my hon. Friend the Minister.

4.35 pm
Mr. Kevin Hughes (Doncaster, North)

I welcome the opportunity to take part in this important debate. Breast cancer services for women in the national health service are an important issue. As the Health Select Committee acknowledged in its report on breast cancer services, we have learnt that although England does not have a particularly high rate of breast cancer occurrence, it has almost the highest recorded breast cancer mortality rate in the world.

Currently, almost 30,000 women are diagnosed with the disease annually and around 14,000 die of it. It is responsible for about 5 per cent. of all women's deaths throughout the country. Understandably, breast cancer is an emotive issue. It is also a very real issue for the tens of thousands of women who have the disease and the thousands who die from it.

We must set this debate against the background from which it emerges—the increasing inequalities in public health. Since the Black report was published, socio-economic differences in health have increased. The difference in mortality rates between the deprived and the affluent has increased substantially. The recent widening of health inequalities mirrors the gross upward redistribution of wealth since 1979. It is vital that patients should have access to the same standards of health care throughout the country, irrespective of where they live or to what socio-economic class they belong. Inequalities in health should be targeted and eradicated.

In the Government's "The Health of the Nation", mortality rates for women suffering from breast cancer are targeted as a leading priority to be reduced in the long term. The Government have recognised the importance and significance of mortality rates for women suffering from breast cancer. They know that the figures are illustrative of the condition of the public health services.

In "The Health of the Nation", targets were set for a reduction in mortality of those screened for breast cancer. In progress reports on "The Health of the Nation", the Government are, I believe, complacent in stating:

progress to date has been in the right direction". Yet statistics from the House of Commons Library show that 60 per cent. of district health authorities are unlikely to meet those targets. Of the 112 district health authorities in England, 54 will fail to meet the target of a 25 per cent. reduction in mortality rates by the year 2000.

The Government's comments are therefore misleading and superficial. The Government's document on variation in health, in commenting on variations in breast cancer, stated:

with respect to mortality there is relatively little variation around the England and Wales average". "The Health of the Nation" dedicates only one page to regional variations but socio-economic variations show that, although the incidence of breast cancer is higher among the wealthier classes, the lower classes are more likely to die from the disease.

Leading health professionals are concerned that breast cancer services continue to vary considerably throughout the United Kingdom.

Mr. David Congdon (Croydon, North-East)

Will the hon. Gentleman give way?

Mr. Hughes


Department of Health public health common data showing regional and local mortality rates from breast cancer illustrate the huge variations between local health authorities and, on a wider and more significant level, large variations between regional health authorities.

I am particularly concerned about those alarming figures because they highlight the high rate of breast cancer mortality in and around my constituency. Although the registration rate for breast cancer in Doncaster is some 7 per cent. lower than the national rate, we have a disturbingly high mortality rate from breast cancer. For most of the past 11 years, the rate has been significantly higher than the national average. In 1993, it was 13 per cent. higher than the national average yet in neighbouring areas mortality rates from the disease have been consistently below the national average. The figures for North and West Yorkshire, for example, are significantly lower.

The House of Commons Library has analysed the progress made towards "The Health of the Nation" targets and assessed Doncaster as having made negative progress. Indeed, it is moving away from the targets set in 1990. A snapshot assessment of breast cancer mortality for women aged between 50 and 69 in 1993 puts the rate in Doncaster at 118 per 100,000 women, one of the highest rates in the country and the fourth worst for that year. The figures for 1994 are 82 per 100,000 women. Despite the reduction, Doncaster will still fail to meet the national standards set by the Government in their report. The Government are failing to meet their standards and failing badly the women of Doncaster.

Figures for the Trent authority show that, once again, there has been a higher than average mortality rate for the past 10 years. Let me compare those statistics with those of the neighbouring health authority. Northern and Yorkshire's statistics show a consistently below average mortality rate for each year in the past 10. The Government must recognise that those variations exist and begin to assess the local rates. They must set local targets rather than rely on a national target that could be set by a collection of varying mortality rates around the country, and seek to achieve those local targets. Perhaps they are too frightened to do so because local targets would emphasise what the Labour party has illustrated—that regional variations mean that many district health authorities would fail the Government's test.

As in any area of the health service, it is vital that women throughout the country receive the same standard of treatment wherever they happen to live. It is important that the Government make progress in meeting the targets that they have set. Why do not they publish local targets? Why has it been left to the Labour party to put those variations in the public domain? Are the Government too ashamed of the progress that has been made? We talk of statistics, but those represent people—in this case, women who suffer and die.

Access to health care and a chance of survival must not depend on where one happens to live. They must be accessible to people in all areas. The Government must monitor more effectively the progress towards their targets. They must deal with those regional variations in health care. We have shown that they have not dealt with those issues. They must now begin to do so.

4.44 pm
Mr. David Congdon (Croydon, North-East)

I was appalled by the speech of the hon. Member for Doncaster, North (Mr. Hughes), who refused to accept an intervention when he was using statistics selectively. The Select Committee asked to see the regional differences in rates of breast cancer and those are published on page 239 of the Select Committee report.

In no area of health care can it be argued that an average figure will be the same for each area of the country. There is no reason why it should be. The population profile of each area differs and it is naive and ludicrous for the hon. Gentleman to think that all areas should conform to the norm. Each health authority should aim to bring about an improvement in the figures for its area, which is why it is important to publish figures and aim at a target. To pretend that differences show that the system is failing is wrong. As the hon. Gentleman said, although he did not pursue the point, breast cancer appears internationally to be a disease of affluence.

Mr. John Austin-Walker (Woolwich)

The hon. Gentleman referred to page 239 of the Select Committee report, which gives the regional figures. Those figures are for breast cancer incidence whereas my hon. Friend the Member for Doncaster, North (Mr. Hughes) said that, although the incidence may be higher in affluent areas, the mortality rate was higher in less affluent areas. Those figures do not reflect mortality rates.

Mr. Congdon

I accept that the table contains incidence figures. If the hon. Gentleman wishes to provide me, after this debate, with figures for mortality in relation to incidence, I should be pleased to study them. I cannot look at figures that the hon. Member for Doncaster, North holds up on the opposite side of the Chamber. I am not complacent about the incidence of or death rate from breast cancer, but it is shameful to try to make party political capital out of this issue.

Mr. Henry McLeish (Fife, Central)


Mr. Congdon

The disgrace is that Opposition Members are trying to make party political capital out of such an important issue.

Ms Jean Corston (Bristol, East)

Will the hon. Gentleman give way?

Mr. Congdon

No, I shall not give way at this point. I want to make some progress.

The Select Committee carried out a useful inquiry into an issue that concerns many people, particularly women. Cancer in any shape or form is a disturbing disease that causes great anxiety and concern, and breast cancer probably causes more concern than most. It tends to strike younger women. Perhaps the most serious cause of concern is that it is often not identified until it is too late.

I said earlier that the incidence of breast cancer tends to be higher in wealthier countries. I would welcome more research into why that is so. The incidence of breast cancer is rising in the United Kingdom but, so far as I am aware from the Select Committee inquiry, no one could give substantive evidence as to why that is so. Perhaps we are simply getting better at diagnosing the disease, so we must take care when arguing about incidence.

The Select Committee was also advised that suddenly in 1989 the death rate started to decline, but nobody seems to know why. It cannot be because of screening because the programme had not started at that time. The importance of the Forrest report's recommendation to implement a screening programme has been acknowledged by all. That programme appears to have been successful, although more evaluation of the figures is necessary.

The United Kingdom was the first European Community country to introduce a national breast screening programme. It is acknowledged to have a good system of quality assurance, which ensures that it is implemented effectively. It was decided that all women between the ages of 50 and 64 should be screened regularly. The Committee received a great deal of evidence to suggest why that should be so. We were advised that screening has not been introduced for younger women because it has no particular impact on mortality; equally important, and more significant, there are difficulties in reading mammograms of pre-menopausal women. Members of the Committee were broadly prepared to accept that advice from the medical profession. There is far more controversy, understandably, about the decision not to screen regularly women above the age of 64. The Committee was advised that there would be a lower take-up by older women, and that there is a greater risk of older women dying from other diseases. The Committee was, frankly, unconvinced by those arguments. I was therefore pleased to support the Committee's recommendation that the screening programme should be extended to women aged 69.

It is particularly interesting to look at the relevant figures on breast cancer, which show that it is more common among older women. In 1989, 8,752 women between the ages of 50 and 64 died from breast cancer, and, 11,179 over the age of 64 died. Those figures reveal that more than 60 per cent. of breast cancer deaths occur in women over the age of 64. Surely that is a good reason for extending screening to include women up to the age of 69.

Rev. Martin Smyth (Belfast, South)

The Government argued that they had decided not to go ahead with breast screening for older women because they felt that it was not cost-effective. Does the hon. Gentleman agree that the evidence that we received suggests otherwise? The Government's response was a disappointment to many members of the Select Committee and to people throughout the country.

Mr. Congdon

I am grateful to my hon. Friend for that intervention. If he had asked me that question half an hour ago I would have agreed with him entirely, but I have just happened to read in Hansardof 4 December that the Government have announced that, from 18 October, pilot schemes have been operating in the Northern and Yorkshire and South Thames regional health authorities to evaluate the effectiveness of extending breast screening to women up to the age of 69. I am a bit behind the times, and was unaware of that when I read the Government's response at the weekend. I welcome that announcement, and I am particularly pleased that I read about it just 15 minutes ago. I am sure that my hon. Friend the Member for Belfast, South (Rev. Martin Smyth) will be pleased about that announcement as well.

Screening is effective if it succeeds in identifying those women with breast cancer early enough so that they can be treated and prevented from dying. The hon. Member for Doncaster, North referred to the relevant figures, which reveal that in 1992, just under 14,000 women died from breast cancer, which is just under 5 per cent. of all female deaths. That is a staggering number of deaths from one particular disease—something that hon. Members on both sides of the House take seriously. Perhaps it is even more significant to note that breast cancer accounts for more deaths than any other form of cancer, including lung cancer. I find that pretty incredible.

A particular problem struck me as I was interviewing witnesses before the Select Committee about screening. The one problem with breast screening is that, apart from identifying those women with breast cancer, it generates a false positive. If a woman is recalled because there is something about which the doctors are concerned on her mammogram, she may have to wait a couple of weeks for an appointment. That woman is obviously subject to unnecessary worry and anxiety. The worst thing about any form of diagnosis is when the doctor says, "We think you have a problem, but we're not sure; we'll need to see you again in two to three weeks' time." That causes a great deal of anxiety.

The key point is revealed by the following figures. Since 1987, 5 million women—a staggering figure—have been screened. Of those, 270,000 have been recalled for further assessment. That does not mean that those 270,000 women had cancer, because just 20,000 of them were identified as suffering from it. I questioned witnesses in the Select Committee about those figures and drew to their attention the fact that that means that for every woman identified by screening as having breast cancer, a further 12 went through an awful lot of anxiety. The thing that surprised me was that a strange atmosphere then descended on the Committee, as though the witnesses had never heard of those figures before. I am concerned about that.

I understand the medical profession's proper desire to ensure that the screening programme works properly and succeeds in identifying those women suffering from cancer, thus preventing them from dying. That is a fantastic achievement, but I do not believe that the profession has paid enough attention to the flip side of the coin—the anxiety caused because the screening programme fails to reduce the number of false positives. That is an important issue.

Mr. Harry Greenway (Ealing, North)

I apologise, Madam Deputy Speaker, for missing the beginning of this debate. I have some constituents in the House, and they have allowed me to pop in for 10 minutes, so I am grateful to my hon. Friend for giving way. Administrators in Ealing are strongly inclined to move the breast cancer service from Ealing hospital to other hospitals at some distance from my constituency. Women in my constituency, however, feel confident about the services that they receive at their local hospital. Does my hon. Friend agree that it is important to avoid imposing difficult, if not impossible journeys on women who go for breast screening? Does he agree that that service should be offered at the hospital in which they are confident, such as Ealing hospital? I am grateful to my hon. Friend for allowing me to say that.

Mr. Congdon

My hon. Friend raises an important point, which reveals the dilemma created when planning any services relating to breast cancer and other diseases.

All recommendations suggest that three-tier models represent the best means of providing a screening service. One needs to ensure that a woman receives good primary care when she goes to her general practitioner, and that she is properly referred on for treatment—assuming that she has not been identified through the screening programme.

As my hon. Friend the Member for Broxbourne (Mrs. Roe), the Chairman of our Select Committee, has already said, all the research shows that a woman stands a better chance of survival if she goes to a unit that deals with more than a few cases of breast cancer a year. It has been recommended that breast cancer units should be established to cater for populations of about 200,000. I cannot comment specifically on Ealing, but from time to time there will inevitably be conflicts between trying to ensure that units of a sufficient size are provided so that an appropriate number of patients can be treated and the unit can develop the necessary skills, and ensuring that those units are not too far away from their patients.

The number of false positive results can be reduced in a number of ways. For instance, I welcome the decision to ensure that women receive their second mammogram at the same time as the first one, because that improves reliability. One will never be able to prevent all false positives, so it is even more important to ensure that all the services that women may require, including further assessment, are carried out at the same time. That means that they do not have to return for further visits, which is important.

Having identified those women suffering from breast cancer, it is crucial to ensure that they receive appropriate treatment to try to reduce the number of deaths—a point made by the hon. Member for Doncaster, North. The Select Committee report contained a number of recommendations; the Cancer Relief Macmillan Fund has also made a number of important recommendations. It suggested that there should be minimum standards of care based on a list of principles.

A significant factor in the Select Committee's investigation was that a number of separate studies had all come to the same conclusion about cancer treatments, including breast cancer. I understand that it is important that people suffering from breast cancer should be treated by not a general surgeon, but a specialist. It is important that patients have a specialist breast care nurse to provide the necessary counselling during a traumatic period.

I am pleased to support the important report on breast cancer, which was unanimously approved. We all recognise that there is room for improvement and I hope that improvements will be made in all parts of the country. I doubt whether that will yield a uniform death rate, but so long as we make progress we shall have been successful.

5 pm

Mr. Henry McLeish (Fife, Central)

I am pleased to participate from the Front Bench in the debate initiated by the hon. Member for Broxbourne (Mrs. Roe). I agreed with much of what she said and with the polite way in which she suggested that the Government might want to be more ambitious about the future of the service than they are currently willing to contemplate or resource.

I say to the hon. Member for Croydon, North-East (Mr. Congdon) that passions often run high in the House. Today's debate is on a serious subject that requires discussion, dialogue and informed criticism. My hon. Friend the Member for Doncaster, North (Mr. Hughes) gave some key statistics on access. One of the most important features of the subject is access—patients' access, access to screening and access to appropriate treatment.

It is worth placing on record some of the cold and clinical statistics. Breast cancer is the leading cause of female cancer death in the United Kingdom. It is the commonest single cause of death in women aged 35 to 54. There are about 24,000 new cases of breast cancer every year and about 15,000 women die from the disease. There are nearly 500 new cases every week and nearly 300 deaths every week. Behind every individual statistic there are members of families and extended families. The problem is huge and, in presenting the case from the Select Committee, the hon. Member for Broxbourne suggested its seriousness.

It is also important to identify the fact that mortality rates have remained virtually unchanged for the past 50 years. It is encouraging to note—as the hon. Members for Broxbourne and for Croydon, North-East did—that in the latter part of the 1980s the mortality rate figures started to come down. That is to be welcomed and one of the outstanding challenges in relation to breast cancer is to maintain that reduction.

Statistics can be translated into humans. I estimate that 15,000 deaths will mean that about 100,000 people—a large number—could be involved in the bereavement process every year. The emotional and physical damage done can be devastating. All those who are given a positive diagnosis face the trauma of uncertainty and they do not know whether treatment might lead to death or a much longer remission period. A hallmark of the national health service programme is the sensitivity surrounding the treatment.

One of the key aims is to try to reduce mortality rates, but it was interesting to read in the section on variations in health in "The Health of the Nation", produced by the Government, an apt phrase that sums up the second major objective: adding years to life and life to years. Clearly, mortality rates provide a fixed benchmark in the debate; they are easily recorded. Not always so obvious are those people who have been screened, receive the appropriate treatment and may go into long-term or short-term remission, when the years-to-life and life-to-years issue is an important factor. I hope that the Minister appreciates—I am sure that he does—that the subject involves not merely death, but living. That key objective should underline our agenda.

We should place on record the House's appreciation of the national health service breast screening programme; the hon. Member for Broxbourne did so and the Opposition agree with her comments. The programme does an excellent service and has a tremendous staff; it is a national programme that is extremely well led. When attacking breast cancer over the next decade it is important to keep the national dimension firmly before the House and the general debate.

Although the service was introduced in 1987 and was fully operational in 1990, there still seems to be huge potential. There have been three or four years in which the service has made an impact on breast cancer. Bearing in mind many of the changes suggested by the Select Committee and some of the advances in technology, and given the necessary resources, the service is well placed to achieve much more in the new millennium, which is now only a few years away.

My key concern involves access and availability; at the argument's core lies the availability of screening, the availability of diagnosis and prognosis and the availability of treatment. We can argue on the degree to which availability varies throughout the nation, but we can possibly agree that availability differs throughout England, Scotland and Wales. That is not necessarily a political point, but is a fact of life: variables will influence health that the health service cannot tackle. But some variations in the figures can be tackled by effective intervention from the health service.

The availability of the service is one factor, but access to it is another. My hon. Friend the Member for Doncaster, North and others have suggested that social and class differences have an impact on access to screening and treatment. Some district health authorities may be more enthusiastic and energetic and may give breast cancer a higher priority. I do not say that as a criticism of the national standards but, clearly, the success or otherwise of the service depends on the approach on the ground. Therefore, the key aspect of my contribution concerns the availability and quality of services, and how access to them varies throughout the country.

The national programme for breast screening shows that the figures for access to screening vary. East Anglia has the highest acceptance rate for screening: 78 per cent. of those invited are screened. In North-East Thames, the adjacent health authority, the figure falls to 62 per cent. A visible indication of screening and access to it—not a value judgment on the reasons for it—is the cold statistic from the national screening programme that suggests that acceptance of screening must be consistently above the average that has been set. The English average is 72 per cent.—the North-East Thames area is 10 per cent. lower and the East Anglia figure is almost 16 per cent. higher. As my hon. Friend the Member for Doncaster, North said, the significant variations were not recognised in "The Health of the Nation" published earlier this year—we should bear that in mind.

My hon. Friend also mentioned some material, which we published last week, that we had obtained from the House of Commons research division. It produced a snapshot of mortality rates for 1993, which found that England had an average of 86, but that 55 authorities fell on or above that average. In South Essex there were 125 deaths and in South-West Surrey there were 45. I stress that it was a snapshot and therefore the figures must be heavily qualified, but I believe that they show the tremendous variations in availability of and access to facilities throughout the country.

Mr. Congdon

I have followed the hon. Gentleman's argument quite carefully. Has his research identified any correlation between the take-up of screening and mortality rates in a particular area? He cited the figure for South-West Surrey, but North-West Surrey has a very high mortality figure of 122. Has his research identified any such correlation?

Mr. McLeish

No, but that is a fair point. We conducted a distribution analysis, which was a fairly cold and clinical look at statistics sourced from the Department of Health and processed through the House of Commons Library. In a sense, it was a factual account of a snapshot for 1993.

I now turn to the Government's target as stated in "The Health of the Nation" White Paper, which relates to those who are eligible for screening. Our research examined mortality rates in each district health authority, measured any changes between 1990 and 1993 and projected those changes towards 2000. It is quite significant that, according to the current rate of change, more than 60 per cent. of district health authorities would not meet the target. It is not a case of whether our figure is right or wrong; the magnitude of our findings—60 per cent. of health authorities—is important. We must debate whether the Government are on target to meet their objectives at regional and local level. I hope that the Minister will respond to that specific point later in the debate.

The Government point out in "The Health of the Nation" that there do not appear to be significant variations in the English and Welsh averages. Our research contradicts that finding, although the Government have access to different technology and to technicians and scientists who provide other information. We believe that "The Health of the Nation" document is flawed to the extent that it concentrates mainly on national targets and whether we are moving towards them. The Government should look at district health authority level, and perhaps at local level, to see whether real progress is being made. Under its remit, the Select Committee was to consider ways in which the quality and availability of breast cancer services in the United Kingdom could be improved, which suggests that there may not be equal service provision throughout the length and breadth of the nation.

On regional or local health service inequality, Conservative Members stress, quite correctly, that many factors—quality of life, housing and genetics—influence health. Health service teams, whether Conservative or Labour, cannot control such factors. However, there must be general areas within the health service where we can intervene more effectively—especially in relation to breast cancer. Deaths can be prevented and programmes and service distribution can be improved.

There are inequalities in health service provision throughout the nation and there are factors that we cannot change easily. However, we can make some obvious changes and it is the responsibility of Government to look more closely at what is occurring in health and to intervene more positively. That is a key issue to consider when discussing variations in health provision and whether the health service could be more interventionist and lever change much more effectively.

The Select Committee produced an excellent report; it heard a wide range of evidence and pinpointed the changes that should be made. The hon. Member for Broxbourne has already outlined some of those changes and I expect that she is hoping that the Government will respond to them positively. The Committee recommended that the upper age limit be extended to 69 for the call and recall screening programmes. Evidence to the Select Committee suggested that that would prove very worth while. The national screening programme has outlined the cash implications of the recommendation and we are not talking about substantial sums of money. However, we are talking about possibly fewer women dying and more women receiving early diagnosis and enjoying an improved quality of life.

That is a very powerful reason why we should look closely at how a small amount of money may be used to improve the length and quality of life and spare families the agony of premature death. As the hon. Lady said, the Government have responded positively and they are taking forward several pilot projects.

The Select Committee also raised the key issue of intervals between screening. Some people were shocked by the detailed figures that showed the number of cancers that grew in three years. The national health screening programme was slightly dismayed by those figures, but it is understandable in a new programme. The three-year interval was based on experience and scientific evidence, and it must now be examined more closely.

The Government claim that they need hard evidence to support any change and the Select Committee has said that there is no point spending money until that evidence is forthcoming. I hope that the Government will demonstrate some urgency and enthusiasm in pursuing that evidence, as it comes down to saving lives and improving the quality of life of many women. Another key issue is the question of future treatment within the three-tier structure. Unlike some of the other suggestions that are more about effective clinical management of the service, this area will require resources. The hon. Lady put it in a nutshell when she said that we do not want to develop national standards that encourage every hospital in the country to establish breast cancer units that, despite appearances, would be unable to do the job because of the quality of staff. The Minister should consider allocating resources in that area: the idea of a properly resourced primary health care service, breast cancer units and specialist centres makes sense to anyone who is seriously interested in tackling the problem.

Reference has been made to the double view or double shot. The information suggests that if two views of each breast were taken at every screening—not just the first, which the Government are quite happy to implement—a potential condition could be assessed much more effectively. I sincerely hope that the Government will consider that issue, along with research and development, training and quality assurance, which I shall mention briefly in a moment.

The Select Committee also made an important recommendation with regard to the Cancer Relief Macmillan Fund, which is an excellent organisation that performs a great deal of work throughout the country. Labour Members may be a little suspicious and sceptical of the patients charter, but it does recommend standards of care. If a diagnosis is complete and if life can be extended, quality of life and quality of care are inextricably linked. The Department of Health dismissed the issue by claiming that some care criteria appear in the patients charter and what is not there is not necessary anyway. I hope that the Minister will not adopt a similar attitude, as it does not address the seriousness with which the Cancer Relief Macmillan Fund has pursued the charter. I urge the Government to rethink the situation.

I am worried that I have been a little over-generous in my support of the Select Committee report. I may be slightly more critical of it than the hon. Lady, but I am sure that she will understand why I must do that. There have been a plethora of reports on breast cancer in the past few years, and the Chairman of the Select Committee has now outlined in detail the Committee's concerns. Obviously the nation is concerned. There is clearly a problem, at least a statistical problem. We have seen the Calman report, research and development has been given priority in other reports and the Secretary of State has spoken of a policy framework for the commissioning of cancer services. We have had a number of debates and discussed a range of issues. The crucial question for those with cancer, however, is what the agenda for action will be.

Given the Government's response, the current slight degree of scepticism is understandable. When the Secretary of State for Health outlined the policy framework for the commissioning of cancer services last April, it was accompanied by an NHS executive memo. Although the Government were vague about resources and timetables in their policy statement, the NHS executive was not. Paragraph 6 of its document is worth reading. A Select Committee has produced an excellent report and the House is united in its wish to tackle an obvious problem, but the NHS executive states, in a rather cruel and clinical way:

The changes in the organisation and provision of cancer services recommended in the report will take several years to implement. There is nothing too specific about the different recommendations. The NHS executive simply makes the blanket statement that implementation will take some years. It continues:

Those planning cancer services on the basis of the recommendations should do so within available resources, taking account of the assessed needs of the local population and having regard to other health and health service priorities. A great deal can, of course, be achieved through better organisation and better use of existing resources. We accept the latter part of that. Better delivery of services is possible in any organisation if changes are made to its resources and other arrangements. Like the hon. Member for Broxbourne, however, we feel that there is no point in having a Rolls-Royce that is being serviced in the same way as—I shall not name the car of which I am thinking in case I get into trouble with my constituents, but I am thinking of a car of lower quality than a Rolls-Royce. We can see all the problems: they have been analysed. I must ask the Minister, however, whether the Government are really committed to improving the service so that it meets the standards demanded by us and the Select Committee.

Although it is not just a question of resources, they will be needed to implement many of the recommendations that have been made—the recommendation for a three-tier structure, for instance, and the recommendations relating to quality. I hope that the Minister will mention that.

Let me raise two or three practical points. The wider brief to consider the future of the service in the next millennium involves immediate and fundamental issues relating to the national screening programme. First, there is the quality assurance programme. I could not agree more with the hon. Member for Broxbourne: that programme is vital. It is this part of the service that makes it different from any other service in Europe. The quality is there, and the service is being delivered; but fundamental concerns surround the continuation of that quality. The fragmentation of the NHS has brought more confusion to the system. The hon. Lady referred to purchasing and providing. We must be cautious and sensitive in the new, artificial market, because the quality of the screening service could be affected.

I should also like to know who will be responsible for quality assurance following the changes that will be introduced in April 1996. The proposal for a regional organisation to oversee the selection of the lead purchaser looks fine on paper, but it prompts many questions about the consistency and cohesion of the whole quality assurance programme. Those involved in the national screening programme are anxious on that score. We must ensure that we do not end up with an arrangement whereby district health authorities and others are purchasing in one environment while there is confusion and a reduction in quality in the quality assurance process.

Then there is the question of ring fencing. Funding for breast cancer at district health authority level is now part of general funding, which means that, if a district health authority gives the service a lower priority than other services, the whole process could suffer. I do not believe that "The Health of the Nation" targets and a national strategy can he left to local organisations; they should not be allowed to dictate priorities.

I agree with the hon. Lady that we should be concerned with mandatory standards. We shall be setting the minimum standards, but they are important. Enterprise and innovation are fine, but let us not use them as a smokescreen to disguise the fact that a lack of central direction and standards of the highest order could result in problems within health authorities. I urge the Minister to consider ring fencing: that, I believe, is the only way in which we can ensure that priorities and minimum standards are the same throughout the service, and that we implement some of the Select Committee's recommendations.

Neither the country nor the House is giving enough thought to the demography of aging. If we decide to extend the screening programme to those aged up to 69—and, indeed, if we continue to provide the same service for those aged between 50 and 64—we shall find that an increasing number of people fall into those groups. There is currently no hint of extra resources to cater for the extra demand. Every NHS executive circular, and every utterance from the Government, suggests that most of the recommendations are accepted, but there is no flexibility in relation to cash. We are told that it must be found from available resources.

That might be possible in some areas, but it is clear that, as we enter the new millennium, demography will play a much greater role throughout the health service. The Government must recognise that if screening is extended to those aged up to 69, if the intervals between screenings are reduced and if double views at every shot are to be introduced, there are bound to be resource implications.

Let me end by reiterating my concerns. I do not want the Government to reject the idea of a national strategy to tackle breast cancer. The reforms in every other part of the NHS have devolved responsibility down the line, but this is a national issue that requires national standards and firm guidance from the centre. I should like to think that the Government will not merely pay lip service to the recommendations of expert bodies and Committees of the House.

I do not think that the Minister should put local breast cancer services at risk by failing to ring-fence money allocated to district health authorities. He should be aware that the fragmentation of the NHS could undermine nationally based programmes. I have mentioned the consequences of failing to acknowledge the resource implications of new technology, and the recommendations made in that context. It is also crucial for the Government not to undermine morale in what is an excellent service. Many members of staff are anxious about their futures, and they are right to be anxious.

So far, the Government have refused to appreciate the urgency of building on this excellent programme. Unlike the NHS executive, I do not think that we have years in which to ponder decisions. We need a national strategy. We must tackle variations; we must ensure that quality is maintained; and a seamless process must take place between screening and treatment. We can build on the progress that has been made, but the Government must approach the matter with more urgency. That is what the Opposition want, and I hope that the Minister will give us some indication that he wants to take speedier action than is currently being suggested.

5.28 pm
Mr. John Whittingdale (Colchester, South and Maldon)

Breast cancer should not be a party political issue. In that spirit, I welcome the contribution of the hon. Member for Fife, Central (Mr. McLeish). I am particularly grateful to him for his praise of the Select Committee's report and I agree with at least part of what he had to say.

Before the Committee's inquiry, I must admit that I had little knowledge of breast cancer. As a man, it is still hard for me fully to appreciate the true horror of the disease. We were fortunate that a quarter of the Committee members were ladies, who perhaps have a better understanding of the trauma that a diagnosis of breast cancer can cause. Although I do not have a full appreciation of that trauma, the inquiry was one of the most harrowing in which I have been involved. All the Committee members found the evidence of Dr. Gwyneth Vorhaus particularly moving. She was undergoing intensive chemotherapy for the disease at the time that she spoke to us. We also heard evidence from the representatives of RAGE—Radiotherapy Action Group Exposure—which is a group of women who have had radiotherapy and some terrible injuries following it.

In examining the diagnosis and treatment of breast cancer, we looked first at its rate of incidence and the associated rate of mortality. The statistics on incidence are cause for alarm. In England and Wales, the incidence rate is 56.1 cases per 100,000 of population, which puts us approximately in the middle of the range for developed countries but certainly well below the United States, which has an incidence rate of 89.2 per 100,000 for white Americans, although the rate is only 65 cases per 100,000 for black Americans. However, the rate is increasing. In this country, it rose by more than 40 per cent. in the 10 years to 1992, although that is less than in some other countries.

There is widespread variation in the incidence rate between different regions in the United Kingdom, as several hon. Members have already said. The 28 per cent. average increase which occurred between 1979 and 1989 masks increases that range from only 3.2 per cent. in the Trent region up to 47 per cent. in Wessex.

There may be a number of reasons for the variation in incidence and for its increase. I accept that the quality of statistics certainly varies widely and that, in some countries, the figures that have been quoted may be highly suspect. Improvements in detection may also explain part of the reason for the rise in incidence. All our witnesses agreed, however, that very little is known about the reasons for international or regional variations in the incidence of breast cancer or why the incidence rate is rising. The variations are so great and the rise is so sharp that there can be little doubt that women in some countries are far more prone to breast cancer than those in other countries and that the number getting the disease is rising rapidly.

The evidence is still more frightening when one comes to examine the mortality rates. As has already been said, on this measure the United Kingdom has almost the highest breast cancer mortality rate in the world. It is way above that of many countries whose incidence rate is higher than our own. That may be because our treatment of the disease is inferior to the treatment in other countries; it could also be because women in the UK are prone to suffer a far more aggressive form of the disease. One of the first questions that I asked our witnesses was why the USA had a higher incidence rate of breast cancer than the UK but a lower mortality rate, and what were they were doing in the USA that we were not doing here? Professor Vessey, the chairman of the advisory committee on breast cancer screening, concluded his reply to me by saying:

there are plenty of suggestions but I do not think that anybody really has a very good answer". In our inquiry, it quickly became abundantly clear that we do not know the answers to these questions. What causes breast cancer? How can it be prevented? Why are there such enormous variations in its incidence between and within countries? Why is it that Japan, which is a developed country with a high standard of living, has one of the lowest rates of breast cancer in the world? Why is it that the incidence is rising rapidly, and why is it that more people die from it in the UK than almost anywhere else in the world?

My first conclusion was that much more research needs to be done. For some reason, research into breast cancer is not accorded the priority that it deserves. One in 20 women is likely to die from breast cancer and, in 1993, there were more than 13,000 registered deaths of women from it in England and Wales. That compares with approximately 1,150 notified deaths from AIDS in the UK. Government expenditure on research into AIDS, however, through the Medical Research Council and the Department of Health, was £17 million. That amount is nearly five times the expenditure on research into breast cancer.

When expenditure by charities such as the Imperial Cancer Research Fund and the Cancer Research Campaign is added into the total, the amount still comes to only £12.5 million, which is 70 per cent. of the figure spend on research into AIDS. We do not have a world breast cancer day, and we do not see celebrities organising concerts to raise money for research into breast cancer. I am not suggesting that we should not be spending money on researching AIDS, but I must question whether we have our priorities right. I think that there is more than a whiff of political correctness about those figures.

Given the lack of knowledge about the disease, I understand why the NHS decided to concentrate on establishing a breast cancer screening programme to enable the early detection and treatment of the disease. We were given ample evidence that screening programmes result in fewer deaths, and we have every right to be proud of the fact that the United Kingdom is one of the first countries to set up a national screening programme. Since the programme was started in 1987, 5 million women have been screened and approximately 20,000 cancers have been detected as a result.

As my hon. Friend the Member for Croydon, North-East (Mr. Congdon) pointed out, however, for every cancer that was detected, nearly 10 women who did not have cancer were recalled because they had false positive results. The anxiety and fear that were raised as a result of those false results can only be imagined. In some cases, women had to undergo unnecessary clinical investigations—even surgery—as a result.

There is also a problem of false negative results when women have been told that they do not have breast cancer but who have gone on to develop the disease shortly afterwards. That is something which might be addressed by the more widespread use of double-view exposures, as has been mentioned already.

It may be that false positives and negatives are a price worth paying. We must address the question raised by Professor Michael Baum, our specialist adviser from the Royal Marsden hospital, as to whether the small benefit of reducing the risk of dying from breast cancer compensates for the undoubted harm resulting from false alarms and unnecessary interventions. He was right to ask whether the money spent on population screening would save more lives if the scarce resources were redirected to the more efficient care of symptomatic women and greater spending on research into improving the treatment of those already suffering from the disease.

I am sorry that Professor Baum did not raise those issues at the time of our inquiry. They are, however, serious issues which deserve examination, and it was a great pity that the media chose simply to report that he had declared the breast test to be useless, which was certainly not the case. I believe that Professor Baum remains a supporter of the breast screening programme.

Professor Baum was also entirely right about the need for more informed choices by patients. All too often clinicians assume that patients do not want to know the details of their condition or the options that are available to them. Alternatively, clinicians do not bother to inform their patients because they think that they will not understand. I suspect that all of us have come across terrible examples of the lack of sensitivity of doctors and consultants when advising patients about their condition. Perhaps the worst example that I have ever heard was the treatment of Dr. Vorhaus, who told us that the night before surgery a junior doctor had casually informed her:

We have decided to do a mastectomy instead of a lumpectomy. When she asked why, he said:

I really don't know what you are worrying about—you've got such small breasts it doesn't matter and anyway, someone with cancer should not be worrying about what happens to their breasts. That was how she was formally told that she had cancer.

Dr. Vorhaus also told us that she met only two doctors who extended any degree of human concern, courtesy and willingness to give her information about her condition and treatment. On the other hand, she told us that she did not meet one nurse who was not helpful and supportive. Of course, that is just one person's experience, and I accept that it does not apply in the vast majority of cases. Nevertheless it should not happen, and we still have much to do to ensure that doctors treat women with this condition with the sensitivity that they deserve.

Finally, I must also pay tribute to my own constituent, Mrs. Hazel Thornton, who came to give evidence to us. She is a lay person. After an abnormality was found in a routine screening, she was invited to participate in a randomised control trial. She was given no information about the options available to her, or any details about what the trial would involve, so she refused to take part. Instead, she found out for herself about the disease and became an expert on it.

Since then, Mrs. Thornton has become a tireless campaigner for the rights and involvement of patients. She has set up the Consumers Advisory Group for Clinical Trials; she has written papers that have been published in The Lancet; and she has travelled across the world to give talks on the subject. Due to her efforts, sometimes in the teeth of opposition from the medical establishment, the patient's voice is at last being heard.

There is still an immense amount to do, but we are making progress. I hope that the Select Committee's report was a contribution to that, and I also welcome the response that has been made by the Government. I look forward to hearing the Minister's remarks later in the debate.

5.41 pm
Mr. John Austin-Walker (Woolwich)

I share the view of the hon. Member for Colchester, South and Maldon (Mr. Whittingdale) that it is surprising that there is not more publicity about this matter. I doubt that there is anyone in the Chamber who is not either close to or who knows someone who is suffering or has suffered from breast cancer. I hope that the efforts that the national coalition has begun to bring groups together to give a much higher profile to breast cancer will succeed. I am sure that those efforts will receive support from all right hon. and hon. Members.

Hon. Members have referred to the fact that the incidence of breast cancer in the United Kingdom is not particularly high by international standards, yet we have the highest recorded rate of mortality in the world. They have also spoken of the regional variations. There may be some arguments to the effect that data from other countries may not be comparable with ours. However, all the witnesses who gave evidence to the Select Committee concluded that even if Britain did not have the highest mortality rate in the world, it was one of the highest, and that it deserved urgent attention.

In the United Kingdom it should be possible to rely on comparability of the data. In that context, the regional differences that have been highlighted are somewhat alarming. Some reasons have been advanced for those regional differences, but most members of the Health Select Committee came to the conclusion that the major reason for the differences in mortality was probably the poor treatment of the disease in some areas. I certainly believe that that is the most convincing reason.

We know that the treatment that women get depends on where they go. The Select Committee heard much evidence, and there is more evidence from other sources—anecdotal and statistical—that many women do not get a quality service or appropriate treatment. It would be foolish to suggest that early diagnosis and early, appropriate treatment will lead to a successful outcome in all cases. However, if detection is not early or treatment is delayed or inappropriate once the disease is diagnosed, the consequences will—almost invariably—be tragic. The Select Committee concluded that it would be possible to reduce the number of deaths from breast cancer each year by some 4,000, if we had a standard quality of service throughout the country.

Some people have criticised the Select Committee and the Government for putting too much emphasis on breast screening. They have suggested that screening is costly and detects only a minority of cancers. The latter is true and I share the view that we should always examine the cost-effectiveness of all screening programmes. However, I remain convinced that the screening programme should be maintained and improved as part of the overall strategy for detecting breast disease and reducing breast cancer mortality.

The quality assurance programme referred to by the Chairman of the Select Committee is vital to ensure that the same high-quality service is available throughout the country. My hon. Friend the Member for Fife, Central (Mr. McLeish) expressed concern about the relationship between quality assurance teams and purchasers, following the proposed move from regional purchasing quality assurance to district health authority lead purchasers. As the Select Committee's report says, district health authorities

will be purchasing services for monitoring their own purchasing". I hope that the Minister will outline in his reply the role of regional offices and regional directors of public health in selecting the lead purchasers, and also the monitoring role of the national co-ordinator. That must be kept under review and I hope that the Select Committee will consider the issue once the new arrangements are up and running next year.

Since the Select Committee report, there have been some developments in the way in which mammography is carried out, which we all hope will lead to a reduction in the number of false negatives and false positives. The possible tragic consequences of a false negative are only too apparent. More accurate diagnosis and early detection can lead to early and appropriate treatment. As my hon. Friend the Member for Fife, Central said, that can lead to more years of life of better quality.

We should not underestimate the effects of false positive results, which the national co-ordinator described as a "downside to … screening". Such false positives not only cause great anxiety and in some cases severe psychological trauma, but they lead to women undergoing unnecessary recalls, further unnecessary clinical investigations, and in some cases unnecessary diagnostic surgery. I appreciate the view expressed by Hazel Thornton of Radiotherapy Action Group Exposure, who described the programme as

costly trawling of a limited asymptomatic public group … creating huge … psychological and physical morbidity". That is why it is important that we do our best to eliminate the false negatives and positives.

The Select Committee believed, however, that there is definite evidence that screening by mammography is effective in reducing breast cancer mortality, certainly in women over 50. Evidence in the Forrest report convinced me that the only way substantially to reduce the number of deaths from the disease is detection before the patient presents with symptoms.

The Select Committee takes the view that it is perhaps too early to make final judgments about the efficacy of the breast screening programme, because of the lead time. We need to observe the mortality information about 10 years from the introduction—after 1997—to get a more accurate picture. I believe that we will see then that the programme has been efficient and effective.

The Committee has highlighted the problem of women placed on early recall, which might mean a wait not of a few weeks, as was suggested earlier, but of six to 12 months in some cases. Such insensitivity can lead to great anxiety, and in many cases acute depressive illness can follow. That is why I, and other members of the Select Committee, urge the establishment of the one-stop shop. That may not necessarily reduce the time between screening and assessment, but it could significantly reduce the time between assessment and diagnosis and considerably minimise anxiety. That is why I believe it important to carry out the recommendations of the Forrest report for routine assessment teams comprised of clinicians, a radiologist, a pathologist, a radiographer, a receptionist and a breast care nurse. Breast cancer screening is not just to do with mammography; it includes all stages in the diagnosis of the disease.

As the hon. Member for Broxbourne (Mrs. Roe) has said, it is generally accepted that there is little benefit in routine screening of younger women, but I believe that further research needs to be done to determine whether there are readily identifiable groups among the younger age groups who may be at higher risk and among whom prevention can be undertaken.

The Committee was convinced of the efficacy of the screening programme for women over the age of 50, and firmly recommended that the upper age limit for inclusion in the call and recall system be extended to 69. The evidence for that is clear, and in this respect I found the Government's response extremely disappointing. I am firmly on the side of Age Concern, the British Medical Association and the Society of Radiographers. The decision to establish some demonstration projects may be a start, but it is not enough and it is quite disappointing.

I urge the Minister to reconsider the Select Committee recommendation. What extra resources are being provided for these demonstration projects? The Government talk about advertising the fact that women over 65 are entitled to be screened every three years. I should like to know what resources have been allocated for extra screening to take account of increased take-up by the over 65s. Without such extra resources it will not be possible to screen more elderly people.

Effective diagnosis is one thing: treatment is another. We have anecdotal and statistical evidence to show wide variations in treatments and outcomes. One thing is absolutely clear from the evidence—surgeons who treat more than 30 cases a year have better survival figures for their patients. Just as we need a team approach to screening, so we need a team approach to treatment. No woman should be referred to a general surgeon working in isolation. That is why the establishment of specialist breast units with defined minimum standards and service requirements is necessary. National standards need to be laid down, nowhere more so than in radiotherapy and related areas.

The hon. Member for Colchester, South and Maldon spoke of the evidence given by RAGE. For some women, the treatment has been horrendous, leaving them either in pain or disabled. For some of them treatment can be worse than the disease. So the same quality of standards as is required for the screening programme needs to be applied to radiotherapy.

In this respect I should like to mention recommendations 29 and 30 of our report. The Government rejected the recommendations calling for the same service quality standards to be applied to treatment and screening, and I found that rather disappointing. The two services are wholly complementary: they involve the same training and the same commitment to specialisation. Experience gained in one sector is also gained in the other. Of course some extra staff and resources would be required; will the Minister tell us why the Government rejected these two recommendations?

I should like to return now to the role of breast care nurses, to which Conservative Members have already alluded. All the people with experience of breast cancer who spoke to us had nothing but praise for the nursing profession and for the crucial role that breast care nurses play. Obviously the remarks that follow will be from a male perspective, but many women who have been told they have breast cancer face not only the fear of the physical consequences—there is deep psychological trauma about the possibly tragic outcome of the disease—but a disease which attacks their identity as women. They feel that their femininity and their feelings about their sexuality are under attack. The women in this category to whom I have spoken have all said that the one person they could talk the matter over with was the breast care nurse. As one of the witnesses who came before the Select Committee said, "If nurses can communicate with us, why can't doctors?" So there is much that still needs to be done in terms of training the doctors.

Gwyneth Vorhaus described for us the time when she was first diagnosed as having breast cancer:

I was left undressed in a cubicle for over two hours at the general surgeon's clinic. I finally wandered out into a room where a junior doctor was sitting looking at an X ray and I discovered that it was my X ray. I had previously been told I probably had fibro adenoma, so I had no reason to prepare myself or bring a friend. The doctor looked very embarrassed. He turned his back on me and started muttering about 'microcalcifications and suspicious lesions'. I had to ask him to turn around and look at me. I said, 'Are you trying to tell me I've got cancer?' He still could not use the word, but his body language told me something was wrong. I believe I went into deep shock at that moment, but I was left to wander off for an explanation to my GP. Perhaps that was an isolated incident, but as the hon. Member for Colchester, South and Maldon said, it is one incident too many. Other women's experiences may not have been as graphic, but witness after witness has described the insensitive manner in which her first diagnosis was given her. Meanwhile everyone praises the commitment and the work of the nurses.

It is important to listen to what women have to say. I do not want to interfere in the debate about high-dose chemotherapy and stem cell rescue. Certainly, we heard Gwyneth Vorhaus say that she felt the treatment was right for her. We should do some random clinical trials to assess the value of high-dose chemotherapy. Most of us on the Committee felt that here was a woman who had exercised choice and weighed up the risks. She said that if nothing had been done she would have died. She was a mother of young children, so she felt that if anything could be done to extend her life by a couple of years, it should be done. For many of us that summed up the issue behind this disease.

My hon. Friend the Member for Halifax (Mrs. Mahon) said in another debate on this subject:

it is important not to view breast cancer as just a woman's disease because it brings devastation and grief to families affected by a sufferer's early death."—[Official Report 15 February 1995; Vol. 254, c. 945.] Women with breast cancer are daughters, mothers, wives, partners, lovers. They have caring responsibilities, and their early and often unnecessary deaths devastate whole families; and the cost to communities is enormous. When looking for the resources needed to build an effective screening and treatment programme we should always remember the 4,000 lost lives each year, and the costs of not saving them.

The Government say that they are considering the Calman proposals; I hope that they will not hide behind them. I believe that breast cancer services can pioneer the way for other cancer services. Hence I hope that the Government will look again at some of the recommendations that they have said they will take account of in due course, and that they will react more positively to the firm recommendations in this report.

5.58 pm
Ms Jean Corston (Bristol, East)

I congratulate the hon. Member for Broxbourne (Mrs. Roe) and her Committee on this excellent report: it is most welcome. It is high time Committees of this House gave specific attention to issues involving women. I pay tribute to the many hon. Members who have kept the subject alive in the all-party group and other forums. I also pay tribute to my hon. Friend the Member for Halifax (Mrs. Mahon), who cannot be here owing to an Inter-Parliamentary Union engagement. I know that she would have liked to be here.

In view of the fact that the Health Select Committee made reference to research, I am pleased to use this opportunity to raise a matter, about which the hon. Member for Broxbourne knows because I have written to her about it, and on which I was lucky enough to secure a debate during private Members' time on 14 June. It refers to research in breast cancer at the Bristol cancer help centre.

The study was published in The Lancet in September 1990. I do not intend to waste the time of the House in rehearsing all the arguments, because they are on the record; suffice it to say that the research purported to show that breast cancer patients attending the Bristol cancer help centre who were also having orthodox treatment were twice as likely to die and three times more likely to relapse than the controls who were having conventional treatment only. It soon became clear that the research was fatally flawed in its methodology and statistical analysis.

During a very helpful and constructive reply to the debate in June, the then Under-Secretary of State for Health, the hon. Member for Bolton, West (Mr. Sackville) said:

I have no doubt that mistakes were made".—[Official Report, 14 June 1995; Vol. 261, c. 758.] The funding bodies, the Imperial Cancer Research Fund and the Cancer Research Campaign, distanced themselves from the research quite early. The Imperial Cancer Research Fund said that no conclusions could be drawn. Its director general, Sir Walter Bodmer, said:

the research suffered from a disastrous mistake in the interpretation. However, the Institute of Cancer Research, which organised the research, still stands by it, and has refused to release the data for independent statistical analysis.

A great deal of correspondence occurred over the summer, and I received a helpful suggestion from the Under-Secretary of State for Health, Baroness Cumberlege, in a letter on 4 August. She acknowledged that I had said that there was a need for an examination of how the two sets of patients compared, and that there should be an independent judgment of the validity of comparing the two groups. I asked whether the Department would recommend an independent statistician. The Minister helpfully suggested that I approach the Royal Statistical Society for assistance, and gave me its address.

I put that suggestion to the person responsible for the research, Professor Claire Chilvers. She said that she was not in a position to be able to give that consent so I went back to the Institute of Cancer Research. Professor Peter Garland of the institute said that it would not be appropriate to release the data to me as a third party. The question is, who is appropriate? To whom should the data be released?

Neither the centre nor the women involved want any follow-up research—it would be pointless and distressing—but there is a need to conduct a statistical analysis of the data. The issue raises questions about the nature of conduct in medical research, to which—obviously—the Health Select Committee has made reference. I am sure that it is concerned.

In February 1991, the Royal College of Physicians published a very helpful document called "Fraud and Misconduct in Medical Research". It defined scientific misconduct at paragraph 2.7 as including—I stress the word "including"—piracy, plagiarism and fraud. The fact that the word "including" was used suggests that the definition was not intended to be restricted to those factors.

The report continued, at paragraph 4.5, to say:

all institutions and responsible bodies must insist that raw data are kept available for inspection for 10 years". That prompts the question: inspection by whom?

The United States Commission on Research Integrity has laid down the following criteria for breaches of research integrity: a misappropriation of data, misrepresentation of research findings, interference with results, and acts that compromise the integrity of the research process.

It seems that the medical research establishment faces a clear choice. There is either resolution of the matters to which I have referred or there is eventual regulation. Although I am sure that the establishment does not really want the latter, such an issue cannot remain unresolved. While it is unresolved, it represents an obstacle not only to good medical research on cancer, but to broader issues of health research and scientific discovery.

We are all, of course, conscious that large amounts of public money fund such research, so while it stays on the record, it is a stain on the character or reputation of an organisation. Frankly, I have been astonished by the number of health professionals who have said to me, "Oh, yes. We all know that that research cannot stand." Yet while that research is forming the body of scientific research and it is not retracted, that stain remains. Indeed, it calls into question the way in which people behave when they conduct scientific research.

I call on the Institute of Cancer Research to release the data. It has to be said that The Lancet, in which the study was published, has not published a retraction, although it would be right to add that the new editor is doing his best to draw together the interested parties in order to resolve the matter. It is important that the editor of The Lancet is able to make progress, so that a retraction can eventually be printed, subsequent to—I hope—independent statistical analysis.

Last night, at St. James's palace, the Prince of Wales held a reception in honour of the Bristol cancer help centre. He made reference to the research, and regretted the negative effect that it had had on the centre. Naturally, if such research stands on the record, charitable foundations and others will find it difficult to make donations, given that it could be said that they were spending money on an institution that has damaged people's health. It is perfectly obvious that that is not case. The Prince of Wales praised the centre's holistic approach and the way in which it focuses on the whole person rather than the illness, the cancer.

I am pleased to say that the centre, which was facing closure this month, has succeeded in raising £267,000 to enable it to continue for some more time. It is very keen to preserve the principle that the care, advice and treatment it gives should be free, and it does not deserve to live under such a cloud. I hope that it will be possible for the matter to be resolved, because it will not go away. I know that other hon. Members, whose support I have appreciated over recent months, share my concern and want to assist me in ensuring that the public money put into that research was not wasted, and that the facts emerge from some statistical analysis.

I should like to turn specifically to a couple of items in the Select Committee report. Its first conclusion states:

It is clear that the aetiology of breast cancer is not yet sufficiently well understood to enable any systematic attempt to reduce mortality by primary prevention to be pursued". Although that conclusion says "any systematic attempt", other factors of scientific literature ought to form part of our understanding; it would not be right to say that nothing that can be done.

In considering just a few instances of scientific research, one finds that it is pretty certain that, if one eats animal fat, one has a 30 per cent. higher chance of getting breast cancer. If one smokes, one has more chance of getting breast cancer—and any cancer. If one is a vegetarian, one is 40 per cent. less likely to die of cancer of any sort. I understand that that research comes from Dr. Margaret Thorogood.

I must declare an interest, because I have not eaten meat for 10 years. I do, however, eat fish. I do not want to advance any argument about vegetarianism. I am aware that there is other relevant research. For example, the King's college study tells us that the incidence of breast cancer is four times higher in people who are under stress.

Only this week, on 9 December, the British Medical Journal contains an article about a research paper on breast cancer. It states:

Key messages: life events have an important influence on physical health; women with breast cancer have more severe life events in the five years before diagnosis; the way a woman deals with stress may also affect the risk of breast cancer". I understand that there was a United States-funded study of 50,000 Chinese subjects who were given vitamins A, C and E and selenium. They had a relatively low vegetable intake, but their cancer death rate declined by 13 per cent. after five years of that treatment. The United States Government have issued guidelines on diet and cancer since 1983.

Furthermore, the Cancer Research Campaign has conducted what could be described as an epic trial. The preliminary results are based on considering cancer in relation to dietary habits throughout Europe. They reveal pronounced variations. There is a far lower rate of cancer in Greece, where people eat a great number of vegetables. Holland and the United Kingdom came out worst. Our respective diets contain more dairy products, such as cheese, cream and yoghurt.

The Women's Environmental Network conducted research into pesticides and insecticides, specifically organochlorines. It found that, in countries where Lindane had been banned, the incidence of breast cancer in the youngest group had declined by about 24 per cent. I know that there are concerns about the reliance that can be put on that sort of research, but it is part of the scientific body of opinion.

There is also the research by Peto and Doll of 1975 and 1992, which found that diet is the greatest environmental factor. It has a contribution rate of 35 per cent., whereas smoking has one of 30 per cent. It cannot be said that research findings are not sufficiently understood to enable any attempt to be made to make improvements. We have quite good statistics.

It is important to consider, as hon. Members on both sides of the House have, the disparity between the incidence of breast cancer and mortality rates. For example, the incidence is higher in the United States, but mortality rates are lower than elsewhere.

It is important also to consider the findings of Dr. Stephen Greer, which might be dismissed by some. He classifies personality types, and goes on to consider how classification may influence survival. I know from medical professionals in my family that there is much interest in the profession about Dr. Greer's findings. He categorises people according to personality. Of those with what he describes as fighting spirit, 80 per cent. were alive after 13 years. Of those described as helpless and hopeless, only 20 per cent. were alive after that period. He describes those in between the two categories as demonstrating denial or stoic acceptance.

Those who come within the higher mortality rate tend to be more passive and compliant patients. Indeed, the word "patient" imports something about compliance and passivity. It suggests that the person is one to whom other people do things, rather than someone who is an equal partner in treatment, cure and survival.

The message is often given that people can do nothing to help themselves. Institutions such as the Bristol cancer help centre are vital in the way in which they encourage people to develop a fighting spirit and a belief that they can be part of their own cure.

Last night, I met people at St. James's palace who had been told 16 years ago that they had three months to live. I met a man who had had two thirds of his liver removed. He was told that there was cancer in the remaining third and that there was no hope for him. He is still alive nine years later.

The message is that people can live with cancer. A cancer patient should be seen as part of the healing process. The work of complementary practitioners, such as those at the Bristol centre, can be extremely valuable as an adjunct to the conventional treatment that is provided by the national health service. Their work is no threat to conventional medicine.

There is evidence that people want complementary treatment. More and more general practitioners want training in it. I hope that purchasing institutions will take note. It is important to take things in the round. We know that people say that they do not want to be a nuisance to their doctor. They fear that, if they are assertive, they may not be treated well in future. I feel that a different attitude is required of some doctors.

Where it is the only route, the Bristol centre helps people to prepare to die. That is important. So often, people are sent home to die and told that they have three months and they must get on with it. On one occasion only, I came across a friend who had something to do with the Bristol centre. That was in the 1980s. She was dying with cervical cancer. She had had four cervical smears, and had been told that she was clear. It was suggested that she was hysterical. It turned out that she was right. By the time her rightness was acknowledged, it was too late.

My friend went to the Bristol centre when she was clearly dying. No one could have saved her life. Those at the centre gave her control over the last few months of her life. They made it into a remarkable period.

Obviously, research is important. Everything to which hon. Members have referred in the debate is important. I wish to be specifically identified with the comments of my hon. Friend the Member for Fife, Central (Mr. McLeish), who spoke from the Opposition Front Bench. It must be recognised, however, that a patient is not merely someone to whom things are done. A patient should be part of the treatment, cure and survival.

6.15 pm
Mr. Simon Hughes (Southwark and Bermondsey)

The debate has been widely welcomed, and I join that welcome. It demonstrates the benefit of the Select Committee system, which we have had for some years. A Select Committee may decide to examine a matter of major public interest. It will do its job properly, and update itself. It will report to the House and then ensure that the issue becomes part of the wider agenda. I, too, pay tribute to the hon. Member for Broxbourne (Mrs. Roe), the Chairman of the Select Committee on Health, to all members of that Committee and to all those who have contributed to the debate. This is not a party political subject.

I speak as a lay person. As a man, I come to a debate about an issue that principally concerns and involves women. I have learnt from reading the Select Committee's report and the minutes of some of the evidence. I have listened to colleagues, and I have checked some of the facts. I am aware of the severity and importance of the issue.

As the hon. Member for Colchester, South and Maldon (Mr. Whittingdale) said, we should draw ourselves up and remind ourselves of the lethal nature of cancer in general, and of breast cancer in particular. We should make ourselves aware of the number of people in this country, irrespective of the relative figures, who continue to die of the disease when compared with those who die from other diseases that are more often talked about.

Like the hon. Member for Woolwich (Mr. Austin-Walker) and other parliamentary colleagues, I have both parliamentary and personal experiences of those who have become ill with breast cancer. Some have come to my surgeries over the years. They have told me about insensitive responses. I endorse the claim that these stories have featured only doctors, never nurses.

It has been clear to me throughout that, specifically and psychologically, breast cancer is one of the intrinsically important areas of concern when dealing with women's health. If it is not treated properly, irrespective of whether, at the end, the condition is curable, it is something that undermines a woman's sense of her integrity, self-respect and self-worth. The disease goes to the heart of those people's being. Breast cancer is hugely important. It is not something that is peripheral to the health service; it is not something that matters only physically. It matters much more than that. Men know that, as well as women.

Most of us have known, many of us from personal experience, of people who have died unnecessarily in the sense that there was not sufficiently early diagnosis. It is not a secret that, a couple of years ago, I lost a brother. He died of malaria. He died because the condition was not diagnosed quickly enough. In days, he went from being ill with what was thought to be flu or a cold to dying from malaria.

For many women, that is the story with breast cancer. One fact that emerged clearly from the evidence to the Select Committee inquiry was that, despite our best efforts, the continuing failure by many women to present themselves, and the consequent failure to have proper treatment at an early stage, is one of the causes of the high mortality rate thereafter.

The first message that the House has heard—I hope that it is going out clearly from the Chamber tonight—is that there is every need for women to make sure that they present themselves for screening. The screening programme is hugely important, and as yet it has not reached everybody who needs it. Given the high proportion of older women who suffer from breast cancer, we must remember that presentation for screening will become increasingly important as the number of older women increases with the longer lives that, happily, people in general will lead.

So first let us encourage people to come in. I say that as somebody who, probably like many Members of Parliament, is very sceptical as a patient in the health service. I am not naturally someone who goes running to the doctor. I tend to assume that there is not a problem, and that things will get better.

Many other people do the same, and we must persuade ourselves and others how important it is not to take risks. After all, we are talking about health care that is preventive, not only in terms of one's own illness and of the consequences to one's family, but even, as the hon. Member for Bristol, East (Ms Corston) rightly said, in terms of the cost to the nation. Early diagnosis and treatment can be a way of saving lives—and money.

As hon. Members will know, I have the privilege of being the Member of Parliament for Guy's hospital. One of the people who gave evidence to the Select Committee was Dr. Michael Richards, who spoke both as a consultant at Guy's and as a representative of the wider community of cancer consultants. Guy's is one of the leading centres for treating breast cancer and doing research into it, and one thing that emerged clearly from Dr. Richards' evidence was that we still have not organised ourselves as well as we could to maximise the efficiency of that work. The hon. Member for Broxbourne and other hon. Members have pointed out that the diversity of places and units in which treatment is carried out, and the small number of cases that many doctors treat per year, militate against best practice.

It is a fairly trite point, but if a doctor sees only one or two patients a year, he or she is far less likely to be competent or expert at giving the best diagnosis, results, advice, treatment and so on. It is important that, although of course there must be neighbourhood access, there should be consolidation of the best practice into the size and sort of unit that the Select Committee, and the expert evidence it took, recommended.

Thirdly, there appears to be clear evidence that we are not training enough people to deal with breast cancer as consultants and nurses. I do not know whether the figures that I have are still accurate, but I understand that, for example, there are only about one tenth as many consultants dealing with breast cancer in this country as there are in France. There is a real dearth of experts.

Likewise, one of the recommendations shows that there is a clear shortage of funds for training nurses and others who have the responsibility of care. That is completely unjustifiable. If cancer is identified in 5,000 new cases a week in this country, that means that as many cancer cases are diagnosed each fortnight as there have been AIDS cases diagnosed in the past 10 years. I say that not in any antagonistic way, but simply to show the scale of the problem that we are discussing. We must react to that by having enough experts—consultants and nurses—available throughout the country, region by region, easily accessible and able to respond to the need.

That leads me to my fourth and most important point. It is clear that with breast cancer, research financed by independent research institutions has been enormously valuable. Such institutions pay for much of the work done in the NHS. People such as Dr. Richards are funded entirely by the Imperial Cancer Research Fund. Many consultant posts, and even whole units, are funded by private charitable money.

Yet we are still miles short of the money that we need to carry out the research programme satisfactorily to a conclusion. In a paper on clinical research produced only about a year ago, Walter Bodmer wrote:

Taking eight hundred million pounds as the total spent on medical research as a whole, and assuming, say, only a quarter of this is really clinical research, gives two hundred million pounds as the total spent on clinical research. The extra NHS costs connected with adequate provision for that clinical research would therefore be one hundred million pounds. Much more recently, after one of the reports that came out this year, the Kenneth Calman report, the Government's response was that there would be no additional new money for the research and treatment services for which the need is clearly identifiable.

The recommendation made by the chief medical officer in April, only eight months ago, was that £200 million was needed to fund changes that would save 15,000 lives a year, by establishing the regional specialist centres that we have talked about. However, the Department of Health says that those costs must be met from existing resources.

I say to the Minister, although again not antagonistically, that I have no doubt that the British public out there would say that we must find that money. It is not acceptable for such areas of work in the health service to be held back, when there is no dispute about what needs to be done. It is clear that we must go on putting in the money to encourage more people to be screened, so that more people can be diagnosed early, and so that more research can be done and more people trained to treat the patients.

That is money that the nation must find. If there is a choice between, to put it crudely, tax cuts or more money to reduce the number of deaths from breast cancer, I am sure that the nation would vote for the money to be spent on cancer treatment rather than on tax cuts.

Although of course the debate has rightly centred on breast cancer—long may it continue to do so—the lessons apply equally to other cancers. The report, and all the other abundant evidence, makes that clear. Perhaps men are worse than women in terms of their willingness to present themselves for screening and the like. But it is most important that we develop screening programmes for other cancers both for women and for men, in all age groups, and that we encourage people to educate themselves about their health and to identify, or to give the experts the opportunity to identify, disease at an early stage.

We must remember that we have a long way to go before we have a system in place to enable us not only to deal with the diseases once they are identified but to ensure that people present themselves early enough for diagnosis and treatment to take place early enough to prevent death. The figures show that, once diagnosed, about half the cases can be treated in such a way that death is prevented.

That being so, we are only at the beginning of the road. I hope that we shall respond rapidly to the excellent work of the Select Committee, and to all the other supportive work that makes it clear that we as a country could take much more effective action on breast cancer, if only we had the mind and the resources to do so.

6.28 pm
The Parliamentary Under-Secretary of State for Health (Mr. John Horam)


Rev. Martin Smyth


Mr. Jeremy Corbyn (Islington, North)


Mr. Horam

I hope that it will be for the convenience of the House if I intervene at this point. I apologise to the two hon. Gentlemen who want to speak, and I shall try to ensure that there is time for them to come back after I have spoken. But if I do not speak now there is a danger that I might be squeezed out of the debate, which would not be in the interests of the House.

Mr. Corbyn

That is not our intention.

Mr. Horam

Nevertheless, I ought to get in to the debate now; otherwise there may be a risk. I believe that we have to finish at 7.4 pm promptly.

First, I am delighted that there is a health subject for debate today. Secondly, I am particularly glad that my hon. Friend the Member for Broxbourne (Mrs. Roe) has been able to secure the subject of breast cancer for the debate, as it is a matter of great concern to us all because of the incidence of the condition in the UK. I also congratulate the Select Committee on Health on its report on the subject, which has been widely welcomed by Members on both sides of the House.

I congratulate my hon. Friend the Member for Broxbourne on her report. My hon. Friend has been a particularly vigorous and effective Chairman of the Select Committee since she took on that responsibility. She has a number of successes to her credit, of which this report is one. I think we all agree that it is an excellent report. It is also fair to say that there is extensive all-party parliamentary interest in this matter.

The Health Committee has considered ways in which the quality and availability of breast cancer services in the UK might be improved, concentrating particularly on the progress made by the breast screening programme in reducing breast cancer mortality, the role of clinical trials in evaluating treatments and ways in which more women might be recruited into trials and the benefits of specialised breast units in the provision of high-quality breast cancer care.

The all-party breast group has explored issues around rising incidence, mortality, treatment and research, and called for a national strategy for breast cancer. The group has done much, in my view, to make its presence felt and has lobbied on behalf of the thousands of women who contract this terrible condition each year.

I am pleased that hon. Members on both sides of the House share our concerns about the high level of breast cancer incidence and mortality. Hon. Members have already told us this afternoon of the statistics, but they are worth repeating because they are truly dreadful. Breast cancer is increasing internationally, with registration data for England and Wales showing that age-standardised incidence rose by 22 per cent. between 1979 and the latest available figures. We know that there are even greater increases in other comparable countries. In England and Wales, breast cancer is the leading cause of cancer deaths in women. Each year, some 27,000 new breast cancer cases are registered and some 13,000 women die from it.

No Government could underestimate the seriousness of a condition which affects so many women, or results in so many deaths each year. We do not know why breast cancer is increasing internationally, but some suggestions have been made. My hon. Friend the Member for Colchester, South and Maldon (Mr. Whittingdale) suggested that an aging population was one possibility, and obesity is another possible factor. The rate of incidence is higher in developed countries—particularly western developed countries—than in less developed countries.

These are all suggestions, but—as has been stated in the debate—there is little evidence to suggest that there are clear links between the various factors involved in this dreadful disease. I emphasise to the House that, while these are the facts, we must take account of the evidence of increasing mortality. We have to take breast cancer very seriously, and we do. That is why in 1987 we announced the setting up of a breast cancer screening programme throughout the UK—the first of its kind in the European Union and one of the first in the world.

All women aged from 50 to 64 are invited for a three-yearly mammogram, with women aged 65 or over being screened on request. Some £55 million has been allocated to establish the programme in England, with £70 million being spent on the programme for the whole UK. Funding for running the services has now been built into health authorities' allocations at an estimated cost of £27 million a year.

The screening programme is a success, and I am pleased that the Committee accorded it such praise. I am sure that the whole House will join me in congratulating those who work on the programme. A number of hon. Members made that point, and I would like to underline that. The breast screening programme is now screening some 4.5 million women and has detected more than 26,000 cancers, many at an early stage when treatment is more successful.

Fewer women are being recalled unnecessarily, and every precaution is taken to minimise women's anxiety about the test and about recall for further assessment. A number of hon. Members—including my hon. Friends the Members for Croydon, North-East (Mr. Congdon) and for Colchester, South and Maldon, and the hon. Member for Woolwich (Mr. Austin-Walker)—made this point. It is a very serious matter and while the situation is getting better, there is clearly further to go and I want to see progress being made.

I come now to quality assurance questions. We built quality assurance standards into the programme from the start, and we will continue to monitor achievement against these standards. I appreciate, though I do not accept, the Committee's concern that devolving of purchasing of quality assurance to health authorities could lead to a pursuit of cheaper options than the gold standard set nationally. We believe strongly that the independence and effectiveness of the quality assurance programmes will continue to be guaranteed by the regional directors of public health, who have been charged with ensuring that quality assurance continues, and by the national NHS screening co-ordination team.

My hon. Friend the Member for Broxbourne asked me for a particular assurance in her speech. She said that there was a danger that the QAP would become simply a means for purchasers to check on provider units, and she asked whether it would continue to ensure that the service which is purchased meets the national standard. I am glad to say to my hon. Friend that the answer to that is yes. The regional directors of public health have been charged with the task of ensuring that quality assurance is purchased to the standard set nationally, and that the service continues to the current high standards. I give her an unequivocal assurance on that point.

The breast screening programme has been based on firm evidence, and one of its strengths is that it is constantly reviewed to ensure that standards are kept up to date. That is why we introduced last August the taking of two views of each breast for all women attending their first screening appointment. We have also announced proposals for the setting up of pilot projects to evaluate the effectiveness of extending the screening programme to women up to the age of 69. That is a particular point of concern which I fully accept, given the mortality rates among women in that age group. I am glad to say that we are making progress in that area. A number of hon. Members made that point, and I can reassure them that—as far as I am concerned—the matter will be a high priority.

We are funding further research into the effectiveness of screening women from the age of 40 and screening more frequently and exploring the management of screen- detected ductal carcinoma in situ. That is going on, although I think that the priority is women up to the age of 69.

A mark of our commitment to cut breast cancer deaths is shown by the fact that we have made this a target in our "The Health of the Nation" initiative. Our goal, as has been said during the debate, is to cut the number of deaths among women invited for screening by 25 per cent. by the end of this decade. That should mean a saving of at least 1,250 lives each year in England alone.

I wish to say something at this point on the question of the regional variations in the figures, a subject mentioned by the hon. Members for Doncaster, North (Mr. Hughes) and for Fife, Central (Mr. McLeish). The hon. Member for Fife, Central made a point about access to screening, but I think he used the wrong word. In looking at the regional and district variations, he should have said take-up instead of access.

There are clear differences in the extent to which screening is taken up in different areas, and it is true that take-up is much lower in inner-city areas and poorer districts. Therefore, health authorities have undertaken specific initiatives and have set local targets to add to the national targets to deal precisely with this matter. There is a difference in the take-up rate, not the access rate. Access is the same everywhere, and everyone gets the same treatment. This difference will be tackled by local initiatives, research into which will be funded by the Department. We are tackling the problem of different levels of take-up in different areas.

A separate point was made by the Opposition spokesman, the hon. Member for Fife, Central and by the hon. Member for Doncaster, North about mortality rates and whether we were on target. The only sensible, tested mortality rates are for 1993. We started the programme only in 1992 so it is absurd to say one year into a programme that is meant to last the eight years until the year 2000 that we are some way off target. We clearly are not off target. We believe that we are absolutely on target.

Mr. McLeish

The subject of our exercise was to look at the base year that the Government selected—1990—take it through to the most recent year—1993—and project the annual current rate forward to 2000. I suspect that, in many respects, that was not the most scientific of exercises, but it extrapolated the trends and showed that up to 60 of the district health authorities did not meet the target. The Minister rightly criticises our figures, but can he provide for me either in a letter or now some analysis carried out by the Government to find out whether the DHAs are on target, even though they are using a national target in local areas?

Mr. Horam

I will look into the additional point made by the hon. Gentleman, but it is our firm view that we are on target.

Of course, we would like to be able to prevent breast cancer occurring at all, but so far, despite enormous levels of research both here and abroad, we do not know how to do so. The trial currently under way in the NHS to evaluate the effectiveness of tamoxifen in preventing breast cancer in women at particularly high risk may help. However, we must be cautious. The beneficial effects of tamoxifen must be weighed carefully against its side effects. It may be years before we know whether it is a real option for preventing breast cancer.

Substantial work is also in hand to identify the gene defects which cause breast cancer in a minority of women, but that work will not stop the problem. Even if we reach the point at which we can identify that a woman is likely to develop cancer because of her genetic make-up, we do not know, despite research, what we can do to stop the cancer developing. Even the most radical option—surgical removal of the breast—does not offer a concrete guarantee, as there is still a remote possibility that the disease could spread before preventive surgery is performed. That is why the Government have put so much research into establishing a national population-based screening programme. Experts agree that early detection is of enormous value in combating breast cancer and improves the chances of effective treatment.

Even recently reported critics of the programme have acknowledged that at present screening remains the best option for women and agreed that the programme should continue. However, screening is only part of the story. All women with breast cancer should have access to good advice, treatment and care, wherever they live. We know that at present there is variety in provision for breast cancer around the country and that some patients seem to have better treatment outcomes than others. The choice of treatment required in individual cases will vary depending on a number of factors, including the stage and site of the cancer and the general health of the woman. Studies of adjuvant therapy indicate that a combination of treatment options—surgery, chemotherapy, adjuvant endocrine therapy—is highly effective, but circumstances differ in individual cases. Clinicians should choose a treatment regime best suited to the individual, after discussion with the patient.

There is increasing evidence that women treated by surgeons and teams with a degree of specialisation in breast cancer have better outcomes. That point has been made in the debate. Concerns about the evidence of variations in cancer treatment options and outcomes led the chief medical officers of England and Wales to ask their expert advisory group on cancer to review how cancer services, including breast cancer, were delivered and to make recommendations for improvement. Following wide consultation, my right hon. Friends the Secretaries of State for Health and for Wales unveiled on 24 April 1995, a new strategic framework for the future development of cancer services.

The report recommends a network of specialised care with cancer services organised at three levels. Primary care is seen as the focus of care, with GPs better informed about the availability of diagnostic and treatment services to allow them to make appropriate referrals and to be informed promptly about the outcomes of tests and of any treatment.

Cancer units will be created in many local hospitals of a sufficient size to support a multi-disciplinary team with the expertise and facilities to treat the more common cancers. A lead clinician will co-ordinate cancer services and develop treatment protocols between primary care, cancer units and cancer centres to ensure a network of care of a high standard. Cancer centres situated in larger hospitals will treat the less common cancers and support cancer units by providing services, including radiotherapy, not available in smaller hospitals. The NHS has already taken forward a great deal of work, making good progress towards the .implementation of this new strategic framework. Key elements in this are, first, regional mapping of current patterns of provision of cancer services, work to designate cancer units and cancer centres, discussion to develop explicit contracts between purchaser and provider for the provision of cancer services and plans for improving the availability and quality of data.

Simultaneously, in order to support work being taken forward regionally, the NHS executive has commissioned work to prepare evidence-based guidance in a rolling programme of work starting with the more common cancers to help purchasers and providers identify cancer units and cancer centres. Recommendations will be made on the characteristics which are necessary if a centre or unit is to be effective. They will cover the specialisation required, compatible with a high quality of service; where appropriate, guidance on the clinical management of cancers; and ways of measuring the quality of care delivered, including measures of outcome. Guidance on breast cancer will be the first product of this programme of work and will be delivered in spring 1996—not too far off.

My hon. Friend the Member for Broxbourne said that we did not want consultants to hang out a notice, as she put it rather graphically, saying, "Specialist Breast Unit", even though the unit had no special expertise. I hope to assure her that the programme that I have just outlined is designed to deal with precisely that point. It should succeed in doing so. I remind the hon. Member for Fife, Central that part of the programme will examine the evolving national picture. That will answer some of his concerns.

Concern has been expressed about research funding. I agree that we will secure reductions in deaths only if our services are built on the basis of sound scientific knowledge. In Britain we have a record of excellence in research in this area. Ours may not be the largest programme in the world, but the work is of a very high quality, and we can be justly proud of it. Moreover, it is a research programme which is well supported by many interests. The medical research charities play a significant role in the national endeavour to combat cancer, based on generous donations from the community. The contribution by drug companies is also very high. Of course, the Government are also a major player, in collaboration with those other bodies. Collaboration in research extends right across the European Union.

The Medical Research Council funds important research on cancer generally, and breast cancer in particular, including work on diet and on breast tumour imaging. It is also a key player in research to evaluate the breast screening programme, which hon. Members have rightly discussed at some length. Total spending on breast cancer research was £14.2 million in 1994-95. Total spending on cancer research as a whole is now approximately £250 million. We must remind ourselves that there are no fewer than 200 forms of cancer, so there is a great deal for the money to cover. In addition, clinical research is supported by NHS research programmes and NHS excess service costs attributed to cancer research. The value of this additional expenditure is significant and will become increasingly apparent.

My hon. Friend the Member for Broxbourne suggested that we might use the United Kingdom Co-ordinating Committee on Cancer Research to channel funding from the Department and the Medical Research Council. The danger is that we would lose flexibility. Improvements in research do not flow in an even stream. We cannot predict exactly what the volatility will be between one year and the next so some flexibility is essential in the research programme. We cannot meet my hon. Friend on that point.

My hon. Friend was also worried about indemnity for clinical trials, which remains a problem, and asked me to say how far we had gone in the review. We are making satisfactory progress. I hope that we shall be able to report at least some initial findings early in the new year. We are therefore dealing with that matter.

In conclusion, as I am anxious to allow the two hon. Members time to contribute to the debate, we are working on the progress already made to ensure that we can further reduce mortality from this serious condition. As has been said, the effect of screening on mortality will take some time to work through, but we estimate that 1,250 lives will be saved each year by the year 2000 and I emphasise that we are making good progress towards that end.

Moreover, in response to recent research findings, we have announced a package of quality initiatives further to strengthen the screening programme, some of which I mentioned today. Finally, in response to emerging evidence of variations in cancer treatment options and outcomes—a concern expressed both by Conservative and by Opposition Members—we have launched a new strategic framework for the organisation of cancer services, which it is predicted can increase long-term survival. Although full implementation is likely to take some years for what is a very ambitious programme, I am confident that significant improvements will be made soon.

6.50 pm
Mr. Jeremy Corbyn (Islington, North)

I shall be brief to allow the hon. Member for Belfast, South (Rev. Martin Smyth) the chance to speak during the last 14 minutes of the debate. I was sorry that I could not speak before the Minister, as I wanted him to answer some questions, but he can no doubt write to me or intervene.

Like many other hon. Members, I welcome this debate and the report that has gone with it. The House should bear in mind the detailed work that the Select Committee on Health has done on the subject and the huge amount of evidence that it has taken from a wide range of organisations, which must add to the strength of that report.

We must also welcome the fact that this is the third time this year that the House has debated breast cancer. There have been two Adjournment debates—I initiated one and my hon. Friend the Member for Edinburgh, Leith (Mr. Chisholm) the other—and now this debate on the estimates and the Select Committee report. The fact that there have been three debates in a year seems to show growing understanding among many people that there has been a large increase in breast cancer and that its treatment here has a low success rate compared to that in some other countries. We must consider that treatment seriously, but we must also consider the causes of breast cancer. I draw the attention of the House to the powerful speech by my hon. Friend the Member for Bristol, East (Ms Corston). She mentioned the contributions made by diet, stress factors and living conditions.

I was also impressed by the point made by the hon. Member for Colchester, South and Maldon (Mr. Whittingdale), among others, on the way in which nurses and doctors treat people. It is certainly my experience that anyone who goes into hospital for almost anything generally has high praise for the nursing auxiliaries and administrative staff, but criticisms of the way in which the medical staff treat them.

Often the medical staff are incredibly highly pressed, and they tend to leave the talking and caring role to others. Frankly, that is not good enough. Highly experienced medical staff, such as doctors, specialists and consultants, should spend more time with the patients if they can and should be straighter about what is wrong with them. They should also understand the degree of shock that a woman suffers when they tell her that all the investigations unfortunately show that there is a serious problem and that breast cancer is present. They should talk the thing through. It is an amazing shock, and although men obviously do not experience breast cancer, they have experience of other forms of cancer. Perhaps the Department could do something about attitudes and training. The Minister might like to reflect on that issue and think of doing some work or having discussions with medical colleges on that aspect of training.

I must make a brief point, but an important one. In my Adjournment debate on 22 November on breast cancer and its victims, I relied extensively on information supplied by Radiotherapy Action Group Exposure, which gave evidence to the Select Committee on compensation for victims of treatment. In some cases, we are talking of women who were treated with radiotherapy many years ago. It may well have cured the cancer, but the side effects and long-term effects have been almost as serious as what was there in the first place—the loss of the use of some limbs, permanent disability and a high level of constant pain, which is something that no one should have to live with all the time. Many of those women have suffered grievously and are still suffering. It is a humbling experience to talk to them about the ways in which their lives have been affected. In some cases, the problems occurred because of accidents, in others as a result of misdiagnosis, and some were caused because, at the time the radiotherapy treatment was given, those who gave it were unaware of its power, or of the importance of targeting the radiotherapy at the cancer cells with absolute accuracy because of the danger of wide-scale tissue damage to the surrounding area.

As part of their campaign for recognition and compensation, the women have been asking for a system of no-fault compensation. The Department has constantly replied that, although it understands their concern, it is not persuaded of the case. It has said that the women should take their cases to court individually. As has been pointed out in the debates, that is not a runner. Either one has to be very rich to afford to undertake a High Court action that can easily cost £200,000, particularly if it is not successful, or one has to be so poor and have such a strong case that one can get it all done on legal aid. Also, it is not a runner because the fault of an individual or organisation must be proved. That is the great failing because many of the people who gave the treatment could justifiably say that there had been a genuine accident on their part and could claim ignorance of the consequences of the treatment.

I have two brief questions for the Minister. First, when the then Under-Secretary of State for Health, the hon. Member for Bolton, West (Mr. Sackville), replied to the debate on 22 November, he mentioned the examination and report that the Royal College of Radiologists was to undertake shortly. Many people were concerned that the college was undertaking the research and thought that there should have been an independent inquiry—perhaps semi-judicial—into the problem of compensation for victims of radiotherapy. He said that he would rather await the college's report. As it is now out, I would be grateful for the Minister's response.

Secondly, on accountability, the then Under-Secretary of State said:

Our legal system holds all individuals accountable for their actions, which arguably has a deterrent effect on malpractice. No-fault compensation could remove or weaken it. That might well be so, but it does not answer my earlier point about changed systems, technologies and knowledge. In response to an intervention from my hon. Friend the Member for Glasgow, Maryhill (Mrs. Fyfe), he went on to say:

Although I have outlined some of the reasons why no-fault compensation has been thought inappropriate, we have recently accepted that a system should be tried for mediation in such cases. The Minister of State recently agreed to set up pilot mediation schemes that may make it easier to reach agreement. We have no wish gratuitously to defend certain cases or to cause any unnecessary delays."—[Official Report, 22 November 1995; Vol. 267, c. 639-40.] I would be grateful to hear what progress has been made and whether the Minister is prepared to reconsider the whole question of a no-fault compensation system to deal with the problems that those women have suffered or are still suffering and that have caused them to incur enormous and horrendous expense merely because they are the victims of problems caused by radiation treatment given when they were dangerously ill with cancer. Obviously, they are grateful to be alive, but they should be able to live decently, and that requires them to be compensated for the injuries that they have suffered.

6.58 pm
Rev. Martin Smyth (Belfast, South)

I appreciate the fact that I have a few minutes to comment and recognise that the response from the Department of Health included Scotland, Wales and Northern Ireland.

I was happy to be a member of the Select Committee on Health which considered the problem. Interestingly enough, since the report was commissioned and the Government response issued, I have received one of the largest mailbags I have ever had. People have been writing to urge us to ensure that the Government implement the recommendations. The Government generally welcomed the report, with one or two qualifications, which I would ask them to reconsider. They can do something positive.

I regret the fact that I was not present for the central part of the debate—I was speaking to a professor from one of the medical schools in Belfast. I discovered to my amazement when I entered the Chamber that the hon. Member for Southwark and Bermondsey (Mr. Hughes) was talking about research in the Department and the fact that the Northern Ireland Department of Health and Social Services has not been appointing a director for research and development. There is supposed to be a fixed percentage of the budget for that. This year, no clinical research awards at all have been made in Northern Ireland. I ask the Government to reconsider the use of the funds that are available to develop that aspect. I pay tribute to the work of Action Cancer, which has pioneered going out into the workplace and the rural community with a mobile van so that people can have mammograms taken in their communities without having to travel to Belfast. When we recently met the Minister responsible, he assured us that the claim that Action Cancer would have to foot the bill for that work—it provides coaches, and so on—was false. I have discovered from the tissue typing pool in the city under the new trust scheme that it has to be paid by Action Cancer. The Minister assured us that that was false. I ask the Minister to press the Department, and perhaps particularly the Eastern health and social services board, to pay the bills for which it is responsible. It is an abomination to expect a charity to start doing that work over and above the other work that it is doing.

I sympathise with the hon. Member for Islington, North (Mr. Corbyn) who again raised the issue of RAGE, Radiotherapy Action Group Exposure, and put it on record that the arguments for specialist breast centres stem from that. It is obvious that some people who were not expert in the field gave wrong advice and, as a result, some patients live in perpetual pain and suffer from paralysis and disability. The argument is clear that specialist breast centres are needed throughout the nation. It is not only national centres of excellence for breast screening that are needed; we also need national centres for breast treatment.

I draw attention to Professor's Blarney's response. As a world specialist in the field, he recommended in December that there should be movement. He stated:

Our argument is that a very good service was introduced for breast screening, precisely the same service is required for women presenting with symptomatic breast disease. Why not emulate this successful model? Why not let the nation take the lead?

My final point is simple. The anxiety that is sometimes created as a result of the pressures that affect this nation adds to the rate of cancers. There is a link there.

Mrs. Roe

With the leave of the House, I shall quickly sum up. I thank my hon. Friend the Minister for his remarks and assurances and express my deep gratitude to all the hon. Members who have participated in this important debate on a vital subject.

In conclusion, I make one important point. There has been a great deal of interest in breast cancer recently, and rightly so. It is a dreadful disease—the third largest cause of death for women in this country. However, I would not like the Committee's recommendations to be seen as relating exclusively to breast canner. I believe that, building on the success of breast screening, a national network of specialist breast units can be established with a national co-ordinator and a quality assurance programme integrated with that of the national health service breast screening programme. I also sincerely hope that that will lead the way for networks of site-specific units for other common cancers.

Question deferred, pursuant to paragraphs (4) and (5) of Standing Order No. 52 (Consideration of Estimates).